Value Institute Publications

Value Institute staff members have authored or co-authored manuscripts focused on a wide range of outcomes, including mortality, provider performance, and cost. In collaboration with key institutional stakeholders our projects provide knowledge that directly impacts efforts to improve patient care. Value Institute projects and their resulting publications encompass every clinically-oriented domain within ChristianaCare.

  • Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations

    Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations

    Neuman MD, Goldstein JN, Cirullo MA, Schwartz JS

    JAMA 2014 May;311(20):2092-100

    PMID: 24867012

    Abstract

    IMPORTANCE: Little is known regarding the durability of clinical practice guideline recommendations over time.

    OBJECTIVE: To characterize variations in the durability of class I ("procedure/treatment should be performed/administered") American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations.

    DESIGN, SETTING, AND PARTICIPANTS: Textual analysis by 4 independent reviewers of 11 guidelines published between 1998 and 2007 and revised between 2006 and 2013.

    MAIN OUTCOMES AND MEASURES: We abstracted all class I recommendations from the first of the 2 most recent versions of each guideline and identified corresponding recommendations in the subsequent version. We classified recommendations replaced by less determinate or contrary recommendations as having been downgraded or reversed; we classified recommendations for which no corresponding item could be identified as having been omitted. We tested for differences in the durability of recommendations according to guideline topic and underlying level of evidence using bivariable hypothesis tests and conditional logistic regression.

    RESULTS: Of 619 index recommendations, 495 (80.0%; 95% CI, 76.6%-83.1%) were retained in the subsequent guideline version, 57 (9.2%; 95% CI, 7.0%-11.8%) were downgraded or reversed, and 67 (10.8%; 95% CI, 8.4%-13.3%) were omitted. The percentage of recommendations retained varied across guidelines from 15.4% (95% CI, 1.9%-45.4%) to 94.1% (95% CI, 80.3%-99.3%; P < .001). Among recommendations with available information on level of evidence, 90.5% (95% CI, 83.2%-95.3%) of recommendations supported by multiple randomized studies were retained, vs 81.0% (95% CI, 74.8%-86.3%) of recommendations supported by 1 randomized trial or observational data and 73.7% (95% CI, 65.8%-80.5%) of recommendations supported by opinion (P = .001). After accounting for guideline-level factors, the probability of being downgraded, reversed, or omitted was greater for recommendations based on opinion (odds ratio, 3.14; 95% CI, 1.69-5.85; P < .001) or on 1 trial or observational data (odds ratio, 3.49; 95% CI, 1.45-8.41; P = .005) vs recommendations based on multiple trials.

    CONCLUSIONS AND RELEVANCE: The durability of class I cardiology guideline recommendations for procedures and treatments promulgated by the ACC/AHA varied across individual guidelines and levels of evidence. Downgrades, reversals, and omissions were most common among recommendations not supported by multiple randomized studies.

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  • Frequency of Sale and Reasons for Purchase of Over-the-Counter Insulin in the United States
  • Is the Over-the-Counter Availability of Human Insulin in the United States Good or Bad?
  • US veterans use vitamins and supplements as substitutes for prescription medication

    US veterans use vitamins and supplements as substitutes for prescription medication

    Goldstein JN, Long JA, Arevalo D, Ibrahim SA, Mao JJ

    Med Care 2014 Dec;52(12 Suppl 5):S65-9

    PMID: 25397826

    Abstract

    BACKGROUND: Vitamins and supplements are the most commonly used form of complementary and alternative medicine in the United States. Growing research suggests that patients substitute vitamins and supplements for their prescription medications. The reasons might include cost of prescription medications and discordant patient and doctor health belief systems.

    OBJECTIVES: To investigate the prevalence of substitution of vitamins and supplements for prescription medications among veterans who receive care in the VA health care system and whether substitution is associated with prescription rationing due to cost, treatment beliefs, or distrust of the health system.

    RESEARCH DESIGN: Cross-sectional observational survey.

    SUBJECTS: Primary care patients (n=275) at the Philadelphia VA Medical Center.

    MEASURES: Medication substitution, prescription medication rationing, treatment beliefs, and health system distrust were measured with structured instruments. Multivariate logistic regression was performed with substitution as the dependent variable.

    RESULTS: A significant number of primary care patients in the VA system use vitamins and supplements 206 (75%). The prevalence of medication substitution is high 48 (18%). Medication substitution is strongly associated with prescription rationing due to cost (adjusted odds ratio 6.3, 95% confidence interval: 2.0-19.5, P=0.001). Similarly, greater belief in complementary and alternative approaches to care positively predicts medication substitution (adjusted odds ratio 1.08, 95% confidence interval: 1.01-1.15, P=0.011). There is no significant association between health system distrust and likelihood of medication substitution.

    CONCLUSIONS: Medication substitution is prevalent in this sample of inner city primary care patients who receive care in the VA system. Cost of prescriptions and belief in the value of complementary and alternative approaches to care appear to be associated with this patient-driven treatment decision.

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  • Analysis of Unregulated Sale of Life-Saving Prescription Drugs Online in the United States
  • Outcomes with advanced versus basic life support in blunt trauma

    Outcomes with advanced versus basic life support in blunt trauma

    Farrell MS, Emery B, Caplan R, Getchell J, Cipolle M, Bradley KM

    Am. J. Surg. 2020 Jan;

    PMID: 32000980

    Abstract

    INTRODUCTION: The role of advanced life support (ALS) versus basic life support (BLS) in blunt trauma is controversial. Previous studies have shown no mortality benefit with ALS for penetrating trauma but the blunt population has mostly remained unaddressed.

    METHODS: A retrospective cohort study was conducted at a Level 1 trauma center comparing outcomes in blunt trauma patients managed by ALS versus BLS from July 1, 2014 to December 31, 2014. Both Injury Severity Score (ISS) and select Abbreviated Injury Score (AIS) were used to determine differences in mortality, length of stay (LOS) and complications based on mode of transportation, prehospital time, and number of prehospital interventions.

    RESULTS: 698 total patients were identified. Mortality and complications were grossly higher in ALS patients (p = 0.01 and < 0.001, respectively). When accounting for ISS and AIS there was no difference in mortality (p=<0.001-0.003). Prehospital interventions did not increase prehospital time (p = 0.7) but did correlate with increased mortality (p < 0.001).

    CONCLUSION: There is no mortality advantage for blunt trauma patients managed by ALS versus BLS.

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  • Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance

    Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance

    Whyte C, Alhasani H, Caplan R, Tully AP

    Clin Neurol Neurosurg 2019 Dec;190:105641

    PMID: 31869626

    Abstract

    BACKGROUND/OBJECTIVE: Systemic prophylactic antibiotics have been used to reduce the rate of neurosurgical drain-related infections (DRIs) but the optimal duration is unknown. The Neurocritical Care Society Consensus Statement for External Ventricular Drain (EVD) management recommends a single antibiotic dose preoperatively. Data regarding antibiotic management for other neurosurgical drains (e.g. subgaleal and subdural drains) are lacking. Previously at our institution antibiotics were continued for the duration of drain placement. In 2016 an EVD bundle was implemented to standardize nursing care, and antibiotic duration was changed to one preoperative dose for all neurosurgical drains. The objective of this study was to compare the incidence of DRI, non-DRI, and antibiotic resistance before and after the implementation of an EVD bundle and limited duration antibiotics.

    PATIENTS AND METHODS: This was a single center, quasi-experimental study that included patients status post EVD or craniotomy/craniectomy with subgaleal or subdural drain placement. The pre-intervention period was June 2014 through May 2015 and the post-intervention period was January 2017 through December 2017.

    RESULTS: Ninety-one patients were included in the pre-intervention group and 54 in the post-intervention group. The use of limited duration antibiotics (< 48 h) was 14.3 % in the pre-intervention group and 96.3 % in the post-intervention group (p < 0.001). Five DRIs were identified in the pre-intervention group and 3 in the post-intervention group (5.5 % vs 5.6 %, p = 1.00). Of patients who developed a non-DRI, 77.5 % had a resistant non-DRI in the pre-intervention group compared to 48 % in the post-intervention group (p = 0.01). The rates of resistant DRI (80 % vs 66.7 %, p = 1.00) andClostridium difficile infection (1.1 % vs 3.7 %, p = 0.56) were similar between groups.

    CONCLUSIONS: Implementation of an EVD bundle and limited duration antibiotics reduced antibiotic exposure with no associated increase in risk of DRI. Rates of resistant non-DRI were significantly lower in the post-intervention group.

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  • Development of a Multidisciplinary Medical Home Program for NICU Graduates

    Development of a Multidisciplinary Medical Home Program for NICU Graduates

    Feehan K, Kehinde F, Sachs K, Mossabeb R, Berhane Z, Pachter LM, Brody S, Turchi RM

    Matern Child Health J 2019 Nov;

    PMID: 31745836

    Abstract

    OBJECTIVE: Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population.

    METHODS: This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs.

    RESULTS: The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down.

    DISCUSSION: Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

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  • Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke

    Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke

    Jung S, Rosini JM, Nomura JT, Caplan RJ, Raser-Schramm J J Stroke Cerebrovasc Dis 2019 Dec;28(12):104329 PMID: 31607439

    Abstract

    BACKGROUND AND PURPOSE: The timely administration of thrombolytic therapy for acute ischemic stroke has been associated with good functional outcomes. Current guidelines recommend alteplase administration within 60 minutes in 75% of eligible patients and within 45 minutes in 50% of patients. There is limited evidence guiding these measures and their effect on outcomes. We report a single-center, retrospective assessment of the safety and efficacy of alteplase treatment within 45 minutes. METHODS: Five hundred and eighty-six patients were treated with alteplase in our emergency departments (EDs) between January 2014 and October 2016; 368 patients were included for analysis. Multivariate regression analysis was used to assess the association between door-to-alteplase (DTA) times and 90-day modified Rankin scale (mRS) scores. Incidence of intracerebral hemorrhage (ICH) was also documented. RESULTS: The median DTA time was 29 minutes versus 64 minutes in the DTA less than or equal to 45 minutes arm and more than 45 minutes arm, respectively. The primary outcome of 90-day mRS 0-1 was achieved in 56% of patients in the less than or equal to 45 minutes group versus 58% in more than 45 minutes group (P = .67). Odds of achieving mRS 0-1 were not significantly impacted by DTA times. In the multivariate regression analysis, patient characteristics associated with achieving mRS 0-1 were: younger age, male sex, not requiring intubation in the ED, and without prior history of hypertension, atrial fibrillation, or stroke. There was no significant difference in rates of ICH for patients less than or equal to 45 minutes versus more than 45 minutes. CONCLUSIONS: Rapid administration of alteplase was not associated with significantly better outcomes nor increased risk of ICH. Conclusions about efficacy are limited due to the retrospective nature of the study, small sample size, and incomplete data points.

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  • Impact of care coordination based on insurance and zip code

    Impact of care coordination based on insurance and zip code

    Goldstein JN, Shinwari M, Kolm P, Elliott DJ, Weintraub WS, Hicks LS

    Am J Manag Care 2019 06;25(6):e173-e178

    PMID: 31211549

    Abstract

    OBJECTIVES: To examine whether a care transitions program, Bridges, differentially reduced rehospitalizations among patients who underwent percutaneous coronary intervention (PCI) based on insurance status and zip code poverty level.

    STUDY DESIGN: Retrospective observational cohort.

    METHODS: We examined data from a single health system in Delaware, collected as part of a care transitions program for patients who underwent PCI from 2012 to 2015 compared with an unmatched historical control cohort from 2010 to 2011. Socioeconomic status was assessed by insurance status and zip code-level poverty data. Patients were divided into tertiles based on the proportion of their zip code of residence living under 100% of the federal poverty level. Rehospitalization rates were analyzed by negative binomial regression and included interaction terms to examine differential effects of Bridges by insurance and poverty level.

    RESULTS: There were 4638 patients representing 5710 hospitalizations: 3212 in the historical control and 2498 in the Bridges cohort. Among patients with Medicaid who received the Bridges intervention, those living in the wealthiest zip codes were 15.5% less likely to be rehospitalized than patients with Medicare and 9.4% less likely than patients with commercial insurance (P = .04). However, patients with Medicaid who lived in the poorest zip codes and those with dual Medicare/Medicaid status had higher rates of rehospitalization post intervention.

    CONCLUSIONS: The Bridges intervention was associated with improved rehospitalization rates for Medicaid patients compared with those with Medicare or commercial insurance within Delaware's wealthier communities. Care transitions programs may differentially affect Medicaid patients based on the wealth of the communities in which they reside.

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  • "Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey"

    "Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey"

    Goldstein JN, Schwartz JS, McGraw P, Hicks LS

    BMC Health Serv Res 2019 Mar;19(1):149

    PMID: 30845953

    Abstract

    BACKGROUND: Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries.

    METHODS: Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed.

    RESULTS: Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30).

    CONCLUSION: The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale.

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  • Evaluation of a Systems-Based Tobacco Cessation Program Using Bedside Volunteers

    Evaluation of a Systems-Based Tobacco Cessation Program Using Bedside Volunteers

    Taylor D, Medaglio D, Jurkovitz C, Patterson F, Zhang Z, Gbadebo A, Bradley E, Wessells R, Goldenberg E

    Nicotine Tob. Res. 2018 Nov;

    PMID: 30462274

    Abstract

    Introduction: Hospitalization and post-discharge provides an opportune time for tobacco cessation. This study tested the feasibility, uptake, and cessation outcomes of a hospital-based tobacco cessation program, delivered by volunteers to the bedside with post-discharge referral to Quitline services. Patient characteristics associated with Quitline uptake and cessation were assessed.

    Methods: Between February and November 2016, trained hospital volunteers approached inpatient tobacco users on six pilot units. Volunteers shared a cessation brochure and used the ASK-ADVISE-CONNECT model to connect ready-to-quit patients to the Delaware Quitline via fax-referral. Volunteers administered a follow-up survey to all admitted tobacco users via telephone or email at 3-months post-discharge.

    Results: Of the 743 admitted tobacco users, 531 (72%) were visited by a volunteer, and 97% (531/547) of those approached, accepted the visit. Over one third (201/531; 38%) were ready-to-quit and fax-referred to the Quitline, and 36% of those referred accepted Quitline services. At 3-months post discharge, 37% (135/368) reported not using tobacco in the last 30 days; intent-to-treat cessation rate was 18% (135/743). In a multivariable regression model of Quitline fax-referral completion, receiving NRT during hospitalization was the strongest predictor (OR: 1.97; 95% CI: 1.34-2.90). In a model of 3-month cessation, receiving Quitline services (OR: 3.21, 95%CI: 1.35-7.68) and having coronary artery disease (OR: 2.28; 95% CI: 1.11-4.68) were associated with tobacco cessation, but a volunteer visit was not.

    Conclusions: An "opt-out" tobacco cessation service using trained volunteers is feasible for connecting patients to Quitline services.

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  • Choosing Wisely in Delaware: Rationale for Evidence-Based Diagnosis & Evaluation of Low Back Pain
  • Patient-Centered Handovers: Ethnographic Observations of Attending and Resident Physicians: Ethnographic Observations of Attending and Resident Physicians

    Patient-Centered Handovers: Ethnographic Observations of Attending and Resident Physicians: Ethnographic Observations of Attending and Resident Physicians

    Mount-Campbell AF, Rayo MF, OʼBrien JJ, Allen TT, Patterson ES

    Qual Manag Health Care 2016 Oct/Dec;25(4):225-230

    PMID: 27749720

    Abstract

    Handover communication improvement initiatives typically employ a "one size fits all" approach. A human factors perspective has the potential to guide how to tailor interventions to roles, levels of experience, settings, and types of patients. We conducted ethnographic observations of sign-outs by attending and resident physicians in 2 medical intensive care units at one institution. Digitally audiotaped data were manually analyzed for content using codes and time spent using box plots for emergent categories. A total of 34 attending and 58 resident physician handovers were observed. Resident physicians spent more time for "soon to be discharged" and "higher concern" patients than attending physicians. Resident physicians spent less time discussing patients which they had provided care for within the last 3 days ("handbacks"). The study suggested differences for how handovers were conducted for attending and resident physicians for 3 categories of patients; handovers differ on the basis of role or level of expertise, patient type, and amount of prior knowledge of the patient. The findings have implications for new directions for subsequent research and for how to tailor quality improvement interventions based upon the role, level of experience, level of prior knowledge, and patient categories.

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  • Patient Satisfaction with Care After Coronary Revascularization

    Patient Satisfaction with Care After Coronary Revascularization

    Mosby DL, Manierre MJ, Martin SS, Kolm P, Abuzaid AS, Jurkovitz CT, Elliott DJ, Weintraub WS

    Patient 2018 04;11(2):217-223

    PMID: 28875457

    Abstract

    OBJECTIVE: Bridging the Divides (Bridges), a Centers for Medicare and Medicaid Services-funded program, developed a post-hospitalization care management infrastructure integrating information technology-enabled informatics with patient care for ischemic heart disease patients. The objective of this study was to assess patient satisfaction with the Bridges program and determine the patient characteristics associated with higher satisfaction.

    METHODS: All adult English-speaking patients who underwent a percutaneous coronary intervention, coronary artery bypass grafting, or catheterization plus acute myocardial infarction and agreed to participate in the Bridges program were eligible. A survey instrument was administered to address patient satisfaction of care received, aspects of care that patients appreciated, and challenges faced. Descriptive statistics were calculated, and primary analyses included comparisons of overall patient satisfaction after discharge between procedure type, and according to age, sex, race, Elixhauser comorbidity count, and length of stay.

    RESULTS: Four hundred and sixty-seven (46%) had complete or partial response rates. There was a statistically significant difference in the overall satisfaction among patients undergoing percutaneous coronary intervention, coronary artery bypass grafting, or catheterization plus acute myocardial infarction (p = 0.023). There were significant procedure by sex (p = 0.052) and procedure by age (p = 0.039) interactions. There were no statistically significant differences in overall satisfaction according to age, sex, race, comorbidity count, or length of stay.

    CONCLUSIONS: This study identified several important components related to patient satisfaction for patients with ischemic heart disease. Results found that patients who underwent coronary artery bypass grafting were reportedly "very satisfied" when compared with patients who underwent percutaneous coronary intervention and catheterization plus acute myocardial infarction, as well as significant age and sex interactions between procedures.

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  • Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit

    Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit

    Vest MT, Kolm P, Bowen J, Trabulsi J, Lennon SL, Shapero M, McGraw P, Halbert J, Jurkovitz C

    Am. J. Crit. Care 2018 Mar;27(2):136-143

    PMID: 29496770

    Abstract

    BACKGROUND: Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting.

    OBJECTIVES: To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship.

    METHODS: A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index.

    RESULTS: Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission.

    CONCLUSION: The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.

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  • Co-occurrence of medical conditions: Exposing patterns through probabilistic topic modeling of snomed codes

    Co-occurrence of medical conditions: Exposing patterns through probabilistic topic modeling of snomed codes

    Bhattacharya M, Jurkovitz C, Shatkay H J Biomed Inform 2018 Jun;82:31-40 PMID: 29655947

    Abstract

    Patients associated with multiple co-occurring health conditions often face aggravated complications and less favorable outcomes. Co-occurring conditions are especially prevalent among individuals suffering from kidney disease, an increasingly widespread condition affecting 13% of the general population in the US. This study aims to identify and characterize patterns of co-occurring medical conditions in patients employing a probabilistic framework. Specifically, we apply topic modeling in a non-traditional way to find associations across SNOMED-CT codes assigned and recorded in the EHRs of >13,000 patients diagnosed with kidney disease. Unlike most prior work on topic modeling, we apply the method to codes rather than to natural language. Moreover, we quantitatively evaluate the topics, assessing their tightness and distinctiveness, and also assess the medical validity of our results. Our experiments show that each topic is succinctly characterized by a few highly probable and unique disease codes, indicating that the topics are tight. Furthermore, inter-topic distance between each pair of topics is typically high, illustrating distinctiveness. Last, most coded conditions grouped together within a topic, are indeed reported to co-occur in the medical literature. Notably, our results uncover a few indirect associations among conditions that have hitherto not been reported as correlated in the medical literature.

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  • Impact of tart cherry juice on systolic blood pressure and low-density lipoprotein cholesterol in older adults: a randomized controlled trial

    Impact of tart cherry juice on systolic blood pressure and low-density lipoprotein cholesterol in older adults: a randomized controlled trial

    Chai SC, Davis K, Wright RS, Kuczmarski MF, Zhang Z

    Food Funct 2018 Jun;9(6):3185-3194

    PMID: 29862410

    Abstract

    Hypertension and dyslipidemia are major risk factors for cardiovascular disease (CVD). Common treatments for high blood pressure (BP) and dyslipidemia include medications, but there is question as to whether natural sources may be adequate to reduce CVD risk factors. We examined the effects of tart cherry juice on lipid profiles, BP, glucose, insulin, and homeostatic model assessment-insulin resistance (HOMA-IR) in older adults. In this randomized-controlled clinical trial, 17 men and 20 women between the ages of 65-80 years were randomly assigned to consume 480 ml of tart cherry juice or control drink daily for 12 weeks. Control beverages were matched for energy and sugar content. Outcome variables were assessed at baseline and after 12 weeks of tart cherry juice or control drink. Systolic BP and low-density lipoprotein cholesterol (LDL) exhibited treatment × time interaction effects. At the end of the study, participants in the tart cherry group had lower levels of LDL cholesterol (difference of -20.6 with P = 0.001) and total cholesterol (difference of -19.11 with P = 0.01), and higher levels of glucose (difference of 7.94 with P = 0.001), triglycerides (difference of 6.66 with P = 0.01) and BMI (difference of 1.06 with P = 0.02) than in the control group. Neither tart cherry juice nor control significantly altered body weight, high-density lipoprotein cholesterol, diastolic BP, insulin and HOMA-IR. Our findings show that tart cherry juice can lower the levels of systolic BP and LDL cholesterol. However, larger and longer follow-up studies are needed to further assess cardio-protective effects of tart cherry juice.

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  • The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study

    The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study

    Goldstein JN, Schwartz JS, McGraw P, Banks TL, Hicks LS

    J Hosp Med 2017 03;12(3):168-172

    PMID: 28272593

    Abstract

    BACKGROUND: Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs.

    OBJECTIVE: To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization.

    DESIGN/SETTING: Observational study using electronic medical record and administrative data from a regional health system.

    PATIENTS: 1323 community-dwelling Medicare patients admitted under observation status.

    MEASUREMENTS: Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit.

    RESULTS: Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P ⟨ 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118).

    CONCLUSIONS: Medicare observation patients' potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172.

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  • Social constraints and fear of recurrence in couples coping with early stage breast cancer

    Social constraints and fear of recurrence in couples coping with early stage breast cancer

    Soriano EC, Pasipanodya EC, LoSavio ST, Otto AK, Perndorfer C, Siegel SD, Laurenceau JP

    Health Psychol 2018 Sep;37(9):874-884

    PMID: 30138023

    Abstract

    OBJECTIVE: Fear of cancer recurrence (FCR) is a top concern of breast cancer (BC) survivors and their spouses. FCR often occurs within an interpersonal context, yet there has been little research on relationship processes that may influence FCR in patients and spouses. It was hypothesized that the inhibition of disclosure of cancer-related concerns, thoughts, and feelings because of perceived partner disinterest or avoidance (termed social constraints) would predict greater FCR in BC patients and their spouses both globally and in the context of everyday life.

    METHOD: Two studies, 1 cross-sectional (N = 46 couples) and 1 daily diary (21 days; N = 72 couples), were conducted to examine the between-person and within-person associations between social constraints and FCR in early stage BC patients and their spouses. Assessments were conducted about 6 months after BC surgery.

    RESULTS: Global social constraints predicted greater global FCR in patients and spouses at the cross-sectional level, controlling for anxiety symptoms, relationship quality, and patient age, physical impairment, and BC stage. At the within-person level, results indicated that on days when more social constraints were reported, both partners were more likely to report greater FCR, controlling for momentary negative affect and relationship quality.

    CONCLUSIONS: This study is the first to examine the within-person association between social constraints and FCR. These findings suggest relationship processes, particularly inhibition of disclosure, can uniquely influence the experience of FCR for both BC patients and their spouses, pointing to an important consideration for future research and possible intervention development. (PsycINFO Database Record

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  • Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors

    Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors

    Otto AK, Soriano EC, Siegel SD, LoSavio ST, Laurenceau JP

    J Cancer Surviv 2018 Oct;

    PMID: 30341560

    Abstract

    PURPOSE: The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors.

    METHODS: Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities.

    RESULTS: FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178).

    CONCLUSIONS: FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs.

    IMPLICATIONS FOR CANCER SURVIVORS: FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.

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  • Investigation of age-adjusted D-dimer using an uncommon assay

    Investigation of age-adjusted D-dimer using an uncommon assay

    Parks C, Bounds R, Davis B, Caplan R, Laughery T, Zeserson E

    Am J Emerg Med 2018 Sep;

    PMID: 30291035

    Abstract

    BACKGROUND: Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED.

    METHODS: This was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age × 5) - 20 and Age × 5 if >50, respectively. Estimates with their exact 95% threshold were performed.

    RESULTS: 4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6-100), specificity of 16.7% (95% CI 15.6-17.8) and NPV of 99.9% (95% CI 99.3-100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8-98.4), specificity of 27.9% (95% CI 26.6-29.2) and NPV of 99.0% (95% CI 98.3-99.5) with the ACEP-endorsed formula demonstrating similar test characteristics.

    CONCLUSION: Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.

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  • Data-driven approach to Early Warning Score-based alert management

    Data-driven approach to Early Warning Score-based alert management

    Capan M, Hoover S, Miller KE, Pal C, Glasgow JM, Jackson EV, Arnold RC

    BMJ Open Qual 2018;7(3):e000088

    PMID: 30167470

    Abstract

    Background: Increasing adoption of electronic health records (EHRs) with integrated alerting systems is a key initiative for improving patient safety. Considering the variety of dynamically changing clinical information, it remains a challenge to design EHR-driven alerting systems that notify the right providers for the right patient at the right time while managing alert burden. The objective of this study is to proactively develop and evaluate a systematic alert-generating approach as part of the implementation of an Early Warning Score (EWS) at the study hospitals.

    Methods: We quantified the impact of an EWS-based clinical alert system on quantity and frequency of alerts using three different alert algorithms consisting of a set of criteria for triggering and muting alerts when certain criteria are satisfied. We used retrospectively collected EHRs data from December 2015 to July 2016 in three units at the study hospitals including general medical, acute care for the elderly and patients with heart failure.

    Results: We compared the alert-generating algorithms by opportunity of early recognition of clinical deterioration while proactively estimating alert burden at a unit and patient level. Results highlighted the dependency of the number and frequency of alerts generated on the care location severity and patient characteristics.

    Conclusion: EWS-based alert algorithms have the potential to facilitate appropriate alert management prior to integration into clinical practice. By comparing different algorithms with regard to the alert frequency and potential early detection of physiological deterioration as key patient safety opportunities, findings from this study highlight the need for alert systems tailored to patient and care location needs, and inform alternative EWS-based alert deployment strategies to enhance patient safety.

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  • Factors Associated with Continued Food Insecurity among Households Recovering from Hurricane Katrina

    Factors Associated with Continued Food Insecurity among Households Recovering from Hurricane Katrina

    Clay LA, Papas MA, Gill KB, Abramson DM

    Int J Environ Res Public Health 2018 Aug;15(8)

    PMID: 30081494

    Abstract

    In 2010, 14.5% of US households experienced food insecurity, which adversely impacts health. Some groups are at increased risk for food insecurity, such as female-headed households, and those same groups are often also at increased risk for disaster exposure and the negative consequences that come with exposure. Little research has been done on food insecurity post-disaster. The present study investigates long-term food insecurity among households heavily impacted by Hurricane Katrina. A sample of 683 households participating in the Gulf Coast Child and Family Health Study were examined using a generalized estimation model to determine protective and risk factors for food insecurity during long-term recovery. Higher income (Odds Ratio (OR) 0.84, 95% Confidence Interval (CI) 0.77, 0.91), having a partner (OR 0.93; 95% CI 0.89, 0.97), or "other" race were found to be protective against food insecurity over a five-year period following disaster exposure. Low social support (OR 1.14; 95% CI 1.08, 1.20), poor physical health (OR 1.08; 95% CI 1.03, 1.13) or mental health (OR 1.13; 95% CI 1.09, 1.18), and female sex (OR 1.05; 95% CI 1.01, 1.10) were risk factors. Policies and programs that increase access to food supplies among high-risk groups are needed to reduce the negative health impacts of disasters.

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  • Cost-effectiveness of Daratumumab-based Triplet Therapies in Patients With Relapsed or Refractory Multiple Myeloma

    Cost-effectiveness of Daratumumab-based Triplet Therapies in Patients With Relapsed or Refractory Multiple Myeloma

    Zhang TT, Wang S, Wan N, Zhang L, Zhang Z, Jiang J

    Clin Ther 2018 Jul;40(7):1122-1139

    PMID: 30006069

    Abstract

    PURPOSE: The prominent efficacy of the addition of daratumumab to lenalidomide and dexamethasone (DRd) or the addition to bortezomib and dexamethasone (DVd) was proven previously for patients with relapsed or refractory multiple myeloma (RRMM). However, the cost-effectiveness of adding daratumumab to traditional doublet regimens versus doublet regimens alone (DRd vs Rd; DVd vs Vd) was unknown.

    METHODS: We developed a semi-Markov model by using a US payer perspective and 10-year time horizon to estimate the cost and quality-adjusted life years (QALYs) for treatments. Clinical data were obtained from the POLLUX (Phase 3 Study Comparing DRd Versus Rd in Subjects with Relapsed or Refractory Multiple Myeloma [RRMM]) and CASTOR (Phase 3 Study Comparing DVd Versus Vd in Subjects with RRMM) trials. Deterministic and probabilistic sensitivity analyses were conducted to evaluate model uncertainty.

    FINDINGS: The incremental cost-effectiveness ratio (ICER) for DVd compared with Vd was $284,180 per QALY; the ICER for DRd compared with Rd was $1,369,062 per QALY. Only when the price of daratumumab was reduced to 37% (US $702/vial) of the current price could the addition of daratumumab to Vd be cost-effective under the US willingness-to-pay (WTP) of $50,000/QALY. However, under no discount level of the daratumumab price is the addition of daratumumab to Rd acceptable. When the WTP increased to $300,000/QALY, the addition of DVd had a 56.7% probability of being cost-effective compared with the Vd regimen.

    IMPLICATIONS: Due to the high price of daratumumab, neither the addition of daratumumab to Rd nor Vd proved to be cost-effective under US WTP. However, if the daratumumab price fell to a certain discount level, the DVd regimen might be cost-effective.

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