Propensity Score-weighted Regression Models Research Articles

Association Between Postoperative Methocarbamol and Postoperative Pain Opioid Dose Requirements: A Retrospective Cohort Study.

We tested the hypothesis that patients who received methocarbamol postoperatively experience less severe pain and require smaller doses of opioids than those who did not receive methocarbamol. This is a retrospective cohort study of patients undergoing surgery involving the musculoskeletal system. Of 9089 patients, 704 received methocarbamol during 48 hours postoperatively, while 8385 did not receive methocarbamol. The patients who received methocarbamol postoperatively and the patients who did not receive methocarbamol were compared on the time-weighted average (TWA) pain score and opioid dose requirements in morphine milligram equivalents (MME) during the first 48 hours postoperatively, using propensity score-weighted regression models to adjusting for preoperative and intraoperative covariates. Postoperative 48-hour TWA pain scores were 5.5±1.7 (mean±SD), and 4.3±2.1 for methocarbamol and non-methocarbamol patients. Postoperative 48-hour opioid dose requirements in MME were 276 [170-347] (median [interquartile range (IQR)]) mg, and 190 [60-248] mg for methocarbamol and non-methocarbamol patients. In propensity score-weighted regression models, receiving methocarbamol postoperatively was associated with 0.97-point higher postoperative TWA pain score (95% CI, 0.83-1.11; P <0.001), and 93.6-MME higher postoperative opioid dose requirements (95% CI, 79.9 to 107.4; P <0.001), compared with not receiving methocarbamol postoperatively. Postoperative methocarbamol was associated with significantly higher acute postoperative pain burden and opioid dose requirements. Although the results of the study are influenced by residual confounding, they suggest a limited-if any-benefit of methocarbamol as an adjunct of postoperative pain management.

Bus rapid transit impacts on land uses and development over time in Bogotá and Quito

Despite the worldwide popularity of bus rapid transit (BRT), empirical evidence of its effects on land uses and development remains limited. This paper examines BRT’s impacts on land use and development in Bogotá and Quito, by using a parcel-level difference-in-differences research design. We estimate a propensity score-weighted regression model of parcel development characteristics in treatment and control areas. In Bogotá, although parcels in close proximity to the BRT are subject to fewer changes in terms of development intensity (changes in built-up area) in relation to parcels in the control area, they are more likely to change uses, shifting toward commercial activities. In Quito, the results are mixed; parcels in one BRT corridor are more likely to be subject to redevelopment, but the parcels in a more recent BRT corridor are less likely to be subject to development activity in relation to parcels in the control corridor. Taken together, our results suggest that changes in land use are important but frequently overlooked impacts produced by BRT implementation. Attempts to capture value from mass transit investments should also consider the ancillary planning decisions required to allow changes in land use.

The effect of rapid exome sequencing on downstream health care utilization for infants with suspected genetic disorders in an intensive care unit

PurposeThis study aimed to compare downstream utilization of medical services among critically ill infants admitted to intensive care units who received rapid exome sequencing (ES) and those who followed alternative diagnostic testing pathways. MethodsUsing propensity score–weighted regression models including sex, age at admission, and severity indicators, we compared a group of 47 infants who underwent rapid ES with a group of 211 infants who did not receive rapid ES. Utilization and cost indicators were compared between cohorts using negative binomial models for utilization and two-part models for costs. ResultsAfter controlling for patients’ sociodemographic and clinical characteristics, we found no statistically significant difference in outpatient visits, hospitalizations, intensive care unit or total length of stay, or length of stay–associated costs between the cohorts at 12- or 26-month follow-up. Similarly, there was no evidence of higher utilization or costs by the ES group when infants who died were removed from the analysis. ConclusionWhen examining utilization during and beyond the diagnostic trajectory, there is no evidence that ES changes frequency of outpatient visits or use of in-hospital resources in critically ill infants with suspected genetic disorders.

Van Velthoven single-knot running suture versus Chlosta's running suture versus single barbed suture V-Loc for vesicourethral anastomosis in laparoscopic radical prostatectomy: a retrospective comparative study.

IntroductionThe quality of vesicourethral anastomosis (VUA) in laparoscopic radical prostatectomy (LRP) is associated with complications that could significantly affect quality of life.AimTo compare different types of sutures (Chlosta’s versus Van Velthoven versus V-Loc), used for VUA in LRP in terms of complication rates and continence recovery.Material and methodsPatients who underwent LRP between 2014 and 2018 in a tertiary center were enrolled in the study. Data were extracted from medical records. Urinary continence was assessed at 3, 6, 12 and 18 months after LRP. Propensity score weighted regression models were used to estimate the effect of sutures on outcomes.ResultsA sample of 504 patients was analyzed, of which 109 patients underwent Chlosta’s suture VUA, 117 patients had Van Velthoven suture VUA, and 278 patients had V-Loc VUA. Median time of anastomosis was 13 (IQR – interquartile range: 10–16) min using Chlosta’s suture, 28 (IQR: 24–30) using Van-Velthoven suture and 12 (IQR: 11–16) min using V-Loc suture (p < 0.001). There were no significant differences between groups concerning complications and urinary continence at 12 and 18 months after surgery. The time of urinary continence recovery was on average 19 days (95% CI: 5–33) and 31 days (95% CI: 16–45) shorter during 1 year of observation when the V-Loc suture was used compared to the Van-Velthoven and Chlosta’s suture, respectively.ConclusionsThe study showed comparable results considering urinary continence recovery at 12 and 18 months after LRP in all VUA groups. Van Velthoven VUA was more time-consuming and continence recovery was faster in the V-Loc group.

The impact of Uber and Lyft on vehicle ownership, fuel economy, and transit across U.S. cities.

SummaryWe estimate the effects of transportation network companies (TNCs) Uber and Lyft on vehicle ownership, fleet average fuel economy, and transit use in U.S. urban areas using a set of difference-in-difference propensity score-weighted regression models that exploit staggered market entry across the U.S. from 2011 to 2017. We find evidence that TNC entry into urban areas causes an average 0.7% increase in vehicle registrations with significant heterogeneity in these effects across urban areas: TNC entry produces larger vehicle ownership increases in urban areas with higher initial ownership (car-dependent cities) and in urban areas with lower population growth (where TNC-induced vehicle adoption outpaces population growth). We also find no statistically significant average effect of TNC entry on fuel economy or transit use but find evidence of heterogeneity in these effects across urban areas, including larger transit ridership reductions after TNC entry in areas with higher income and more childless households.

Ischemic Stroke Occurs Less Frequently in Patients With COVID-19: A Multicenter Cross-Sectional Study.

The impact of coronavirus disease 2019 (COVID-19) on the occurrence of ischemic stroke has been the subject of increased speculation but has not been confirmed in large observational studies. We investigated the association between COVID-19 and stroke. We performed a cross-sectional study involving patients discharged from a healthcare system in New York State, from January to April 2020. A mixed-effects logistic regression analysis and a propensity score-weighted analysis were used to control for confounders and investigate the association of COVID-19 with ischemic stroke. Similar techniques were used to detect the impact of concurrent COVID-19 infection on unfavorable outcomes for patients with stroke. Among 24 808 discharges, 2513 (10.1%) were diagnosed with COVID-19, and 566 (0.2%) presented with acute ischemic stroke. Patients diagnosed with COVID-19 were at one-quarter the odds of stroke compared with other patients (odds ratio, 0.25 [95% CI, 0.16-0.40]). This association was consistent in all age groups. Our results were robust in sensitivity analyses, including propensity score-weighted regression models. In patients presenting with stroke, concurrent infection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) was associated with higher case-fatality (odds ratio, 10.50 [95% CI, 3.54-31.18]) and a trend towards increased occurrence of discharge to rehabilitation (odds ratio, 2.45 [95% CI, 0.81-1.25]). Using a comprehensive cross-section of patients from a large NY-based healthcare system, we did not identify a positive association between ischemic stroke and COVID-19. However, patients with stroke with COVID-19 had worse outcomes compared with those without, with over a 9-fold increase in mortality. Although no definitive conclusions can be reached from our observational study, our data do not support the concerns for an epidemic of stroke in young adults with COVID-19.

Association of atopic dermatitis severity with cognitive function in adults

Atopic dermatitis (AD) is associated with itch, pain, and sleep disturbance, all of which may contribute toward cognitive dysfunction. To determine the relationship of AD severity and cognitive function in adults. We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n=386). Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function 8-item Short-Form. At baseline, 118 patients (58.1%) reported ≥1 symptoms of cognitive dysfunction in the past 4weeks, with 29 (14.3%) having mild, 11 (5.4%) moderate, and 4 (2.0%) severe PROMIS Cognitive Function T-scores. In propensity score-weighted regression models, PROMIS Cognitive Function T-scores were inversely associated with patient-reported global AD severity, Patient Oriented Eczema Measure (POEM), Numeric Rating Scale worst itch and skin pain, SCORing Atopic Dermatitis (SCORAD)-sleep, POEM-sleep, Eczema Area and Severity Index, and SCORAD, with stepwise decreases of cognitive function with worsening AD severity. At all AD severity levels, cognitive dysfunction was associated with increased Dermatology Life Quality Index and ItchyQoL scores. Changes from baseline in PROMIS Cognitive Function T-scores were weakly to moderately inversely correlated with changes from baseline in multiple AD outcomes. Single-center study without non-AD controls. Cognitive dysfunction is associated with AD severity. Cognitive function may be an important end point for monitoring treatment response in AD.

Effects of on-demand ridesourcing on vehicle ownership, fuel consumption, vehicle miles traveled, and emissions per capita in U.S. States

We estimate the effect of on-demand ride-hailing service market entry by Transportation Network Companies (TNCs) Uber and Lyft on per-capita vehicle ownership, energy use, travel distances, and emissions in U.S. states from 2005 to 2015 using a difference-in-difference propensity score-weighted regression model. We find evidence that TNC entry appears to cause a decline in state per-capita vehicle registrations by 3%, on average (95% confidence interval: 0.7–5.5%). Our results regarding travel distances, gasoline consumption, and several air pollutants are not conclusive, but we find evidence of a negative relationship with some EPA-estimated vehicle air emissions, representing a decline of $300 million to $900 million in externalities during the analysis period. However, these air emissions data are modeled, rather than directly measured, so we are cautious about causal interpretations, and uncertainty in the effects of TNC entry on travel distances and gasoline consumption suggests potential additional externality effects that could dominate the air emissions effect.

Relationship between early-life nutrition and ages at menarche and first pregnancy, and childbirth rates of young adults: Evidence from APCAPS in India.

India's Integrated Child Development Services (ICDS) provides daily supplementary nutrition and other public health services to women and children. We estimated associations between exposure to early‐childhood ICDS nutrition and adult reproductive outcomes. During 1987–1990, a balanced protein–calorie supplement called “upma”—made from locally available corn–soya ingredients—was rolled out by subdistricts near Hyderabad and offered to pregnant women and children under age 6 years. In a controlled trial, 15 villages received the supplement and 14 did not. We used data from a 2010–2012 resurvey of adults born during the trial (n = 715 in intervention and n = 645 in control arms). We used propensity score matching methods to estimate the associations between birth in an intervention village and menarcheal age, age at first pregnancy, and fertility of adults. We found that women born in the intervention group during the trial, as compared with the control group, had menarche 0.45 (95% confidence interval [CI: 0.22, 0.68]; p < .001) years later and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later. Married women from the intervention group had menarche 0.36 (95% CI [0.09, 0.64]; p < .01) years later, first cohabitation with partner 0.8 (95% CI [0.27, 1.33]; p < .01) years later, and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later than married women in the control group. There was no significant difference between intervention and control group women regarding whether they had at least one childbirth or the total number of children born. The findings were similar when we employed inverse propensity score weighted regression models.

Health Care Utilization and Costs of Veterans Evaluated for Traumatic Brain Injury Through Telehealth.

Background:Mild traumatic brain injury (TBI) is prevalent among Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) Veterans. With clinical video telehealth (CVT), Veterans screening positive for potential deployment-related TBI can receive comprehensive TBI evaluations by providers at specialized centers through interactive video communication.Introduction:We examined health care utilization and costs for Veterans during the 12 months before and after being evaluated through CVT versus in-person.Materials and Methods:We examined OEF/OIF Veterans receiving comprehensive evaluations at specialized Veterans Affairs facilities from October 2012 to September 2014. Veterans evaluated through CVT and in-person at the same facilities were included. We used a difference-in-difference analysis with propensity score weighted regression models to examine health care utilization and costs between TBI evaluation groups.Results:There were 554 Veterans with comprehensive evaluations through CVT (380 with and 174 without confirmed TBI) and 7,159 with in-person evaluations (4,899 with and 2,260 without confirmed TBI). Veterans in the in-person group with confirmed TBI had similar increases in outpatient, inpatient, and total health care costs as Veterans who had TBI confirmed through CVT. However, Veterans with a confirmed TBI evaluated in-person had greater increases in rehabilitation and other specialty costs.Discussion:When visits are in-person, Veterans may have opportunities to discuss more issues and concerns, whether TBI-related or not. Thus, providers might make more referrals to rehabilitation and specialty care after in-person visits.Conclusion:Veterans receiving in-person evaluations who were diagnosed with TBI had similar increases in health care costs as Veterans with TBI confirmed through evaluations through CVT.

Impact of Health Plan Deductibles and Health Insurance Marketplace Enrollment on Health Care Experiences.

High-deductible health plans (HDHPs) have become increasingly prevalent among employer-sponsored health plans and plans offered through the Health Insurance Marketplace in the United States. This study examined the impact of deductible levels on health care experiences in terms of care access, affordability, routine checkup, out-of-pocket cost, and satisfaction using data from the Health Reform Monitoring Survey. The study also tested whether the experiences of Marketplace enrollees differed from off-Marketplace individuals, controlling for deductible levels. Results from multivariable and propensity score weighted regression models showed that many of the outcomes were adversely affected by deductible levels and Marketplace enrollment. These results highlight the importance of efforts to help individuals choose the plan that fits both their medical needs and their budgets. The study also calls for more attention to improving provider acceptance of HDHPs and Marketplace plans as these plans become increasingly common over time.

Trends and surgical outcomes of laparoscopic versus open pyloromyotomy.

Hypertrophic pyloric stenosis (HPS) is one of the most common pediatric illnesses necessitating surgical intervention. Controversy remains over the optimal surgical approach between laparoscopic pyloromyotomy (LP) and open pyloromyotomy (OP). LP has gained acceptance for management of HPS in an era of expanding minimal access surgical approaches to pediatric conditions. Several studies suggest advantages of LP over OP; however, selection bias and small sample sizes remain a concern. This study compares the outcomes of LP versus OP using propensity score methods. The 2013-2015 ACS NSQIP Pediatric PUF was queried for all infants undergoing pyloromyotomy. The trend in the proportion of infants undergoing LP was described and perioperative outcomes between the OP and LP cohorts were compared using propensity score weighted regression models. 4847 infants were identified to have undergone surgical pyloromyotomy. The proportion of LP performed increased significantly from 59% in 2013 to 65.5% in 2015 (p < 0.001). LP was associated with lower overall complications (1.4% vs 2.9%) (ORadj0.52, 95% CI 0.34-0.80), surgical site-related complications (1.1% vs 2.1%) (ORadj0.52, 95% CI 0.32-0.84), and post-operative length of stay (1.5days vs 1.9days) (ORadj0.89, 95% CI 0.81-0.98) without significant differences in related re-operation (0.9% vs 0.9%) (ORadj1.01, 95% CI 0.52-1.93) or readmissions (1.4% vs 2.1%) (ORadj0.73, 95% CI 0.46-1.17). Our study demonstrates that LP is increasingly utilized for management of hypertrophic pyloric stenosis and is associated with shorter length of stay, and lower odds of surgical site-specific and overall complications without differences in related re-operations. This study supports LP as a safe and effective method for management of HPS.

Multiple child care arrangements and school readiness in kindergarten

Nationally, nearly one in five children younger than age 5 experiences multiple, concurrent child care arrangements. Yet, it remains unclear whether the use of multiple arrangements contributes to school readiness at kindergarten-entry, or whether these associations vary by the timing of multiple arrangements and the type(s) of care used. Using nationally-representative data (N=6450), this study estimated associations between experiencing multiple arrangements at ages 9 months, 2 years, and 4 years and children’s school readiness in the fall of kindergarten. It also examined whether these associations depend on the type(s) of care combined. Results from OLS and propensity score weighted regression models suggest that multiple arrangements are associated with positive, neutral, or negative school readiness outcomes depending on both the timing and the type(s) of care used.

Corticosteroid Dosing in Pediatric Acute Severe Ulcerative Colitis: A Propensity Score Analysis.

We aimed to explore the optimal dosing of intravenous-corticosteroids (IVCS) using a robust statistical method on the largest pediatric cohort of acute severe colitis to date. Two hundred eighty-three children treated with IVCS for ulcerative colitis were included and studied for 1 year (46% boys, age 12.1 ± 3.9 years, disease duration 2 (interquartile range [IQR] 0-14) months, baseline Pediatric Ulcerative Colitis Activity Index 69 ± 13 points). Confounding by indication was addressed by matching high- and low-IVCS dose patients according to the propensity score method, using 3 cutoffs (1 mg · kg · methylprednisolone to 40 mg · day, 1.25 mg · kg to 50 mg · day and 2 mg · kg to 80 mg · day). The median IVCS dose in the entire cohort was 1.0 mg · kg · day (IQR 0.8-1.4) and 44 mg · kg · day (32-60). Ninety-four of 283 children were matched in the low-dose cutoff (1 mg · kg · day), 218 of 283 were matched in the middle cutoff (1.25 mg · kg · day), and 86/283 in the high dose cutoff (2 mg · kg · day). No differences were found in 25 pretreatment baseline variables in the three cutoffs, implying successful matching. There were no statistical differences in the outcomes of the two lower cutoffs (including need for salvage therapy during admission and by 1 years, admission duration, and day-5 Pediatric Ulcerative Colitis Activity Index<35 points; all P > 0.05). In the high cutoff, the higher doses were somewhat better but this benefit reversed in a sensitivity analysis excluding one center. High doses were not associated with better outcome also in a propensity score-weighted regression model on the entire cohort. Our data support present guidelines that doses of IVCS >1 to 1.5 mg · kg · day (maximum 40-60 mg · kg · day) are not justified in acute severe colitis.

Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer.

We assessed the associations between the 21-gene recurrence score assay (RS) receipt, subsequent chemotherapy use, and medical expenditures among patients with early-stage breast cancer. Data from the Pennsylvania Cancer Registry were used to assemble a retrospective cohort of women with early-stage breast cancer from 2007 to 2010 who underwent initial surgical treatment. These data were merged with administrative claims from the 12-month periods before and after diagnosis to identify comorbidities, treatments, and expenditures (n = 7,287). Propensity score-weighted regression models were estimated to identify the effects of RS receipt on chemotherapy use and medical spending in the year after diagnosis. The associations between RS receipt and outcomes varied markedly by patient age. RS use was associated with lower chemotherapy use among women younger than 55 (19.2% lower; 95% CI, 10.6 to 27.9). RS use was associated with higher chemotherapy use among women 75 to 84 years old (5.7% higher; 95% CI, 0.4 to 11.0). RS receipt was associated with lower adjusted 1-year medical spending among women younger than 55 ($15,333 lower; 95% CI, $2,841 to $27,824) and with higher spending among women who were 75 to 84 years old ($3,489 higher; 95% CI, $857 to $6,122). RS receipt was associated with reduced use of adjuvant chemotherapy and lower health care spending among women with breast cancer who were younger than 55. Conversely, among women 75 and older, RS testing was associated with a modest increase in chemotherapy use and slightly higher spending. From a population perspective, the impact of RS testing on breast cancer treatment and health care costs is much greater in younger women.

Clinical Trial Participation as Part of End-of-Life Cancer Care: Associations With Medical Care and Quality of Life Near Death

ContextClinical trials are a common therapeutic option for patients with advanced incurable cancer. ObjectivesTo examine the associations between trial participation and end-of-life (EOL) outcomes, including aggressive care and quality of life (QOL). MethodsCoping with Cancer, a multicenter prospective cohort study of patients with metastatic cancer, progressed after at least first-line chemotherapy. Baseline chart review documented clinical trial participation. Baseline interviews assessed psychosocial characteristics and EOL preferences. Caregiver interview and chart review assessed medical care and QOL near death. The primary outcome was aggressive EOL care (ventilation, resuscitation, or intensive care unit admission in last week of life). Propensity score weighting balanced patient characteristics that differed by trial participation, including care preferences and EOL discussion. Propensity score–weighted regression models estimated the effect of trial participation on outcomes. ResultsOf 352 patients followed to death, 37 were enrolled in a clinical trial at baseline. In propensity score–weighted analyses, trial participation was significantly associated with aggressive EOL care (21.6% vs. 12.0%, adjusted odds ratio [AOR] 2.04, 95% confidence interval [CI] 1.00–4.15), late hospice enrollment (51.4% vs. 42.2%, AOR 1.96, 95% CI 1.10–3.50), hospital death (48.6% vs. 25.7%, AOR 2.74, 95% CI 1.37–5.47), intensive care unit death (16.2% vs. 6.3%, AOR 3.53, 95% CI 1.29–9.65), and inferior QOL near death (least squares mean 5.93 vs. 7.69, P<0.001). Controlling for EOL care, trial enrollment was no longer associated with QOL near death (P=0.342). ConclusionClinical trial participation is associated with aggressive EOL care. Aggressive EOL care appears to explain the association between trial participation and QOL near death.

Clinical trial participation as part of end-of-life (EOL) cancer care: Associations with medical care near death and bereaved caregivers’ mental health.

9102 Background: Clinical trial participation is necessary to improve existing therapies, encouraged by national guidelines, and common among advanced cancer patients. The relationships between trial participation and important EOL outcomes such as aggressive care are unknown. Methods: Coping with Cancer Study, an NCI-funded multicenter prospective cohort study of advanced cancer patients and their caregivers, enrolled September 2002 – February 2008. Patients were interviewed at baseline, and clinical trial participation was documented by chart review. Patients were followed to death, (median 4.4 months from baseline). Medical care and quality of life (QOL) in the last week of life was assessed by caregiver interview and chart review. Caregiver interview 6 months post-bereavement assessed QOL and mental health (Structured Clinical Interview for the DSM-IV). The primary outcome was aggressive EOL care (ventilation, resuscitation, or chemotherapy in the last week of life). Secondary outcomes were bereaved caregivers’ mental health and QOL. Propensity-score weighting balanced patient characteristics (e.g. clinical variables, EOL preferences) that differed by trial participation. Propensity-score weighted regression models estimated the effect of trial participation on outcomes. Results: Of 246 patients followed to death with non-missing propensity scores, 27 were clinical trial participants. In propensity-score weighted analyses, trial participation was significantly associated with aggressive EOL care [29.6% v 9.1%; adjusted OR (AOR), 12.14; 95% CI, 3.65-40.36], ICU admission, mechanical ventilation, chemotherapy, and a trend toward inferior QOL near death (p = 0.069). Of 180 matched caregivers, trial participation predicted less mental illness [AOR, 0.15; 95% CI 0.04-0.57], major depression [AOR, 0.25; 95% CI, 0.08-0.80], but was unassociated with QOL (p = 0.15) in adjusted analyses. Conclusions: Clinical trial participation is associated with increased risk of aggressive EOL care for advanced cancer patients, but better mental health for bereaved caregivers.