Health Care Utilization Research Articles

The healthcare burden of isolated aortic valve insufficiency

To analyze and compare the differences in mortality, healthcare utilization, and costs between patients with symptomatic and asymptomatic isolated aortic insufficiency (AI). We utilized Optum United Health Care Database for US patients who had an AI claim between 2017 and 2022, with 12 months of continuous enrollment (baseline period) prior to diagnosis. Exclusion criteria were AVR during the baseline period or a diagnosis of aortic stenosis. Patients were split into two cohorts: those with symptoms (SAI) and those without (AAI). SAI patients had ≥ 2 visits for heart failure, angina, dyspnea, or syncope at baseline. Outcomes of interest were all-cause mortality, time to home health, time to SNF, annualized healthcare utilization, and annualized costs. We used the Cox proportional model to estimate mortality and general linear models to estimate healthcare utilization and costs. Outcomes were modeled separately. Of 249,660 patients, 58.23% were symptomatic; they were generally older and sicker than the AAI cohort, and less than 1% received AVR. Almost half of AAI patients were estimated to develop symptoms within 5 years post-diagnosis. SAI outcomes were consistently higher across all measured outcomes. SAI patients have higher mortality, healthcare utilization, and costs than AAI. However, AI can progress quickly from asymptomatic to symptomatic. Early detection and timely interventions to slow the progression or address it surgically should be emphasized to limit the impact of AI.

Healthcare Resource Utilization and Economic Burden of Prurigo Nodularis in the United States.

The impacts of prurigo nodularis (PN) on healthcare resource utilization (HCRU) and associated costs are unclear. This retrospective, cross-sectional claims analysis (IQVIA PharMetrics® Plus) compared HCRU and costs over 1year in adults with PN versus matched controls (region, payer type, age, sex, year) from 2016 to 2019, and also in patients with PN receiving advanced versus localized/no therapy. For patients with data in multiple calendar years, 1year was randomly selected. Outcomes were compared by chi-square tests, ttests, or negative binomial tests. We matched 16,888 patients with PN with 16,888 controls. Most comorbidities (mental health, metabolic conditions, type2 inflammatory diseases) appeared more frequently in patients with PN versus controls. HCRU was significantly (P < 0.001) higher for patients with PN versus controls, including mean (standard deviation, SD) number of outpatient visits (17.0 [15.5] vs 8.1 [10.7]) and proportion of patients with hospitalizations (9.3% vs 5.9%). Mean (SD) total costs were significantly (P < 0.001) greater for patients with PN versus controls ($18,315 [$66,476] vs $8451 [$30,982]). Patients with PN receiving advanced therapy had higher HCRU and costs versus localized/no therapy. Patients with PN (particularly those receiving advanced therapies) incurred higher all-cause HCRU burden and associated costs than matched controls. Enhanced feature (slides, video, animation) (MP4 12313 KB).

Exploring drug utilization patterns, healthcare resource utilization, and epidemiology of rheumatoid arthritis in Colombia: a retrospective claims database study

BackgroundIn Colombia, there is a lack of recent real- word studies that provide information on the epidemiology and healthcare resource utilization (HCRU) of rheumatoid arthritis (RA) at national level.MethodsTo describe the burden of RA in Colombia, focusing on trends in drug utilization patterns, healthcare resource utilization (HCRU), and the epidemiology of adult patients diagnosed with RA between January 2017 and December 2022. This retrospective descriptive study used real-world data obtainedfrom a national claim database, SISPRO (Sistema de Información para la Protección Social). We included registries of adult patients diagnosed with RA between 2017 and 2022. We estimated the age-standardized incidence and prevalence of RA each year, drug utilization patterns for disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids, rates of medical consultations, emergency room visits, and hospitalizations, and associated comorbidities and healthcare-related and pharmacy-related costs.ResultsOverall, 327,430 unique patients with RA between 2017 and 2022 were included in the analysis, comprising 94,093 incident cases and 722,569 prevalent cases. The age-standardized incidence of RA ranged between 34.7 and 51.4 per 100,000 inhabitants, and the age-standardized prevalence ranged between 0.282 and 0.382 per 100 inhabitants between 2017 and 2022. The proportion of patients prescribed conventional synthetic DMARDs and biologic DMARDs decreased over the study period, from 39.23% in 2017 to 28.61% in 2021 and from 6.07% in 2017 to 3.72% in 2021, respectively. The proportion of patients prescribed targeted synthetic DMARDs increased from 0.9% in 2017 to 1.8% in 2021. The rate of medical consultations increased over the study period (from 2,406.6 in 2017 to 3,354.2 per 1,000 patients with RA in 2022). Consultation costs were the largest among all-cause annual healthcare-related costs.ConclusionThis study described the heavy burden of RA in Colombia with an increasing incidence of RA, and significant healthcare resource utilization and associated costs. Patients with RA in the country are increasingly able to access consultations with specialists and receive advanced therapies. However, there remains a need for efforts to facilitate treatment among this population. These findings emphasize the importance of tailoring RA management strategies to the local context.

Risk of Hepatocellular Cancer in U.S. Patients With Compensated Cirrhosis Treated With Direct-Acting Antivirals Versus Interferon.

Few studies have examined the risk of de novo hepatocellular carcinoma (HCC) among hepatitis C virus (HCV)-infected patients with cirrhosis who received interferon (IFN)-free direct-acting antiviral (DAA) therapy relative to patients who received IFN-containing therapy or remained untreated. To estimate the risk of de novo HCC with DAA treatment in cirrhotic HCV patients compared to no anti-HCV treatment and those treated with IFN-based therapy. We identified patients with chronic HCV infection and compensated cirrhosis in the US Department of Veterans Affairs healthcare system treated with IFN (2005 to 2013) or DAAs (2013 to 2017). We compared the risk of de novo HCC for patients treated with DAAs, IFN-containing regimens or no treatment after accounting for differences in demographics, alcohol and drug abuse, comorbidities, laboratory values, healthcare utilisation, prior HCV treatment and HCC surveillance. A total of 53,847 patients contributed to untreated time, 27,147 patients contributed to DAA-treated time (15,641 contributed to both untreated and DAA-treated times) and 6809 patients contributed to IFN-treated time. HCC risk associated with DAA treatment was significantly lower than untreated [adjusted HR: 0.70 (95% CI: 0.65-0.74)]. The risk of HCC was not significantly different for patients treated with DAA compared with those treated with IFN [adjusted HR: 0.98 (95% CI: 0.87-1.10)]. The study shows a reduced risk of de novo HCC among patients with chronic HCV-related compensated cirrhosis who received DAA treatment compared to that of untreated patients. There were no differences in HCC risk between DAA-treated and IFN-treated patients.

Efficiency of a virtual fracture clinic review protocol in adult patients with distal radial fractures requiring semi-acute surgical treatment

PurposeThe aim of this study was to evaluate the effect of implementation of a Virtual Fracture Clinic (VFC) review protocol on the time between injury and surgery, and on secondary healthcare utilization, in patients with Distal Radius Fractures (DRFs) requiring semi-acute surgery.MethodsData for this retrospective before-after study were gathered between April 2017 and March 2019 (Pre-VFC n = 269), and between April 2021 and March 2023 (VFC n = 440) in a large level 2 urban trauma center. The primary outcome was the number of days between injury and operation. Furthermore secondary healthcare utilization was assessed.ResultsThe average time between injury and surgery was 11.0 days (95% CI: 10.6–11.5) before and 9.2 days (95% CI: 8.9–9.6) after VFC-implementation ( p < 0.001). Following VFC-implementation, 33% (was 17%) of patients underwent surgery within 7 days, 92% (was 84%) within 2 weeks, and 99% (was 96%) within 3 weeks (p < 0.001). This included patients with delays of up to 15 days between injury and their initial hospital presentation. Hospital contacts decreased from 5 (IQR: 4–6) to 4 (IQR: 3–5) whereof physical consults decreased from 4 (IQR: 3–5) to 1 and telephone contacts increased from negligible to 1 (IQR: 1–2). Radiographs reduced from 6 (IQR: 5–7) to 4 (IQR: 3–5).ConclusionsImplementation of a VFC-review protocol is associated with a reduced time between injury and semi-acute surgery for DRFs and reflects an improvement in quality of timely planning. Secondary healthcare utilization is reduced and a shift to remote delivery of care is observed.Level of evidenceLevel III.

Assessing Racial and Ethnic Health Disparities in a Diverse Cohort with Pediatric Inflammatory Bowel Disease.

To identify racial and ethnic disparities in disease phenotype, treatment, and outcome in an diverse cohort of children with pediatric inflammatory bowel disease (IBD). Patients aged 7 through 18 with IBD diagnosed at a single institution between March 2020 and June 2021 with self- or parent-identified race and ethnicity of non-Hispanic (NH) Black, NH-White, or Hispanic were included. Demographics, Centers for Disease Control/Agency for Toxic Substances and Disease Registry Social Vulnerability Index, Childhood Opportunity Index, disease phenotype, time to diagnosis, treatment, and healthcare utilization were compared between the racial and ethnic groups. Ninety-seven patients were included. 18.6% of the cohort self- or parent-identified as NH-Black, 53.6% as NH-White, and 27.8% as Hispanic. Ulcerative colitis was found to be significantly more common in Hispanic patients. Hispanic patients were also significantly more likely to be hospitalized at time of diagnosis and have more emergency department visits within 2 years of diagnosis compared with non-Hispanic White patients. Race and ethnicity may affect the diagnosis and treatment of pediatric IBD, and these findings should serve as a foundation for establishing equitable care. Larger cohorts are needed to validate these findings.

An observational, multigenerational platform for health systems and population health interventions to minimise intergenerational transmission of non-communicable diseases in India: the YUVAAN cohort study protocol

IntroductionNon-communicable diseases (NCDs) pose a significant health burden in India, with preventable risk factors contributing to their prevalence. In rural populations, inequalities may be reinforced by health risks passed down...

The AFFIRM Framework for gender-affirming care: qualitative findings from the Transgender and Gender Diverse Health Equity Study

BackgroundTransgender, nonbinary, and gender diverse (TGD) people experience stigma in healthcare settings impacting healthcare utilization, including avoidance of care due to anticipated discrimination. Gender-affirming care refers to care for medical gender affirmation, such as gender-affirming hormones and surgery, as well as general care that affirms and respects TGD patients. This study sought to explore the experiences of TGD adults to inform gender-affirming care delivery and develop an actionable framework for practice.MethodsBetween May–October 2021, one-time individual in-depth interviews were conducted with 27 TGD adults receiving any healthcare in the greater Boston Massachusetts area to gather data about gender-affirming care. Interviews were semi-structured, explored prior and current experiences in healthcare and ideal gender-affirming care models, and conducted virtually via a secure Zoom platform. Analyses were conducted using immersion crystallization and reflexive thematic analysis; interview transcripts were double coded by two coders.ResultsParticipants had a mean age of 28.5, ranging 18–45 years, and were: 7 transgender men, 6 transgender women, 8 nonbinary, 3 genderqueer, 1 agender, and 2 gender not specified. Themes about gender-affirming care coalesced into the acronym AFFIRM: (1) Affirms in individual interactions: Participants called for affirmation of TGD identity, lived expertise, and competent TGD providers and staff. (2) Flexible and accessible: Participants expressed the need for gender-affirming care to be available beyond urban population-specific clinics, in a timely fashion without long wait lists, and in a community-centered manner such as offering non-traditional times and settings. (3) Fights systemic oppression: Participants emphasized the need for providers and health systems to eliminate gatekeeping practices for gender-affirming care and create care models that resist intersecting oppressive systems such as racism and cisgenderism. (4) Interacts with community: Patients desired intentional interaction with TGD community to holistically address health and unmet gender affirmation needs. (5) Retains patients in care: Patients shared the need to collaboratively identify and problem-solve obstacles to gender-affirming care with providers and healthcare systems to optimize TGD-specific retention strategies. (6) Multidisciplinary: Patients called for interdisciplinary teams with co-located services such as primary care and mental healthcare with letter-writing for surgical care, and incorporation of peer navigators to meet the broader social, health, and well-being needs of TGD people.ConclusionsFindings from this study and the AFFIRM Framework which emerged from TGD patient narratives can be applied to improve current care and set benchmarks for high-quality gender-affirming care delivery and practice.

PREVALENCE AND PATTERNS OF OPIOID USE IN CHRONIC PANCREATITIS.

Opioids are used to treat pain in chronic pancreatitis (CP), but little is known about current use patterns. The aims of this study were to characterize the utilization of opioids, and associations with clinical characteristics in adult patients with CP. This cross-sectional analysis utilized baseline data from participants with definite CP enrolled in a cohort study in the US (PROCEED). Data on demographics, pain medication use, health care utilization, disability, and pain patterns were systematically collected in case report forms while quality of life (QOL) was assessed with patient-reported outcome instruments. Opioid use was classified according to strength (weak or strong) and frequency (scheduled or as-needed). A total of 681 participants (n=364, 53% male) were included: 299 (44%) were current opioid users (22% only weak opioids and 22% at least one strong opioid). Increasing frequency and severity of pain was associated with increase of weak, strong, as-needed, or scheduled opioids. Neuromodulators were used by ∼40% of participants; increasing use was associated with increasing frequency and severity of pain. On multivariate analysis, independent predictors associated with strength and frequency of current opioid use were pain patterns (ORs 1.84-8.32 and ORs 1.92-8.52, respectively, p<0.001) and prior celiac plexus block (OR 3.54, 95% CI 1.82-6.87) and (OR 3.42, 95% CI 1.76-6.64), respectively. Participants using opioids had higher prevalence of disability, healthcare utilization and poorer QOL. Opioid use in CP is common and associated with increased pain severity and constancy. These data provide foundational estimates for future trials that can elucidate the complex interactions between patient factors, pain, and interventions.

Community perspectives regarding brain-computer interfaces: A cross-sectional study of community-dwelling adults in the UK.

Brain-computer interfaces (BCIs) represent a ground-breaking advancement in neuroscience, facilitating direct communication between the brain and external devices. This technology has the potential to significantly improve the lives of individuals with neurological disorders by providing innovative solutions for rehabilitation, communication and personal autonomy. However, despite the rapid progress in BCI technology and social media discussions around Neuralink, public perceptions and ethical considerations concerning BCIs-particularly within community settings in the UK-have not been thoroughly investigated. The primary aim of this study was to investigate public knowledge, attitudes and perceptions regarding BCIs including ethical considerations. The study also explored whether demographic factors were related to beliefs about BCIs increasing inequalities, support for strict regulations, and perceptions of appropriate fields for BCI design, testing and utilization in healthcare. This cross-sectional study was conducted between 1 December 2023 and 8 March 2024. The survey included 29 structured questions covering demographics, awareness of BCIs, ethical considerations and willingness to use BCIs for various applications. The survey was distributed via the Imperial College Qualtrics platform. Participants were recruited primarily through Prolific Academic's panel and personal networks. Data analysis involved summarizing responses using frequencies and percentages, with chi-squared tests to compare groups. All data were securely stored and pseudo-anonymized to ensure confidentiality. Of the 950 invited respondents, 846 participated and 806 completed the survey. The demographic profile was diverse, with most respondents aged 36-45 years (26%) balanced in gender (52% female), and predominantly identifying as White (86%). Most respondents (98%) had never used BCIs, and 65% were unaware of them prior to the survey. Preferences for BCI types varied by condition. Ethical concerns were prevalent, particularly regarding implantation risks (98%) and costs (92%). Significant associations were observed between demographic variables and perceptions of BCIs regarding inequalities, regulation and their application in healthcare. Conclusion: Despite strong interest in BCIs, particularly for medical applications, ethical concerns, safety and privacy issues remain significant highlighting the need for clear regulatory frameworks and ethical guidelines, as well as educational initiatives to improve public understanding and trust. Promoting public discourse and involving stakeholders including potential users, ethicists and technologists in the design process through co-design principles can help align technological development with public concerns whilst also helping developers to proactively address ethical dilemmas.

An Economic Evaluation of Direct Oral Penicillin Challenge for De-Labelling Low Risk Patients With a Penicillin Allergy Label.

Removing inaccurate penicillin allergy labels (PALs) can reduce unnecessary exposure to 'watch' and 'reserve' groups of antibiotics and thereby reduce antimicrobial resistance. The most efficient model for a non-allergy-specialist-led penicillin allergy de-labelling (PADL) service has not been established. To determine the costs to the UK National Health Service of a direct oral penicillin challenge (DPC) for low-risk patients with a PAL in three hospitals in England, each with a different non-allergy-specialist delivery model: pharmacist-led, nurse-led, and mixed multidisciplinary. Cost analysis of the DPC pathway, including resources related to staff time and antibiotics. The effect of de-labelling on healthcare utilisation over 5 years was modelled using data from the published literature. In total, 2257 patients from the Acute Medical or Infectious Disease Unit (AMU/IDU), Pre-surgical, and Haematology-Oncology departments were screened. Subsequently, 126 underwent DPC, and 122 were de-labelled. Twenty-two of these were de-labelled in time to affect their antibiotic regimen; 6 from AMU/IDU and 16 Pre-surgery. The DPC represented 22%-23% of the pathway cost in the pharmacist-led and mixed models, and 15% in the nurse-led model. Across departments and models, the cost per de-labelled patient varied between £577 (95% Credible Interval: 370, 633) for haematology-oncology patients to £2329 (947, 19,504) for AMU/IDU patients, both under the nurse-led model. After 5 years, recouping costs was unlikely for AMU/IDU patients under any model or for all patients combined under the mixed model. The penicillin allergy de-labelling pathway cost was ≥ 4-fold that of the DPC alone. Costs were up to 3 times higher in an acute compared to an elective setting. No short-term cost savings were identified from proactive or opportunistic penicillin allergy de-labelling in this study.

A population-based study on the burden of hospitalized pediatric pneumococcal disease in Taiwan before and after the introduction of 13-valent pneumococcal conjugate vaccine into the childhood immunization program in 2015

BackgroundTo estimate the burden of invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, and acute otitis media before and after inclusion of the 13-valent pneumococcal vaccine (PCV13) into Taiwan’s Childhood Immunization Program in 2015.MethodsEpisodes of eligible children aged < 18 years hospitalized with invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, or acute otitis media between 1 January 2011 and 31 December 2019 were identified from the National Health Insurance Research Database. Annual hospitalized incidence rate, case fatality rate, and healthcare resource utilization and costs were estimated. Incidence time trends were assessed with interrupted time series analyses.Results1,284 invasive pneumococcal disease episodes, 25,074 non-bacteremic pneumococcal pneumonia episodes, and 23,139 acute otitis media episodes were identified. The overall annual incidence rates of invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, and acute otitis media were 3.31, 64.61, and 59.62 episodes per 100,000 person-years, respectively. Interrupted time series analyses results showed a significantly lower baseline incidence rate (incidence rate ratio [IRR]:0.58, p-value = 0.001) for invasive pneumococcal disease, and significantly higher baseline incidence rate (IRR:1.17, p-value < 0.001) for non-bacteremic pneumococcal pneumonia in the post-PCV13 period. Baseline incidence rates between the two periods were comparable for acute otitis media. A significant increase in trend of incidence rate was observed for all three diseases. Case fatality rate was 1.79%, 0.09%, and 0.00% for invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia, and acute otitis media, respectively. Median length of hospitalization per inpatient visit was comparable between the two periods for invasive pneumococcal disease and non-bacteremic pneumococcal pneumonia, but significantly shorter in the post-PCV13 period for acute otitis media. In the post-PCV13 period, average total costs per episode was lower for invasive pneumococcal disease and non-bacteremic pneumococcal pneumonia, but higher for acute otitis media.ConclusionsResidual clinical and economic burden of pneumococcal diseases remained substantial after PCV13 inclusion into Taiwan’s Childhood Immunization Program. To further reduce the disease burden among children, additional research to investigate the cause of increasing trends of hospitalized invasive pneumococcal disease, non-bacteremic pneumococcal pneumonia and acute otitis media in the post-PCV13 era will be required.

Supporting primary care clinicians in caring for patients with alcohol use disorder: study protocol for Records for Alcohol Care Enhancement (RACE), a factorial four-arm randomized trial

BackgroundUnhealthy alcohol use, a spectrum of use inclusive of risky consumption and alcohol use disorder (AUD), is a leading cause of preventable death in the United States. Most people with unhealthy alcohol use do not receive evidence-based treatment. This four-arm factorial design randomized trial will assess whether population health management (PHM) and clinical care management (CCM) support for primary care providers (PCPs) are associated with improved AUD treatment engagement among their patients, beyond electronic health record (EHR) prompting and decision support alone.MethodsPCPs from an urban safety-net hospital-based primary care clinic are randomized to one of four groups (1) EHR best practice advisory (BPA) and clinical decision support tools for unhealthy alcohol use (BPA), (2) BPA plus population health manager support, (3) BPA plus clinical care manager support, and (4) all three. All PCPs will have access to the EHR BPA and decision support tools which provide chart-based advisories and order set navigation. PCPs assigned to receive PHM support will receive quarterly panel-level feedback on AUD treatment metrics for their patients. PCPs assigned to receive CCM support will receive CCM facilitation of AUD treatment processes including medication counseling, referrals, and support through direct patient interactions. The primary outcome will be the percent of patients engaged in AUD treatment among those with a new AUD diagnosis on a PCP’s panel. Secondary outcomes include the percent of patients with a new diagnosis of AUD who (1) initiated AUD treatment, (2) were prescribed AUD medications within 90 days, and (3) numerical counts of a range of AUD health services (outpatient encounters, specialty AUD care encounters, referrals, and acute healthcare utilization) in this sample. We will assess the primary outcome and the acute healthcare utilization secondary outcomes using Medicaid claims; the remaining secondary outcomes will be assessed using EHR data.DiscussionThe study will evaluate how a targeted EHR innovation alone, compared with population health and care management enhancements alone or in combination, impact engagement in AUD treatment, a national quality of care measure. Findings will advance understanding of supports needed to improve systems of care for AUD in general settings.Trial registrationClinicalTrials.gov identifier/registration number (NCT number): NCT05492942

Healthcare trajectories of aging individuals during their last year of life: application of process mining methods to administrative health databases

ContextWorld is aging and the prevalence of chronic diseases is raising with age, increasing financial strain on organizations but also affecting patients’ quality of life until death. Research on healthcare trajectories has gained importance, as it can help anticipate patients’ needs and optimize service organization. In an overburdened system, it is essential to develop automated methods based on comprehensive and reliable and already available data to model and predict healthcare trajectories and future utilization. Process mining, a family of process management and data science techniques used to derive insights from the data generated by a process, can be a solid candidate to provide a useful tool to support decision-making.ObjectiveWe aimed to (1) identify the healthcare baseline trajectories during the last year of life, (2) identify the differences in trajectories according to medical condition, and (3) identify adequate settings to provide a useful output.MethodsWe applied process mining techniques on a retrospective longitudinal cohort of 21,255 individuals who died between April 1, 2014, and March 31, 2018, and were at least 66 years or older at death. We used 6 different administrative health databases (emergency visit, hospitalisation, homecare, medical consultation, death register and administrative), to model individuals’ healthcare trajectories during their last year of life.ResultsThree main trajectories of healthcare utilization were highlighted: (i) mainly accommodating a long-term care center; (ii) services provided by local community centers in combination with a high proportion of medical consultations and acute care (emergency and hospital); and (iii) combination of consultations, emergency visits and hospitalization with no other management by local community centers or LTCs. Stratifying according to the cause of death highlighted that LTC accommodation was preponderant for individuals who died of physical and cognitive frailty. Conversely, services offered by local community centers were more prevalent among individuals who died of a terminal illness. This difference is potentially related to the access to and use of palliative care at the end-of-life, especially home palliative care implementation.ConclusionDespite some limitations related to data and visual limitations, process mining seems to be a method that is both relevant and simple to implement. It provides a visual representation of the processes recorded in various health system databases and allows for the visualization of the different trajectories of healthcare utilization.

A qualitative analysis of unintended effects of a digital conditional cash transfer intervention to encourage healthcare utilization in Southern Madagascar

IntroductionCash transfer interventions, including those using mobile money, are becoming increasingly widespread, particularly in Sub-Saharan Africa. As such interventions can have significant positive and negative unintended consequences, further analyses are needed to identify these consequences.MethodsWe investigated the unintended consequences of a digital conditional cash transfer intervention implemented at fifteen health facilities in Southern Madagascar. The intervention offered partial cost coverage for patients seeking care for potentially life-threatening conditions, accidents and injuries, maternal or pediatric care between February 2021 and June 2022. We conducted a qualitative analysis of in-depth interviews with policymakers, healthcare providers, (non-) beneficiaries of the intervention, and staff that implemented the intervention using reflexive thematic analysis.ResultsWe identified three key positive and three key negative unintended consequences of the intervention. The key positive unintended consequences were: i) improved quality of care, ii) improved interpersonal relationships, including between patients and providers and between healthcare providers, and iii) digital skills development of healthcare providers and increased trust in mobile money. The three key negative consequences we identified were i) facility overcrowding, ii) an increase in costs of care, and iii) cases of hospital imprisonment.ConclusionsDesigners and implementers of future (digital) cash transfer interventions should carefully consider and proactively seek to leverage the positive and mitigate the negative unintended consequences of cash transfer interventions for healthcare such as those highlighted in our work.

Reverse Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Nationwide Analysis

Introduction: Reverse shoulder arthroplasty (RSA) was originally developed for treating rotator cuff arthropathy but is now commonly used for rheumatoid arthritis (RA)-related shoulder degeneration. While previous studies have identified RA to be a risk factor for complications following total shoulder arthroplasty, its specific impact on RSA outcomes remains unclear. This study aims to evaluate the post-operative medical and implant-related complications, and healthcare utilization, among RA patients undergoing RSA. Methods: A retrospective analysis of patients undergoing RSA was conducted using a national administrative claims database from 2010 to 2023. Patients who underwent RSA with and without RA were identified using corresponding diagnoses and procedural codes. Patients with RA who underwent RSA had propensity score matched to a control on a 1:5 basis. The control group consisted of patients who did not have RA and underwent RSA for any other indication. Results: A total of 7232 of RSA patients with RA were matched to 36,054 control patients. The RA cohort had significantly higher rates of 90-day medical complications when compared to the control (p &lt; 0.001), with the highest rates in urinary tract infections (OR: 9.69), pulmonary embolisms (OR: 9.69), and the need for blood transfusions (OR:9.41). Patients with RA had significantly greater odds of developing all implant-related complications within 2 years compared to the control group (p &lt; 0.001). This cohort also had significantly higher fall rates (p &lt; 0.001) and mean lengths of stay (3.42 vs. 2.0 days, p &lt; 0.0001). Conclusions: RSA patients with prior diagnoses of RA face a higher risk of implant-related and medical complications, falls, and prolonged hospital stays compared to the control. These findings suggest that RA is an independent risk factor for reverse total shoulder arthroplasty. Therefore, these patients should be closely monitored post-operatively to reduce complications, cost of care, and length of stay. Level of Evidence: III, retrospective case–control study

Volume Matters: Examining The Management Of Necrotizing Pancreatitis In The United States.

To examine the impact of hospital volume on mortality and healthcare utilization in patients admitted with necrotizing pancreatitis (NP). Over 20% of patients with acute pancreatitis develop NP, which has been associated with higher rates of procedural intervention, morbidity, and mortality. Adult patients admitted with NP were identified in the 2016-2019 Nationwide Readmissions Database 2016-2019. Hospital volume cutoffs were defined by tertiles of total NP admissions per year (low-volume [<9 admissions/year]; medium-volume [9-25 admissions/year]; high-volume [≥26 admissions/year]). Subgroup analyses were performed for NP patients undergoing procedural intervention. The primary outcome was in-hospital mortality. Multivariable logistic regression models determined the association between clinical outcomes and hospital volume. A total of 25,483 patients were identified, 14.3% of whom underwent procedural intervention, with the highest rate of intervention occurring in high-volume hospitals. The most common interventions offered at low- and medium-volume hospitals were open necrosectomy and percutaneous drainage. In contrast, high-volume hospitals had increased rates of minimally invasive surgery and endoscopic management. High-volume centers had the highest mortality rate among all patients (7.3% vs. 6.6% vs. 5.5%, P<0.001) but the lowest among the intervention-only cohort (7.5% vs. 10.4% vs. 12.0%, P<0.001). After adjusting for confounders, high-volume centers had lower odds of mortality in all patients (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.65-0.93) and in the intervention-only cohort (OR 0.64, 95% CI 0.42-0.96). High-volume hospitals were also associated with a shorter hospital stay and lower healthcare costs. Management of NP at high-volume hospitals was associated with improved survival and decreased healthcare utilization. As interventional techniques advance, following evidence-based guidelines and implementing clear referral pathways will optimize outcomes for both patients and hospital systems.

Current Insights on Temporary Mechanical Circulatory Support in Adults with Post-Cardiotomy Cardiogenic Shock

Abstract Post-cardiotomy cardiogenic shock (PCCS) is a critical condition characterized by persistent low cardiac output syndrome (LCOS) that manifests either as an inability to wean from cardiopulmonary bypass (CPB) or as severe cardiac dysfunction in the immediate postoperative period despite optimal medical therapy. With an incidence of 2% to 20%, PCCS is associated with high morbidity, mortality, and healthcare resource utilization. This review explores the pathophysiology of PCCS while emphasizing mechanisms such as direct myocardial damage, ischemia-reperfusion injury, and systemic effects of extracorporeal circulation. It also discusses key diagnostic tools for PCCS including echocardiography, pulmonary artery catheters (PAC), vasoactive inotropic scores (VIS), and lactate clearance, which facilitate early recognition and management. Treatment pathways center on temporary mechanical circulatory support (tMCS), tailored to clinical scenarios such as the inability to wean from CPB or refractory LCOS. The pivotal role of the multidisciplinary Heart Team in decision-making, collaboration, and patient-centered care is highlighted. Finally, weaning protocols and considerations for long-term outcomes are discussed, underscoring the need for timely interventions and a personalized approach. Advances PCCS management continue to evolve, aiming to improve survival and long-term outcomes for this high-risk population.

Variation in Rates of Neonatal Opioid Withdrawal Syndrome and Opioid-related Hospitalizations in New York State, 2018

Background and Objective Rates of neonatal opioid withdrawal syndrome (NOWS) among infants and opioid-related hospitalizations among adults have increased in recent decades. We examined rates of NOWS births and opioid-related hospitalizations among adult females of childbearing age overall and by sociodemographic and geographic factors using hospitalization data. Methods We used data from the New York State Inpatient Database for 2018 from the Healthcare Cost and Utilization Project. We identified infants with NOWS and opioid-related hospitalizations using diagnosis codes and calculated rates of NOWS per 1,000 live births and opioid-related hospitalizations per 1,000 hospitalizations among females of childbearing age. We compared rates by geographic and sociodemographic factors and examined the correlation between county-level rates. Results The NOWS rate was 4.66 per 1,000 live births, while the rate of opioid-related hospitalizations was 36.6 per 1,000 hospitalizations. There was variation by county and sociodemographic factors including urban-rural classification, race and ethnicity, insurance payer, and median income. We found the highest rates for both NOWS and opioid-related hospitalizations in non-metropolitan areas, among patients with public insurance, and among non-Hispanic White or Native American populations. There was a significant linear correlation (r=0.28; p=0.03) between county-level rates; however, only 32% of counties were concordant in quartiles for both measures. Conclusion Our findings indicate variation in rates of NOWS and opioid-related hospitalizations by geographic and sociodemographic factors, with only moderate concordance in county-level rates. These findings may provide a nuanced interpretation by examining measures impacting both women and infants and have important implications in prioritizing treatment access.

A Multidimensional Regression Model for Predicting Recurrence in Chronic Low Back Pain.

Recurrence is common in chronic low back pain (CLBP). However, predicting the recurrence risk remains a challenge. The aim is to develop and validate a machine learning tool to predict the recurrence risk in patients with CLBP by using multidimensional medical information. This prospective cohort study consecutively enrolled 341 patients with CLBP from two hospitals between 1 January 2021 and 31 December 2021. Patients from both centres were used for model development and internal validation, employing multivariate logistic regression (MRL) along with three additional machine learning algorithms. The multidimensional model (MDM) was used to predict recurrence in the next 2 years and was compared with the widely used prognostic tool, the STarT BACK Tool (SBT). The models' performance in detecting recurrence was evaluated using several metrics, including the area under the receiver operating characteristic curve (AUC), decision curve analysis, accuracy, sensitivity and specificity. A total of 131 patients (38.42%) experienced recurrence. In the MRL model, factors linked to recurrence odds included progressive lower limb weakness, anxiety, mechanical pressure test, number of previous episodes, Oswestry disability index and multifidus proton density fat fraction. For recurrence prediction, the MRL-MDM achieved an AUC of 0.813 (95% CI, 0.765-0.862), sensitivity of 85.2% and specificity of 70.2% in internal validation. In comparison, the SBT for recurrence had an AUC of 0.555 (95% CI, 0.518-0.592), sensitivity of 93.3% and specificity of 17.6%. The MDM may predict recurrence in patients with CLBP over a 2-year period, surpassing the performance of SBT. This study found that the STarT BACK tool is suboptimal in predicting the 2-year recurrence of chronic low back pain (CLBP). Our proposed multidimensional machine learning model aids clinicians in identifying patients at high risk for future recurrence of CLBP and in implementing appropriate preventive measures. Given the considerable healthcare resource utilisation associated with the frequent recurrence of CLBP, our novel model provides significant assistance in addressing this issue, demonstrating substantial clinical relevance.