Publications

INTRODUCTION: This study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs).

RESEARCH DESIGN AND METHODS: A retrospective study included 2011-2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported.

RESULTS: Among 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (p<0.05). Multivariable analysis showed that AAs (aHR=1.9, 95% CI 1.7 to 2.2, p<0.0001) and NAs (aHR=1.8, 95% CI 1.3 to 2.6, p=0.001) were associated with an increased risk of major amputation compared with whites. Beneficiaries with DFUs and/or DFIs diagnosed by a podiatrist or primary care physician (aHR=0.7, 95% CI 0.6 to 0.8, p<0.0001, specialists as reference) or at an outpatient visit (aHR=0.3, 95% CI 0.3 to 0.3, p<0.0001, inpatient stay as reference) were associated with a decreased risk of major amputation.

CONCLUSIONS: Racial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.

Because they contain detailed individual-level data on various patient characteristics including their medical conditions and treatment histories, electronic health record (EHR) systems have been widely adopted as an efficient source for health research. Compared to data from a single health system, real-world data (RWD) from multiple clinical sites provide a larger and more generalizable population for accurate estimation, leading to better decision making for health care. However, due to concerns over protecting patient privacy, it is challenging to share individual patient-level data across sites in practice. To tackle this issue, many distributed algorithms have been developed to transfer summary-level statistics to derive accurate estimates. Nevertheless, many of these algorithms require multiple rounds of communication to exchange intermediate results across different sites. Among them, the One-shot Distributed Algorithm for Logistic regression (termed ODAL) was developed to reduce communication overhead while protecting patient privacy. In this paper, we applied the ODAL algorithm to RWD from a large clinical data research network-the OneFlorida Clinical Research Consortium and estimated the associations between risk factors and the diagnosis of opioid use disorder (OUD) among individuals who received at least one opioid prescription. The ODAL algorithm provided consistent findings of the associated risk factors and yielded better estimates than meta-analysis.

OBJECTIVES: To examine health outcomes associated with adherence to Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management (AMM) during acute and continuation phases of depression treatment among older adults with dementia and major depressive disorder (MDD).

DESIGN: Retrospective cohort study.

SETTING: Medicare 5% sample data (2011-2013).

PARTICIPANTS: Older adults (aged 65 years or older) with dementia and MDD.

MEASUREMENTS: The first antidepressant prescription claim from 1 May 2011 through 30 April 2012 was considered the index prescription start date (IPSD). Adherence during acute- and continuation-phase AMM was based on HEDIS guidelines. Study outcomes included all-cause mortality, all-cause hospitalization, and falls/factures (with mortality being the competing event for hospitalization and falls/fractures) during follow-up from end of acute-/continuation-phase AMM adherence. Due to the proportionality assumption violation of Cox models, fully non-parametric approaches (Kaplan-Meier and modified Gray's test) were used for time-to-event analysis adjusting for the inverse probability of treatment weights.

RESULTS: Final study samples consisted of 4330 (adherent (N) = 3114 (71.92%)) and 3941 (adherent (N) = 2407 (61.08%)) older adults with dementia and MDD during acute- and continuation-phase treatments, respectively. No significant difference (p > 0.05) between adherent and non-adherent groups was observed for all-cause mortality and falls/fractures in both the acute and continuation phases. There was a significant difference in time to all-cause hospitalization during acute-phase treatment (p = 0.018), with median times of 530 (95% CI: 499-587) and 425 (95% CI: 364-492) days for adherent and non-adherent groups, respectively.

CONCLUSIONS: Acute-phase adherence to HEDIS AMM was associated with reductions in all-cause hospitalization risk among older adults with dementia and MDD.

BACKGROUND/OBJECTIVES: Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.

DESIGN: National cross-sectional survey.

SETTING: Ambulatory.

PARTICIPANTS: Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians.

MEASUREMENTS: Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.

RESULTS: In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists).

CONCLUSIONS: While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.

IMPORTANCE: Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.

OBJECTIVE: To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.

MAIN OUTCOMES AND MEASURES: Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.

RESULTS: Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.

CONCLUSIONS AND RELEVANCE: In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.

BACKGROUND: Limited English proficiency is associated with decreased access to ambulatory care, however, it is unclear if this disparity leads to increased use of emergency departments (EDs) for low severity ambulatory care sensitive conditions (ACSCs).

OBJECTIVE: We sought to determine the association between the patient's preferred language and hospital utilization for ACSCs.

RESEARCH DESIGN: We conducted a retrospective cohort study of all ED visits in New Jersey in 2013 and 2014. The primary outcome was hospital admission for acute ACSCs, chronic ACSCs, and fractures (a nonambulatory care sensitive control condition). Secondary outcomes included intensive care unit (ICU) utilization and length of stay. Mixed-effect regression models estimated the association between preferred language (English vs. non-English) and study outcomes, controlling for demographics, comorbidities, and hospital characteristics.

RESULTS: We examined 201,351 ED visits for acute ACSCs, 251,193 visits for chronic ACSCs, and 148,428 visits for fractures, of which 13.5%, 11.1%, and 9.9%, respectively, were by non-English speakers. In adjusted analyses, non-English speakers were less likely to be admitted for acute ACSCs [-3.1%; 95% confidence interval (CI), -3.6% to -2.5%] and chronic ACSCs (-2.3%; 95% CI, -2.8% to -1.7%) but not fractures (0.4%; 95% CI, -0.2% to 1.0%). Among hospitalized patients, non-English speakers were less likely to receive ICU services but had no difference in length of stay.

CONCLUSIONS: These findings suggest non-English-speaking patients may seek ED care for lower acuity ACSCs than English-speaking patients. Efforts to decrease preventable ED and increase access to ambulatory care use should consider the needs of non-English-speaking patients.