Inverse Probability-weighted Regression Models Research Articles

Impact assessment of sustainable agricultural practices on smallholder households food security: evidence from Burkina Faso

ABSTRACT This study investigates the factors affecting smallholder farmers’ decisions to adopt Sustainable Agricultural Practices (SAPs) and the impacts of single and multiple SAPs adoption on household food security in the Hauts-Bassins region of Burkina Faso. Data were collected through an individual face-to-face survey with 384 farmers. The study used both the multinomial endogenous switching regression and the average treatment effect model complemented with the multivalued inverse probability weighted regression model for the analyses. Results showed that age, education, cooperative membership, farm size, and access to climate and technology information are some socio-economic determinants of farmers’ decisions to adopt SAPs. Several factors can affect the adoption of SAPs and the impact of adopted SAPs on household welfare. Therefore, adopting single or joint SAPs can’t lead to a positive impact on crop yield, income, and further food security, unless implemented in suitable conditions. Also, the adoption of SAPs may enable food diversification and availability but not cover all aspects of food security. Thus, future studies can deeply explore the impact of SAPs on the different dimensions of food security. Our findings advocate for policies that target reducing constraints faced by farmers in successfully implementing SAPs.

Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

The benefit of primary care physician (PCP) follow-up as a potential means to reduce readmissions in hospitalized patients has been found in other medical conditions and among patients receiving high-risk surgery. However, little is known about the implications of PCP follow-up for patients with an emergency general surgery (EGS) condition. To evaluate the association between PCP follow-up and 30-day readmission rates after hospital discharge for an EGS condition. This cohort study used data from the Centers for Medicare & Medicaid Services Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for beneficiaries aged 66 years or older who were hospitalized with an EGS condition that was managed operatively or nonoperatively between September 1, 2016, and November 30, 2018. Eligible patients were enrolled in Medicare fee-for-service, admitted through the emergency department with a primary diagnosis of an EGS condition, and received a general surgery consultation during the admission. Data were analyzed between July 11, 2022, and June 5, 2023. Follow-up with a PCP within 30 days after hospital discharge for the index admission. The primary outcome was readmission within 30 days after discharge for the index admission. An inverse probability weighted regression model was used to estimate the risk-adjusted association of PCP follow-up with 30-day readmission. The secondary outcome was readmission within 30 days after discharge stratified by treatment type (operative vs nonoperative treatment) during their index admission. The study included 345 360 Medicare beneficiaries (mean [SD] age, 74.4 [12.0] years; 187 804 females [54.4%]) hospitalized with an EGS condition. Of these, 156 820 patients (45.4%) had a follow-up PCP visit, 108 544 (31.4%) received operative treatment during their index admission, and 236 816 (68.6%) received nonoperative treatment. Overall, 58 253 of 332 874 patients (17.5%) were readmitted within 30 days after discharge for the index admission. After risk adjustment and propensity weighting, patients who had PCP follow-up had 67% lower odds of readmission (adjusted odds ratio [AOR], 0.33; 95% CI, 0.31-0.36) compared with patients without PCP follow-up. After stratifying by treatment type, patients who were treated operatively during their index admission and had subsequent PCP follow-up within 30 days after discharge had 79% reduced odds of readmission (AOR, 0.21; 95% CI, 0.18-0.25); a similar association was seen among patients who were treated nonoperatively (AOR, 0.36; 95% CI, 0.34-0.39). Infectious conditions, heart failure, acute kidney failure, and chronic kidney disease were among the most frequent diagnoses prompting readmission overall and among operative and nonoperative treatment groups. In this cohort study, follow-up with a PCP within 30 days after discharge for an EGS condition was associated with a significant reduction in the adjusted odds of 30-day readmission. This association was similar for patients who received operative care or nonoperative care during their index admission. In patients aged 66 years or older with an EGS condition, primary care coordination after discharge may be an important tool to reduce readmissions.

EXPLORING QUALITY AND COVID MEASURES OF NEW YORK STATE LONG-TERM CARE FACILITIES INVOLVED IN THE SAFE STAFFING LAWSUIT

Abstract In April 2021, New York's "Safe Staffing" law capped Long-Term Care Facility (LTCF) profits. LTCFs with "excess profits" are now challenging the law in court. This study examined how LTCFs involved in the lawsuit differed from other NY state LTCFs before and during the COVID-19 pandemic. LTCF “Safe Staffing” lawsuit data were obtained from Long Term Care Community Coalition, then linked with Centers for Medicare and Medicaid Services COVID-19 and Small Business Association Paycheck Protection Program (PPP) data. First, we tested for differences across quality measures. We found that, compared to LTCFs not involved in the lawsuit, LTCFs in the lawsuit were more likely to be located outside of a hospital, report more certified beds and higher occupancy rates, and have higher overall quality scores. LTCFs in the lawsuit also reported lower staff ratings and staffing hours, which have previously been identified as a determinant of higher mortality in LTCFs. To create valid comparisons given these systematic differences, we specified “Doubly Robust” Augmented Inverse Probability Weighted regression models and tested if lawsuit involvement was associated with COVID-19 outcomes. Despite finding higher rates of admitting patients infected with COVID-19 in “excess profit” LTCFs, we did not find that COVID-19 deaths differed by lawsuit involvement. Finally, lawsuit involvement was associated with a higher probability of receiving a PPP loan. Before and during the pandemic, LTCFs with "excess profits" appeared fundamentally different than other NY LTCFs. How these differences impact the health of older adults receiving long-term care beyond the pandemic remains unknown.

Clinical and economic outcomes associated with upfront comprehensive genomic profiling in newly diagnosed advanced lung cancer in the United States from 2018-2020: Evidence from the SEQUENCE study.

9126 Background: As the number of approved molecularly-targeted therapies for the treatment of lung cancer increases, the debate continues as to whether a clinical strategy leveraging next-generation sequencing (NGS) comprehensive genomic profiling (CGP) to match patients to targeted treatments is advantageous versus a narrow/single-gene (N/S) panel testing. We examined clinical and economic outcomes of patients with advanced lung cancer (aLC) in the United States (US). Methods: In this retrospective study, newly diagnosed aLC patients aged 65-89 years were identified from a US Medicare Advantage plan from 2018-2020. Patients receiving genomic testing within 90 days of diagnosis and an FDA-approved pharmacotherapy cancer treatment after diagnosis were categorized by initial sequencing with NGS CGP (51+ genes) vs N/S (≤50 genes) panel testing using administrative claims based on previously validated algorithms. We assessed the proportion of patients with an inpatient or emergency department (INP/ED) visit for select outcomes (e.g., neutropenia) within 6 months of start of treatment, all-cause mortality, and PPPM (per patient per month) total healthcare costs through all available follow-up. Genomic testing costs within 90 days of cancer diagnosis were estimated using the Medicare fee schedule. Among patients with treatment within 30 days of testing, we assessed the proportion who did not switch treatment and were alive within 6 months. Descriptive analyses were conducted, and average effects were estimated using inverse probability weighted regression models. Results: We identified 3,532 patients who received genomic testing and pharmacotherapy cancer treatment (NGS CGP, n = 968; N/S, n = 2,564). Characteristics were similar between testing groups. The proportion of patients with INP/ED for outcomes of interest was similar following NGS CGP vs. N/S panels (15.0% vs. 17.8%; IRR [95% CI]: 0.76 [0.57 – 1.02]; p = 0.066), as were mortality (56.2% vs. 59.2%; HR: 1.05 [0.95 - 1.16]; p = 0.323) and PPPM costs (PPPM median cost difference -$575; ratio from regression 0.99, 0.94-1.04; p = 0.228). Among a subgroup of patients treated within 30 days of testing, a higher proportion receiving NGS CGP did not switch treatment and were alive after 6 months (47.6%) vs those receiving N/S panels (39.8%) (OR [95% CI]: 1.33 [1.12 - 1.59]; p = 0.001). Median genomic testing costs were $3,049 for NGS CGP vs. $218 for N/S testing. Conclusions: Outcomes were similar between patients receiving NGS CGP and N/S panel testing. Among patients with treatment within 30 days of testing, upfront NGS CGP was associated with fewer patients switching treatment and 6-month survival. Upfront testing with NGS CGP may represent a beneficial genomic profiling strategy as part of the initial management of patients with aLC.

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study

Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs. This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment). In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm. Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001). Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.

Automated estimation of echocardiogram image quality in hospitalized patients.

We developed a machine learning model for efficient analysis of echocardiographic image quality in hospitalized patients.This study applied a machine learning model for automated transthoracic echo (TTE) image quality scoring in three inpatient groups. Our objectives were: (1) Assess the feasibility of a machine learning model for echo image quality analysis, (2) Establish the comprehensiveness of real-world TTE reporting by clinical group, and (3) Determine the relationship between machine learning image quality and comprehensiveness of TTE reporting. A machine learning model was developed and applied to TTEs from three matched cohorts for image quality of nine standard views. Case TTEs were comprehensive studies in mechanically ventilated patients between 01/01/2010 and 12/31/2015. For each case TTE, there were two matched spontaneously breathing controls (Control 1: Inpatients scanned in the lab and Control 2: Portable studies). We report the overall mean maximum and view specific quality scores for each TTE. The comprehensiveness of an echo report was calculated as the documented proportion of 12 standard parameters. An inverse probability weighted regression model was fit to determine the relationship between machine learning quality score and the completeness of a TTE report. 175 mechanically ventilated TTEs were included with 350 non-intubated samples (175 Control 1: Lab and 175 Control 2: Portable). In total, the machine learning model analyzed 14,086 echo video clips for quality. The overall accuracy of the model with regard to the expert ground truth for the view classification was 87.0%. The overall mean maximum quality score was lower for mechanically ventilated TTEs (0.55 [95% CI 0.54, 0.56]) versus 0.61 (95% CI 0.59, 0.62) for Control 1: Lab and 0.64 (95% CI 0.63, 0.66) for Control 2: Portable; p = 0.002. Furthermore, mechanically ventilated TTE reports were the least comprehensive, with fewer reported parameters. The regression model demonstrated the correlation of echo image quality and completeness of TTE reporting regardless of the clinical group. Mechanically ventilated TTEs were of inferior quality and clinical utility compared to spontaneously breathing controls and machine learning derived image quality correlates with completeness of TTE reporting regardless of the clinical group.

Shortened IV Antibiotic Course for Uncomplicated, Late-Onset Group B Streptococcal Bacteremia.

We performed a multicenter retrospective cohort study of infants aged 7 days to 4 months who were admitted to children's hospitals in the Pediatric Health Information System database from 2000 to 2015 with GBS bacteremia. The exposure was shortened IV antibiotic therapy, defined as discharge from the index GBS visit after a length of stay of ≤8 days without a peripherally inserted central catheter charge. The primary outcome was readmission for GBS bacteremia, meningitis, or osteomyelitis in the first year of life. Outcomes were analyzed by using propensity-adjusted, inverse probability-weighted regression models. Of 775 infants who were diagnosed with uncomplicated, late-onset GBS bacteremia, 612 (79%) received a prolonged IV course of antibiotic therapy, and 163 (21%) received a shortened course. Rates of treatment with shortened IV courses varied by hospital (range: 0%-67%; SD: 20%). Three patients (1.8%) in the shortened IV duration group experienced GBS recurrence, compared with 14 patients (2.3%) in the prolonged IV duration group (adjusted absolute risk difference: -0.2%; 95% confidence interval: -3.0% to 2.5%). Shortened IV antibiotic courses are prescribed among infants with uncomplicated, late-onset GBS bacteremia, with low rates of disease recurrence and treatment failure.

Analyzing medical costs with time-dependent treatment: The nested g-formula.

As medical expenses continue to rise, methods to properly analyze cost outcomes are becoming of increasing relevance when seeking to compare average costs across treatments. Inverse probability weighted regression models have been developed to address the challenge of cost censoring in order to identify intent-to-treat effects (i.e., to compare mean costs between groups on the basis of their initial treatment assignment, irrespective of any subsequent changes to their treatment status). In this paper, we describe a nested g-computation procedure that can be used to compare mean costs between two or more time-varying treatment regimes. We highlight the relative advantages and limitations of this approach when compared with existing regression-based models. We illustrate the utility of this approach as a means to inform public policy by applying it to a simulated data example motivated by costs associated with cancer treatments. Simulations confirm that inference regarding intent-to-treat effects versus the joint causal effects estimated by the nested g-formula can lead to markedly different conclusions regarding differential costs. Therefore, it is essential to prespecify the desired target of inference when choosing between these two frameworks. The nested g-formula should be considered as a useful, complementary tool to existing methods when analyzing cost outcomes.

Prevalent digoxin use and subsequent risk of death or hospitalization in ambulatory heart failure patients with a reduced ejection fraction—Findings from the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) randomized controlled trial

BackgroundDespite more than 200 years of clinical experience and a pivotal trial, recently published research has called into question the safety and efficacy of digoxin therapy in heart failure (HF). MethodsHF-ACTION (ClinicalTrials.gov Number: NCT00047437) enrolled 2331 outpatients with HF and an EF ≤35% between April 2003 and February 2007 and randomized them to aerobic exercise training versus usual care. Patients were grouped according to prevalent digoxin status at baseline. The association between digoxin therapy and outcomes was assessed using Cox proportional hazard and inverse-probability weighted (IPW) regression models adjusted for demographics, medical history, medications, laboratory values, quality of life, and exercise parameters. ResultsThe prevalence of digoxin therapy decreased from 52% during the first 6 months of enrollment to 35% at the end of the HF-ACTION trial (P <0.0001). Study participants were 59± 13 years of age, 72% were male, and approximately half had an ischemic etiology of HF. Patients receiving digoxin at baseline tended to be younger and were more likely to report New York Heart Association functional class III/IV symptoms (rather than class II) compared to those not receiving digoxin. Patients taking digoxin had worse baseline exercise capacity as measured by peak VO2 and 6-min walk test and greater impairments in health status as reflected by the Kansas City Cardiomyopathy Questionnaire. The association between digoxin and the risk of death or hospitalization differed depending on whether Cox proportional hazard (Hazard Ratio 1.03, 95% Confidence Interval 0.92–1.16; P = .62) or IPW regression models (HR 1.08, 95% CI 1.00–1.17; P = .057) were used to adjust for potential confounders. ConclusionAlthough digoxin use was associated with high-risk clinical features, the association between digoxin therapy and outcomes was dependent on the statistical methods used for multivariable adjustment. Clinical equipoise exists and additional prospective research is required to clarify the role of digoxin in contemporary clinical practice including its effects on functional capacity, quality of life, and long-term outcomes.

Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction.

We aimed to determine the frequency of aortic valve surgery (AVR) with or without coronary artery bypass grafting (CABG), among patients with moderate/severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD), and its relationship with survival. The Duke Echocardiographic Database (N = 132 804) was queried for patients with mean gradient ≥25 mmHg and/or peak velocity ≥3 m/s and LVSD (left ventricular ejection fraction ≤50%) from 1 January 1995-28 February 2014. For analyses purposes, AS was defined both by mean gradient and calculated aortic valve area (AVA) criteria. Time-dependent indicators of AVR in multivariable Cox models were used to assess the relationship of AVR and all-cause mortality. A total of 1634 patients had moderate (N = 1090, 67%) or severe (N = 544, 33%) AS by mean gradient criteria. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. There were 863 (53%) deaths observed up to 5 years following index echo. After multivariable adjustment in an inverse probability weighted regression model, AVR was associated with higher 5-year survival amongst patients with moderate AS and severe AS whether classified by AVA or mean gradient criteria. Over all, AVR ± CABG compared with medical therapy was associated with significantly lower mortality [hazard ratio, HR = 0.49 (0.38, 0.62), P < 0.0001]. Compared with CABG alone, CABG + AVR was associated with better survival [HR = 0.18 (0.12, 0.27), P < 0.0001]. In patients with moderate/severe AS and LVSD, mortality is substantial and amongst those selected for surgery, AVR with or without CABG is associated with higher survival. Research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.