Select Chronic Conditions Research Articles

Impact of initiating oral anticancer agents for leukemia on adherence to medications for multiple chronic conditions.

Increased use of oral anticancer agents (OAAs) has empowered adults with chronic lymphocytic leukemia (CLL) and chronic myelogenous leukemia (CML) to manage their therapy, but this shift may complicate medication use, particularly among adults with multiple chronic conditions (MCC). This retrospective cohort study used 2013-2018 commercial and Medicare claims data to assess medication use in adults with CML or CLL. To be included, patients must have been at least 18 years old, diagnosed with and had 2+ claims for an OAA indicated for either CML or CLL, continuously enrolled 12 months before and after OAA initiation, and treated for (2+ fills) at least two select chronic conditions. Proportion of days covered (PDC) determined medication adherence and was compared for 12 months before and after OAA initiation by Wilcoxon signed-rank tests, McNemar's tests, and difference-in-differences models. Among CLL patients, mean OAA adherence in the first year of therapy was 79.8% (SD: 21.1) and 74.7% (SD: 24.9) for commercial and Medicare patients, respectively; mean adherence for CML patients was 84.5% (SD: 15.8) and 80.1% (SD: 20.1) for commercial and Medicare patients, respectively. Adherence and the proportion adherent (PDC ≥ 80%) to comorbid therapies was generally unchanged following OAA initiation. Consistently unremarkable changes in MCC adherence were observed in 12-month difference-in-differences models, but significant decline was observed in MCC adherence after 6 months of OAA use. OAA initiation among adults with CML or CLL was not associated with significant, initial changes to adherence to medications for chronic diseases.

Impact of Initiating Oral Anticancer Agent Therapy for Chronic Lymphocytic Leukemia Among Adults with Multiple Chronic Conditions

Background: Increased use of oral anticancer agents (OAA) has empowered adults with chronic lymphocytic leukemia (CLL) to manage their therapy independently. However, comorbid chronic disease is common among patients with CLL, and initiating OAA therapy increases the treatment burden on adults with both cancer and multiple chronic conditions (MCC). The objective of this research was to examine adherence to OAAs in adult patients with CLL newly initiating OAA treatment and assess the extent to which such initiation impacted adherence to medications for existing comorbid chronic conditions. Methods: This retrospective cohort study used commercial (MarketScan) and Medicare (20% sample) claims data for 2013-2018 to assess medication use in adults with CLL. To be included, patients must have been: 1) at least 18 years old; 2) diagnosed with and had 2+ claims for an OAA indicated for either CLL; 3) continuously enrolled 12 months before and after OAA initiation; and 4) treated for (2+ fills before and after OAA initiation) at least 2 select chronic conditions (diabetes, hypertension, or hyperlipidemia plus at least 1 other chronic condition). Proportion of days covered (PDC) determined medication adherence for all included medication classes and was compared for the 12 months before and after OAA initiation by Wilcoxon signed-rank tests and McNemar's tests. Multivariable logistic regression identified predictors of OAA adherence in the first year of therapy while controlling for available demographic and clinical characteristics. Difference-in-differences models assessed the change in adherence to select comorbid chronic disease medications before and after OAA initiation. Results: The final analysis included 246 (commercial) and 805 (Medicare) adults with CLL and MCC. Mean OAA adherence in the first year of therapy was 79.8% (SD: 21.1) and 74.7% (SD: 24.9) for commercial and Medicare patients, respectively, translating to 68.3% (commercial) and 59.1% (Medicare) being adherent (PDC>80%). An increase in comorbidity burden was associated with a lower odds of OAA adherence and was the sole significant predictor in the Medicare models: OR=0.87 (95% CI: 0.82-0.92) for Medicare members and OR=0.83 (95% CI: 0.73-0.95) with commercial coverage. Among adults with commercial coverage, the odds of OAA adherence were lower for residents of the South (OR=0.39; 95% CI: 0.16-0.94; compared to the Northeast), but higher among those using a greater number of medications overall (OR=1.08; 95% CI: 1.01-1.16). No significant changes in mean adherence to MCC medications were observed, irrespective of payer, when comparing values before and after OAA initiation (Figure Panel A), including when accounting for OAA adherence in the first year of therapy. However, compared to the first 6 months post-OAA initiation, mean PDCs in the second half of the year noticeably declined, irrespective of comorbidity or payer cohort, with PDC declines ranging from 3.0 (antihypertensives, Medicare) to 11.1 (antihypertensives, Medicare) percentage points (Figure Panel B). Conclusion: Using nationally representative claims data, this study found that initial OAA adherence was generally good among adults with CLL, with a majority of patients reaching accepted thresholds of adequate anticancer medication use. Additionally, few differences in adherence were observed in multivariable analyses using a range of patients’ characteristics, irrespective of payer or cancer type. Importantly, limited evidence of changes in adherence to oral antidiabetic, antihypertensive, or lipid-lowering agents were found in the first year following OAA initiation. However, these findings do not negate the need for careful monitoring of medication use in these populations over the course of time as some eventual declines in comorbid chronic disease medication adherence were observed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of Initiating Oral Anticancer Agent Therapy for Chronic Myelogenous Leukemia Among Adults with Multiple Chronic Conditions

Background: The availability of oral anticancer agents (OAA) has facilitated adults’ ability to manage independently their treatment for chronic myelogenous leukemia (CML). However, pre-existing chronic disease is common among patients with cancer and initiating OAA therapy increases treatment burden on adults with both CML and multiple chronic conditions (MCC). The objective of this research was to examine adherence to OAAs in adult patients with CML who were treatment naïve and initiating an OAA and to assess whether such initiation affected adherence to medications for existing chronic conditions. Methods: This was a retrospective cohort study that used MarketScan commercial claims and a 20% sample of Medicare claims for 2013-2018 to assess medication use in adults with CML. To be included in the analysis, patients must have met the following criteria: 1) at least 18 years old; 2) diagnosed with and had 2+ claims for an OAA indicated for CML; 3) continuously enrolled 12 months before and after OAA initiation; and 4) treated for (2+ fills before and after OAA initiation) at least 2 select chronic conditions (diabetes, hypertension, or hyperlipidemia plus at least 1 other chronic condition). The proportion of days covered (PDC) metric determined medication adherence for all included medication classes and was compared for the 12 months before and after OAA initiation by Wilcoxon signed-rank tests and McNemar's tests. Multivariable logistic regression identified predictors of OAA adherence in the first year following initiation while controlling for available demographic and clinical characteristics. Difference-in-differences models assessed changes in adherence to select comorbid chronic disease medications prior to and following OAA initiation. Results: The final analysis included 256 and 658 adults with CML and MCC with commercial or Medicare coverage, respectively. Mean first-year OAA adherence was 84.5% (SD: 15.8) and 80.1% (SD: 20.1) for commercial and Medicare patients, respectively, and these corresponded to 78.1% and 67.1% of commercially insured adults and Medicare members being deemed adherent to their OAA (PDC > 80%). An increase in comorbidity burden was associated with a lower odds of OAA adherence and was the sole significant predictor in the Medicare models: OR=0.92 (95% CI: 0.87-0.97) in Medicare; OR=0.78 (95% CI: 0.67-0.90) in commercial. Among those with commercial insurance, the odds of initial OAA adherence were higher among those with any ED visit (OR=2.49; 95% CI: 1.07-5.84), but lower among those with an inpatient admission (OR=0.46; 95% CI: 0.22-0.94). Compared to the year before OAA initiation, average adherence to statins declined in the subsequent year among Medicare members on statins, but significant improvements were observed among those commercially insured on antihypertensives or antidiabetics (Figure Panel A). However, compared to the first 6 months post-OAA initiation, mean PDCs in the second half of the year post-OAA initiation were noticeably lower, irrespective of comorbidity or payer cohort, with PDC declines ranging from 4.2 (antihypertensives, Medicare) to 10.1 (antidiabetics, commercial) percentage points (Figure Panel B). Conclusion: Using nationally representative claims data, this study found that initial OAA adherence was generally good among adults with CML, and a majority of patients reached accepted thresholds of adequate OAA use. Using a range of patients’ characteristics, few differences in OAA adherence were observed in multivariable analyses, but consistent evidence pointed to poorer adherence as comorbidity burden increased. Additionally, limited changes in adherence to oral antidiabetic, antihypertensive, or lipid-lowering agents were observed over the first year following OAA initiation, but results suggest this pattern may not be maintained over the entire year post-OAA initiation. Consequently, these findings imply a need for careful monitoring of medication use in patients with CML and MCC over the course of time given the risk for eventual declines in comorbid chronic disease medication adherence. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Challenge of a dual burden in rapidly aging Delaware: Comorbid chronic conditions and subjective cognitive decline.

Epidemiologic trends forecast a "dual burden"- increase in both physical chronic diseases and Alzheimer's disease (AD)- for Delaware. Estimating the burden and characteristics of this "dual burden" is critical. Cognizant of the unavailability of precise models to measure AD, SCD-a population-based measure- was used as an alternative. The primary objective was to delineate selected chronic conditions among Delaware adults with SCD in order to present: (i) prevalence of SCD by select sociodemographic characteristics, (ii) compare the prevalence of chronic conditions among people with and without SCD, and (iii) compare the prevalence of SCD associated functional limitations in Delawareans with and without comorbid chronic conditions. Combined data (2016 and 2020) for Delaware were obtained from the Behavioral Risk Factor Surveillance System. Analyses included 4,897 respondents aged 45 years or older who answered the SCD screening question as "yes" (n = 430) or "no" (n = 4,467). Descriptive statistics examined sociodemographic characteristics and chronic conditions in Delawareans with and without SCD. Overall, 8.4% (CI: 7.4-9.5) of Delaware adults reported SCD. Delawareans with SCD were more likely to be in the younger age group (45-54 years), less educated, low income and living alone. Over 68 percent had not discussed cognitive decline with a health care professional. More than three in four Delawareans with SCD had a 1.5 times higher prevalence of having any one of the nine select chronic conditions as compared to those without SCD. Adults with SCD and at least one comorbid chronic condition were more likely to report SCD-related functional limitations. Delaware cannot afford to postpone public policies to address the dual burden of SCD and chronic conditions. Results from this study can help public health stakeholders in Delaware to be informed and prepared for the challenges associated with cognitive decline and comorbidity.

Medication Adherence Among Adults With Comorbid Chronic Conditions Initiating Oral Anticancer Agent Therapy for Multiple Myeloma.

Increased use of oral anticancer agents (OAAs) has empowered adults with multiple myeloma (MM) to manage their oncolytic therapy, but such a shift may result in issues with medication use, particularly among patients being concurrently treated for pre-existing, multiple chronic conditions. This retrospective cohort study used 2013-2018 commercial and Medicare claims data to assess medication use in adults with MM. To be included, adults (18 years and older) must have been diagnosed with and had 2+ claims for an OAA, had continuous enrollment for 12 months before and after OAA initiation, and have been previously diagnosed with and had prescription fills for 2+ select chronic conditions. The proportion of days covered metric assessed medication adherence and was compared for 12 months before and after the OAA initiation by Wilcoxon signed-rank tests, McNemar's tests, and difference-in-differences models. The mean OAA adherence in the first year of therapy was 58.3% (standard deviation: 24.5) and 65.1% (standard deviation: 27.01) for commercial and Medicare patients, respectively. Adherence and the proportion adherent (proportion of days covered ≥ 80%) to comorbid therapies generally declined in the first year after OAA initiation. Changes in medication use were particularly noticeable among those on antihypertensive therapy: adjusted analyses uncovered a 2.5% (Medicare) and 5.2% (commercial) difference in adherence to these medications between those initially adherent and nonadherent to OAA therapy (both P < .05). Initiating OAA therapy in adults with MM may complicate an already complex treatment regimen, resulting in poor overall medication adherence in patients with multiple comorbid conditions.

Excess Mortality Attributed to Hurricane Irma Among Assisted Living Residents With Chronic Conditions in Florida

Little is known about the impact of hurricanes on residents in assisted living communities (ALs), especially among individuals with chronic conditions that increase their risk of death after storms. We examined how the association between exposure to Hurricane Irma in 2017 and mortality differed by select chronic conditions. With Medicare data, we identified cohorts of AL residents in 2015 (n= 30,712) and 2017 (n= 29,842 ) and compared their rates of 30-day and 90-day and mortality. We adjusted rates for demographic characteristics and other comorbidities. AL residents with diabetes were at highest risk of death after the storm; between 2015 and 2017 they experienced a 50% increase in their 30-day mortality rates (0.6% in 2015, 0.9% in 2017) and a 43% increase in their 90-day mortality rates (2.1% in 2015, 3.0% in 2017). Policy makers should consider strategies to ensure that diabetic residents maintain continuity of medical care during disasters.

Racial and ethnic disparities in subjective cognitive decline: a closer look, United States, 2015\u20132018

BackgroundSubjective cognitive decline (SCD), characterized by self-experience of deterioration in cognitive performance may be a precursor to Alzheimer’s disease (AD). Given the association of AD with dependence and disability for a long duration, earlier the detection, the sooner people and their families can receive information regarding better management. It is critical to explore disparities amongst racial and ethnic populations with SCD in order to facilitate targeted interventions. The primary objective was to identify disparities in prevalence of SCD amongst Whites, Blacks and Hispanics by select sociodemographic characteristics and functional limitations in a U.S. population-based sample of non-institutionalized adults aged 45 and older. The secondary objective was to assess the association between SCD and select chronic conditions (angina, heart attack, stroke, diabetes, high blood pressure and high cholesterol) by race/ethnicity.MethodsCombined data (2015–2018) were obtained from the Behavioral Risk Factor Surveillance System (BRFSS) to conduct a population -based study. Analyses included 179,852 respondents aged 45 years or older who answered the SCD screening question as “yes” (n = 19,276) or “no” (n = 160,576). Descriptive statistics examined sociodemographic characteristics including functional limitations amongst racial/ethnic groups with SCD. Association of SCD with chronic conditions by race/ethnicity was also calculated.ResultsOverall, 10.8% (CI: 10.6–11.1) of adults aged 45 years or older reported SCD.10.7% Whites, 12.3% Blacks and 9.9% Hispanics experienced SCD. Blacks and Hispanics with SCD were more likely to be in the younger age group (45–54 years), less educated, low income, without access to health care, living alone and with functional limitations. Only half had discussed cognitive decline with a health care professional. Prevalence of selected chronic conditions was significantly higher in all racial/ethnic groups with SCD.ConclusionsDemographic trends predict a larger proportion of Hispanics and Blacks with SCD in the coming years. This information can lead to identification of opportunities for addressing negative SCD outcomes in minorities affected by inequitable conditions.

Changes in chronic disease medication adherence following oral anticancer agent initiation in patients with multiple myeloma.

e18760 Background: Improvements in treatment options for multiple myeloma (MM) have led to double-digit increases in 5-year survival rates over the past 40 years. Such extended survival has increased emphasis for the management of comorbid chronic conditions. Initial analyses suggest that oral anticancer agent (OAA) initiation for MM may correspond to significant reductions in adherence to chronic disease medications. Methods: This was a retrospective cohort study of adults diagnosed with and being treated for MM between 2013-2018 using data from the IBM MarketScan Commercial Claims and Encounters databases and a 20% sample of Medicare claims data. Adults (18 years and older) were included if they were diagnosed with and had at least two claims for an OAA indicated for MM, had continuous enrollment for 12 months both before and after OAA initiation, and were previously diagnosed with two chronic conditions and had prescription fills for select chronic conditions. Medication adherence was determined using the proportion of days covered (PDC) metric and was compared for the 12 months before and after the OAA initiation by Wilcoxon signed-rank tests, McNemar’s tests, and difference-in-differences (DinD) models. Results: A slight majority of the 2,765 patients (total N from both databases) were male (52.3%), and hypertension (94.5%) and hyperlipidemia (69.2%) were the most common comorbid conditions. Mean OAA adherence in the first year of therapy was 55.8% (SD: 23.5) and 63.5% (SD: 26.9) for commercial and Medicare patients, respectively. PDCs for comorbid therapies declined in the first year after OAA initiation, irrespective of payer (table), and the proportion adherent to these therapies (PDC &gt; 80%) also declined consistently. OAA adherence tended to align with the direction of changes in comorbid therapy adherence with those nonadherent to their OAA (PDC &lt; 80%) demonstrating general declines in comorbid therapy PDCs post-OAA initiation (p&lt;0.05 in 4 of 6 DinD models). Conclusions: Among adults with MM and multiple chronic conditions, the pre-OAA initiation level of adherence appears to dictate chronic disease medication use patterns after OAA initiation. The starting of OAA therapy facilitates an opportunity for providers to reinforce the need for total regimen adherence to improve the odds of positive cancer- and non-cancer-related outcomes. [Table: see text]

Multiple chronic conditions and associated health care expenses in US adults with cancer: a 2010\u20132015 Medical Expenditure Panel Survey study

BackgroundCancer increases the risk of developing one or more chronic conditions, yet little research describes the associations between health care costs, utilization patterns, and chronic conditions in adults with cancer. The objective of this study was to examine the treated prevalence of chronic conditions and the association between chronic conditions and health care expenses in US adults with cancer.MethodsThis retrospective observational study used US Medical Expenditure Panel Survey (MEPS) Household Component (2010–2015) data sampling adults diagnosed with cancer and one or more of 18 select chronic conditions. The measures used were treated prevalence of chronic conditions, and total and chronic condition-specific health expenses (per-person, per-year). Generalized linear models assessed chronic condition-specific expenses in adults with cancer vs. without cancer and the association of chronic conditions on total health expenses in adults with cancer, respectively, by controlling for demographic and health characteristics. Accounting for the complex survey design in MEPS, all data analyses and statistical procedures applied longitudinal weights for national estimates.ResultsAmong 3657 eligible adults with cancer, 83.9% (n = 3040; representing 16 million US individuals per-year) had at least one chronic condition, and 29.7% reported four or more conditions. Among those with cancer, hypertension (59.7%), hyperlipidemia (53.6%), arthritis (25.6%), diabetes (22.2%), and coronary artery disease (18.2%) were the five most prevalent chronic conditions. Chronic conditions accounted for 30% of total health expenses. Total health expenses were $6388 higher for those with chronic conditions vs. those without (p < 0.001). Health expenses associated with chronic conditions increased by 34% in adults with cancer vs. those without cancer after adjustment.ConclusionsIn US adults with cancer, the treated prevalence of common chronic conditions was high and health expenses associated with chronic conditions were higher than those without cancer. A holistic treatment plan is needed to improve cost outcomes.

PIT9 IMPACT OF FALLS IN THE ELDERLY POPULATION FOR THE SPANISH NATIONAL HEALTH SYSTEM

Falls in the elderly are associated with high morbidity, diminished quality of life and an increased risk of mortality and constitutes a serious public health concern. Visual impairment is an important risk factor for falls; additional risk factors include older age, previous falls, chronic diseases and multiple medication use. The objective of this research was to estimate the clinical and economic impact of falls on the Spanish population older than 64 years, under the perspective of the Spanish National Health System (NHS), considering a 1-year time horizon. A targeted literature research was performed, with a view to estimating the incidence of falls and their associated clinical consequences in a Spanish context. Furthermore, the main risks factors for falls were assessed. Spanish NHS costs attributable to the clinical consequences of falls were sourced from publically available statistics, as were estimates of the Spanish population >64 years. Considering 8,908,151 people >64 years, the following clinical consequences (number of cases) were identified as the main cost drivers for the NHS: hip fractures (109,205), Colles (52,228), pelvis (18,992), other fractures (37,984), hospital visits (883,136) and ambulatory emergency services (631,490). The overall annual cost for the NHS was estimated as being close to €820 million. One of the most common intrinsic risk factors identified was visual impairment, as well as advanced age, previous falls, select chronic conditions and balance/muscular problems. In addition, several extrinsic factors must be considered, such as slippery surfaces, dim lighting or psychoactive medications. This research highlights that falls in the elderly Spanish population are associated with high morbidity and significant costs, which are estimated here as being close to €820 million annually. While multiple factors are associated with the increased risk of falling in the older population, the evidence suggests visual impairment plays a significant role.

From Invisible to Visible to Valued: Improving Population Health of People With Intellectual and Developmental Disabilities.

From Invisible to Visible to Valued: Improving Population Health of People With Intellectual and Developmental Disabilities.

On Your Mark, Get Set, Go: Levels of Physical Activity in the Kingdom of Saudi Arabia, 2013.

With the lack of appropriate data, we conducted a large household survey in 2013 to determine current rates of physical activity in the Kingdom of Saudi Arabia (KSA). The Saudi Health Interview Survey is a national multistage survey of individuals aged 15 years or older. We used a multivariate logistic regression model to measure association between sociodemographic and selected characteristics and meeting the recommended levels of moderate and vigorous weekly physical activity. Of a total of 12,000 households contacted, 10,735 (89.4%) participants completed Saudi Health Interview Survey. An estimated 4.5 million (34.5%) Saudis aged 15 years or older reported no weekly physical activity, while only 1.7 million (12.9%) meet the recommended levels of moderate physical activity (MPA). The likelihood of meeting MPA decreased with age, education, among women, those with a history of diagnosis of select chronic conditions, including diabetes. Similar results were found for the likelihood of meeting the recommended levels of vigorous weekly physical activity. We found very low levels of physical activity in KSA. Perhaps, KSA can challenge communities or employers to devise solutions and reward those with the best results. These solutions would be of great value to other Gulf countries, as well.

Risk factors for in-hospital mortality among a cohort of children with Clostridium difficile infection.

The incidence of Clostridium difficile infection (CDI) has increased and has been associated with poor outcomes among hospitalized children, including increased risk of death. The purpose of this study was to identify risk factors for all-cause in-hospital mortality among children with CDI. A multicenter cohort of children with CDI, aged 1-18 years, was established among children hospitalized at 41 freestanding children's hospitals between January 1, 2006 and August 31, 2011. Children with CDI were identified using a validated case-finding tool (ICD-9-CM code for CDI plus C. difficile test charge). Only the first CDI-related hospitalization during the study period was used. Risk factors for all-cause in-hospital mortality within 30 days of C. difficile test were evaluated using a multivariable logistic regression model. We identified 7,318 children with CDI during the study period. The median age of this cohort was 6 years [interquartile range (IQR): 2-13]; the mortality rate was 1.5% (n=109); and the median number of days between C. difficile testing and death was 12 (IQR, 7-20). Independent risk factors for death included older age [adjusted odds ratio (OR, 95% confidence interval), 2.29 (1.40-3.77)], underlying malignancy [3.57 (2.36-5.40)], cardiovascular disease [2.06 (1.28-3.30)], hematologic/immunologic condition [1.89 (1.05-3.39)], gastric acid suppression [2.70 (1.43-5.08)], and presence of >1 severity of illness marker [3.88 (2.44-6.19)]. Patients with select chronic conditions and more severe disease are at increased risk of death. Identifying risk factors for in-hospital mortality can help detect subpopulations of children that may benefit from targeted CDI prevention and treatment strategies.

Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program

Readmission is associated with high mortality, morbidity, and cost. We used the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) to determine risk factors for readmission after lower extremity bypass (LEB). We identified all patients who received LEB in the 2011 ACS-NSQIP database. Multivariable logistic regression was used to assess independent predictors of 30-day readmission. We also identified our institutional contribution of LEB patients to the ACS-NSQIP from 2005 to 2011 to determine our institution's rate of readmission and readmission indications. Among 5018 patients undergoing LEB, ACS-NSQIP readmission analysis was performed on 4512, excluding those whose readmission data were unavailable, who suffered a death on index admission, or who remained in the hospital at 30 days. Overall readmission rate was 18%, and readmission rate of those with NSQIP-captured complications was 8%. Multivariable predictors of readmission were dependent functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.08-1.79), dyspnea (OR, 1.28; 95% CI, 1.02-1.60), cardiac comorbidity (OR, 1.46; 95% CI, 1.16-1.84), dialysis dependence (OR, 1.44; 95% CI, 1.05-1.97), obesity (OR, 1.28; 95% CI, 1.07-1.53), malnutrition (OR, 1.42; 95% CI, 1.12-1.79), critical limb ischemia operative indication (OR, 1.40; 95% CI, 1.10-1.79), and return to the operating room on index admission (OR, 8.0; 95% CI, 6.68-9.60). The most common postdischarge complications occurring in readmitted patients included wound complications (55%), multiple complications (22%), and graft failure (5%). Our institutional data contributed 465 LEB patients to the ACS-NSQIP from 2005 to 2012, with an overall readmission rate of 14%. Unplanned readmissions related to the original LEB (related unplanned) made up 75% of cases. The remainder 25% included readmissions that were planned staged procedures related to the original LEB (related planned, 11%) and admissions for a completely unrelated reason (unrelated unplanned, 14%). The most common readmission indications included wound infection (37%) and graft failure (10%). Readmissions were attributable to NSQIP-captured postdischarge complications in 44% of cases, an additional 44% had a non-NSQIP-defined reason for readmission, and the remainder (12%) included patients admitted for complications described in NSQIP but not meeting strict NSQIP criteria. Readmissions are common after LEB. Optimization of select chronic conditions, closer follow-up of patients in poor health and those who required return to the operating room, and early detection of surgical site infections may improve readmission rates. Our finding that 25% of readmissions after LEB are not procedure related informs the broader discussion of how a readmission penalty affects vascular surgery in particular.

Patient Demographic and Health Factors Associated With Frequent Use of Emergency Medical Services in a Midsized City

To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health. The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users. Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse-related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher. The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions.

Greater prevalence of select chronic conditions among Aboriginal and South Asian participants from an ethnically diverse convenience sample of British Columbians

Canadians currently experience elevated rates of chronic conditions compared with past populations, and ethnic differences in the experience of select chronic conditions have previously been identified. This investigation examined the prevalence of select chronic conditions among an ethnically diverse convenience sample of British Columbian adults. A sample of adults (≥18 years) from around the province of British Columbia, including Aboriginal (n = 991), European (n = 3650), East Asian (n = 466), and South Asian (n = 228), were evaluated. Individuals reported their personal histories of cardiovascular disease and diabetes, and physical activity behaviour. Direct measures of health status included body mass index, waist circumference, resting blood pressure, and nonfasting blood glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, and glycosylated hemoglobin A1C. All ethnic groups were found to have high rates of low HDL (>33%), physical inactivity (>31%), hypertension (>16%), and ethnic-specifically defined obesity (>23%) and abdominal obesity (>33%). Aboriginal and South Asian populations generally demonstrated higher rates of select chronic conditions. The implementation of ethnic-specific body composition recommendations further underscores this poorer health status among South Asian populations. Actions to improve chronic condition rates should be undertaken among all ethnic groups, with particular attention to Aboriginal and South Asian populations.

Dysfunctional sleep in persons with spinal cord injuries and disorders

Cross-sectional survey of veterans with spinal cord injuries and disorders (SCI/D). To describe sleep dysfunction (independent of sleep apnea) in persons with traumatic and non-traumatic SCI/D, and to examine characteristics and health outcomes independently associated with sleep dysfunction unrelated to sleep apnea. Seven Veterans Affairs SCI care facilities in the United States. Mailed cross-sectional survey with follow-up calls completed by end of 2008. Bivariate analyses to compare measures outcomes in persons with SCI/D who were dysfunctional sleepers vs those who were not. Multivariate logistic regression used to identify variables independently associated with dysfunctional sleep in veterans with SCI/D. Overall, 49% of the sample had sleep dysfunction unrelated to sleep apnea. In this subgroup, bivariate analyses showed that a greater proportion of dysfunctional sleepers than non-dysfunctional sleepers were current smokers, had problems with drinking alcohol, hypertension, asthma, chronic obstructive pulmonary disease (COPD) and problematic weight gain. Variables independently associated with higher odds of dysfunctional sleep included white race, being a current smoker, problems with drinking alcohol, asthma, COPD and problematic weight gain. Consistent with epidemiological evidence for the general population, we found significant associations of sleep dysfunction with weight gain, smoking, alcohol misuse and select chronic conditions (COPD, asthma). Sustained sleep dysfunction may contribute to health deterioration and mortality, highlighting the need to address the high prevalence of sleep dysfunction (independent of sleep apnea) in persons with SCI/D. In particular, efforts aimed at modifying problematic weight gain, alcohol misuse and smoking are warranted in this cohort to improve sleep.

The Impact of 90-Day Prescriptions on Adherence at Workplace Pharmacies Compared to Traditional Mail Order

This study evaluated adherence to medications used to treat chronic conditions for patients with 90-day prescriptions, comparing patients with access to workplace pharmacy services versus patients using mail order services. De-identified pharmacy claims data were used to compute medication possession ratio and gaps in therapy. Results were compared for patients who filled 90-day prescriptions at workplace pharmacies versus patients who filled 90-day prescriptions using mail order pharmacy services in a 1-year period. Statistical tests to assess between group differences were performed controlling for differences because of age, sex, number of select chronic conditions, number of unique medication therapeutic classes, and patient out-of-pocket cost per therapy day. Statistically significant differences were found between patients who filled their maintenance medications at the worksite compared to those who used mail-order pharmacy services. Patients filling prescriptions at a workplace pharmacy were 22% less likely to have a gap in therapy of over 30 days compared to similar patients using mail order services. Workplace pharmacy utilizers also had overall adherence rates 3.68% higher than patients who utilized mail order pharmacy services. Our analysis suggests that it may not be just the quantity of medication dispensed that impacts patients' adherence to their prescription medication, but a variety of other factors including pharmacist-patient interaction. Having a pharmacist on-site and available to patients with chronic considerations could provide added value. These results can aid employers and other stakeholders to decide which prescription benefits to offer their employees and members.

Patient-reported care coordination: associations with primary care continuity and specialty care use.

Care coordination is increasingly recognized as a necessary element of high-quality, patient-centered care. This study investigated (1) the association between care coordination and continuity of primary care, and (2) differences in this association by level of specialty care use. We conducted a cross-sectional study of Medicare enrollees with select chronic conditions in an integrated health care delivery system in Washington State. We collected survey information on patient experiences and automated health care utilization data for 1 year preceding survey completion. Coordination was defined by the coordination measure from the short form of the Ambulatory Care Experiences Survey (ACES). Continuity was measured by primary care visit concentration. Patients who had 10 or more specialty care visits were classified as high users. Linear regression was used to estimate the association between coordination and continuity, controlling for potential confounders and clustering within clinicians. We used a continuity-by-specialty interaction term to determine whether the continuity-coordination association was modified by high specialty care use. Among low specialty care users, an increase of 1 standard deviation (SD) in continuity was associated with an increase of 2.71 in the ACES coordination scale (P <.001). In high specialty care users, we observed no association between continuity and reported coordination (P= .77). High use of specialty care may strain the ability of primary care clinicians to coordinate care effectively. Future studies should investigate care coordination interventions that allow for appropriate specialty care referrals without diminishing the ability of primary care physicians to manage overall patient care.

Prevalence of Obesity Among Children With Chronic Conditions

New evidence suggests that children with chronic conditions may be predisposed to overweight and obesity. This study provides prevalence estimate of obesity for children and adolescents with select chronic conditions. We analyzed reported height and weight and the corresponding BMI from 46,707 subjects aged 10-17 years collected by the National Survey of Children's Health (NSCH-2003). Our main outcome measure was the prevalence of obesity (defined as >/=95th percentile of the sex-specific BMI for age growth charts), adjusted for underlying demographic and socioeconomic factors. We found that the prevalence of obesity among children 10-17 years of age without a chronic condition was 12.2% (95% confidence interval (CI) 11.5-13.0); the prevalence of obesity for children with asthma was 19.7% (19.5-19.9); with a hearing/vision condition was 18.4% (18.2-18.5); with learning disability was 19.3% (19.2-19.4); with autism was 23.4% (23.2-23.6); and with attention-deficit/hyperactivity disorder was 18.9% (18.7-19.0). Our findings suggest that children 10-17 years of age with select chronic conditions were at increased risk for obesity compared to their counterparts without a chronic condition.