Significant Difference In Odds Research Articles

Maternal depressive symptoms, sleep, and odds of spontaneous early birth: implications for racial inequities in birth outcomes.

Delivery prior to full term affects 37% of US births, including ~400,000 preterm births (<37 weeks) and >1,000,000 early term births (37-38 weeks). Approximately 70% of cases of shortened gestation are spontaneous-without medically-indicated cause. Elucidation of modifiable behavioral factors would have considerable clinical impact. This study examined the role of depressive symptoms and sleep quality in predicting the odds of spontaneous shortened gestation among 317 women (135 black, 182 white) who completed psychosocial assessment in mid-pregnancy. Adjusting for key covariates, black women had 1.89 times higher odds of spontaneous shortened gestation compared to White women (OR [95% CI] = 1.89 [1.01, 3.53], p = 0.046). Women who reported only poor subjective sleep quality (PSQI > 6) or only elevated depressive symptoms (CES-D ≥ 16) exhibited no statistically significant differences in odds of spontaneous shortened gestation compared to those with neither risk factor. However, women with comorbid poor sleep and depressive symptoms exhibited markedly higher odds of spontaneous shortened gestation than those with neither risk factor (39.2% versus 15.7% [OR (95% CI) = 2.69 (1.27, 5.70)], p = 0.01). A higher proportion of black women met criteria for both risk factors (23% of black women versus 11% of white women; p = 0.004), with a lower proportion experiencing neither risk factor (40.7% of black versus 64.3% of white women; p < 0.001). Additive effects of poor subjective sleep quality and depressive symptoms were observed with markedly higher odds of spontaneous shortened gestation among women with both risk factors. Racial inequities in rates of comorbid exposure corresponded with inequities in shortened gestation. Future empirical studies and intervention efforts should consider the interactive effects of these commonly co-morbid exposures.

Obesity paradox in HFrEF hospitalizations: analysis of national inpatient sample 2016-2018

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Obesity is a common and known risk factor for many cardiovascular diseases. Prior studies on chronic systolic heart failure have demonstrated that obesity is inversely associated with mortality, the so-called obesity paradox. Purpose To study the phenomenon of obesity paradox in HFrEF hospitalizations Methods We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of HFrEF. Patients with an associated diagnosis of obesity and higher BMI were also identified based on appropriate ICD-10 CM codes. We used the Chi-square test to evaluate the differences between binary or categorical variables, and Student’s t-test for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders. Results We identified 639,944 weighted HFrEF hospitalizations across three years. Of which, 130,949 (20.4%) of them were associated with obesity. HFrEF with obesity hospitalizations were associated with younger age (mean age 62.0 vs 70.7 yrs; P &amp;lt; 0.01), lesser CAD (55% vs 61%; P &amp;lt; 0.01), higher rate of comorbidity (% of &amp;gt;3 Elixhauser comorbidity score 99.2% vs 94.1%; P &amp;lt; 0.01) and higher Medicaid primary payer (18.2% vs 12.7%, P &amp;lt; 0.01). After adjusting for patient and hospital-level characteristics, we observe statistically significant difference in odds of in-hospital mortality when HFrEF with obesity hospitalizations was compared to HFrEF without obesity [Odds Ratio (OR): 1.1 (0.8 – 1.5); P = 0.52]. We observed statistically significant association with increased LOS [6.0 vs 5.3 days; P &amp;lt; 0.01], increased total hospitalization charges [US$ 61524 vs 55677; P &amp;lt; 0.01] and decreased coronary catheterizations [OR: 0.7 (0.5 – 0.9); P = 0.01] in HFrEF with obesity group compared to HFrEF without obesity. Conclusion In this retrospective cohort of hospitalized patients with HFrEF, higher BMI and obesity was not associated with in-hospital mortality. However, it was associated with longer LOS and higher total hospitalization charges. HFrEF with obesity hospitalizations are associated with lesser left coronary catheterizations. This may be explained by lesser burden of CAD in this patient population.

Clinical outcomes of renal and liver transplant patients undergoing transcatheter aortic valve replacement: analysis of national inpatient sample database

ABSTRACT Background: The transcatheter aortic valve replacement (TAVR) has recently gained traction as a viable alternative to surgical aortic valve replacement (SAVR), but data on its safety and clinical outcomes in transplant patients are limited. Methods: We retrieved relevant demographic and clinical outcome data from the U.S. National Inpatient Sample (NIS) for the year 2012–2015. The clinical outcomes of TAVR in renal transplant (RT) and liver transplant (LT) were ascertained using an adjusted odds ratio (aOR) with a 95% confidence interval (CI) on Mantzel–Hensel test. Results: A total of 62,399 TAVR patients were identified; 62,180 (99.6%) with no history of transplant, 219 (0.4%) with RT and 85 (0.1%) with LT. There was no significant difference in odds of in-hospital mortality (OR 0.61, 95% CI 0.25–1.5, p = 0.37), major cardiovascular, respiratory or neurological complications in patients with and without RT. Similarly, the odds of cardiac complications, renal and neurological complications between patients with and without LT were identical. Conclusion: Compared to non-transplant patients, TAVR appears to be associated with similar odds of major systemic complications or mortality in patients with a history of kidney or liver transplant.

Long-term prognostic factors of clinical success after interventional bronchoscopy in patients with scarring central airway stenosis

BackgroundScarring central airway stenosis (SCAS) is a potentially life-threatening condition with debilitating symptoms. Interventional bronchoscopy is increasingly used to relieve symptoms in patients with SCAS, but recurrent stenosis is frequently observed. Little data exist on the long-term prognosis of interventional bronchoscopy for SCAS. We aimed to assess the prognostic factors of bronchoscopic interventions in patients with SCAS to optimize treatment.MethodsThis was a retrospective study that enrolled 119 consecutive patients with SCAS from January 2010 to April 2019 at our institution. Long-term clinical success was defined as airway stenosis < 50%, no limitation of physical activity, and a stable condition for > 12 months after the last interventional procedure. We compared patients’ demographics, airway stenosis characteristics, and interventional procedures between the successful and unsuccessful groups, and identified significant predictors of long-term outcome with univariate and multivariate logistic regression.ResultsA total of 119 patients with 577 therapeutic bronchoscopies were included. Seventy-five (63%) patients were considered to have long-term clinical success. Older age, male gender, smoking, elevated C-reactive protein level, subglottic stenosis, stent or T-tube implantation, previous interventional treatment, and multiple procedures per year were potentially associated with unsuccessful long-term outcomes in the univariate analysis. Current smoker status (odds ratio [OR] 5.70, 95% confidence interval [CI] 1.35–24.17, P = 0.018), subglottic stenosis (OR 4.35, 95% CI 1.31–14.46, P = 0.017), and stent implantation (OR 4.96, 95% CI 1.33–18.48, P = 0.017) were associated with decreased odds of long-term success in the multivariate logistic regression analysis. Of note, there was no significant difference in odds of success between former smokers and nonsmokers.ConclusionsCurrent smoker status, subglottic stenosis, and stent implantation are independent factors associated with reduced long-term efficacy of interventional bronchoscopy for SCAS. Smoking cessation should be encouraged to improve the outcome of therapeutic bronchoscopy.

Socioeconomic status is not associated with the delivery of care in people with diabetes but does modify HbA1c levels: An observational cohort study (Elzha-cohort 1).

BackgroundStructured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle‐related target indicators amongst people with type 2 diabetes and with better HbA1c levels. Whether socioeconomic status affects the delivery of care in terms of monitoring and its association with HbA1c levels within this approach, is unclear. This study aims to understand whether, within a structured care approach, (1) socioeconomic categories differ concerning diabetes monitoring as recommended; (2) socioeconomic status modifies the association between monitoring as recommended and HbA1c.MethodsObservational real‐life cohort study with primary care registry data from general practitioners within diverse socioeconomic areas, who are supported with the implementation of structured diabetes care. People with type 2 diabetes mellitus were offered quarterly diabetes consultations. “Monitoring as recommended” by professional guidelines implied minimally one annual registration of HbA1c, systolic blood pressure, LDL, BMI, smoking behaviour and physical activity. Regarding socioeconomic status, deprived, advantageous urban and advantageous suburban categories were compared to the intermediate category concerning (a) recommended monitoring; (b) association between recommended monitoring and HbA1c.ResultsAim 1 (n = 13 601 people): Compared to the intermediate socioeconomic category, no significant differences in odds of being monitored as recommended were found in the deprived (OR 0.45 (95% CI 0.19‐1.08)), advantageous urban (OR 1.27 (95% CI 0.46‐3.54)) and advantageous suburban (OR 2.32 (95% CI 0.88‐6.08)) categories. Aim 2 (n = 11 164 people): People with recommended monitoring had significantly lower HbA1c levels than incompletely monitored people (−2.4 (95% CI −2.9; −1.8) mmol/mol). SES modified monitoring‐related HbA1c differences, which were significantly higher in the deprived (−3.3 (95% CI −4.3; −2.4) mmol/mol) than the intermediate category (−1.3 (95% CI −2.2; −0.4) mmol/mol).ConclusionsWithin a structured diabetes care setting, socioeconomic status is not associated with recommended monitoring. Socioeconomic differences in the association between recommended monitoring and HbA1c levels advocate further exploration of practice and patient‐related factors contributing to appropriate monitoring and for care adjustment to population needs.

Risk of primary graft dysfunction following lung transplantation in selected adults with connective tissue disease-associated interstitial lung disease

Previous studies have reported similarities in long-term outcomes following lung transplantation for connective tissue disease-associated interstitial lung disease (CTD-ILD) and idiopathic pulmonary fibrosis (IPF). However, it is unknown whether CTD-ILD patients are at increased risk of primary graft dysfunction (PGD), delays in extubation, or longer index hospitalizations following transplant compared to IPF patients. We performed a multicenter retrospective cohort study of CTD-ILD and IPF patients enrolled in the Lung Transplant Outcomes Group registry who underwent lung transplantation between 2012 and 2018. We utilized mixed effects logistic regression and stratified Cox proportional hazards regression to determine whether CTD-ILD was independently associated with increased risk for grade 3 PGD or delays in post-transplant extubation and hospital discharge compared to IPF. A total of 32.7% (33/101) of patients with CTD-ILD and 28.9% (145/501) of patients with IPF developed grade 3 PGD 48-72 hours after transplant. There were no significant differences in odds of grade 3 PGD among patients with CTD-ILD compared to those with IPF (adjusted OR 1.12, 95% CI 0.64-1.97, p = 0.69), nor was CTD-ILD independently associated with a longer post-transplant time to extubation (adjusted HR for first extubation 0.87, 95% CI 0.66-1.13, p = 0.30). However, CTD-ILD was independently associated with a longer post-transplant hospital length of stay (median 23 days [IQR 14-35 days] vs17 days [IQR 12-28 days], adjusted HR for hospital discharge 0.68, 95% CI 0.51-0.90, p = 0.008). Patients with CTD-ILD experienced significantly longer postoperative hospitalizations compared to IPF patients without an increased risk of grade 3 PGD.

Clinical Characteristics and Outcomes of Patients Hospitalized for COVID-19 in Africa: Early Insights from the Democratic Republic of the Congo.

.Little is known about the clinical features and outcomes of SARS-CoV-2 infection in Africa. We conducted a retrospective cohort study of patients hospitalized for COVID-19 between March 10, 2020 and July 31, 2020 at seven hospitals in Kinshasa, Democratic Republic of the Congo (DRC). Outcomes included clinical improvement within 30 days (primary) and in-hospital mortality (secondary). Of 766 confirmed COVID-19 cases, 500 (65.6%) were male, with a median (interquartile range [IQR]) age of 46 (34–58) years. One hundred ninety-one (25%) patients had severe/critical disease requiring admission in the intensive care unit (ICU). Six hundred twenty patients (80.9%) improved and were discharged within 30 days of admission. Overall in-hospital mortality was 13.2% (95% CI: 10.9–15.8), and almost 50% among those in the ICU. Independent risk factors for death were age < 20 years (adjusted hazard ratio [aHR] = 6.62, 95% CI: 1.85–23.64), 40–59 years (aHR = 4.45, 95% CI: 1.83–10.79), and ≥ 60 years (aHR = 13.63, 95% CI: 5.70–32.60) compared with those aged 20–39 years, with obesity (aHR = 2.30, 95% CI: 1.24–4.27), and with chronic kidney disease (aHR = 5.33, 95% CI: 1.85–15.35). In marginal structural model analysis, there was no statistically significant difference in odds of clinical improvement (adjusted odds ratio [aOR] = 1.53, 95% CI: 0.88–2.67, P = 0.132) nor risk of death (aOR = 0.65, 95% CI: 0.35–1.20) when comparing the use of chloroquine/azithromycin versus other treatments. In this DRC study, the high mortality among patients aged < 20 years and with severe/critical disease is of great concern, and requires further research for confirmation and targeted interventions.

Communication Strategies Used to Obtain Clinical Histories Before Remotely Prescribing Antibiotics for Postal Treatment of Uncomplicated Genital Chlamydia: Service Evaluation.

BackgroundWeb-based services for testing of sexually transmitted infections are widely available across the United Kingdom. Remote prescriptions with medications posted home may support prompt treatment; however, the absence of face-to-face contact with clinicians raises clinical safety issues as medical history may not be accurately provided.ObjectiveThis service evaluation aimed to capture the use and explore the safety of 3 remote communication strategies employed within a web-based service offering remote prescriptions of antibiotics, delivered via post, for uncomplicated genital Chlamydia trachomatis. User acceptability and time-from-diagnosis-to-treatment were also obtained.MethodsThree iterations of the service were compared, where medical history was collected via SMS text message, telephone, or a secure web form before a prescription was issued. We contacted users after they were issued a prescription and completed the medical history a second time via telephone, asking when they took their medication and how they felt about the service. The primary safety measure was agreement in information supplied at 2 assessments (ie, clinical and evaluation assessment) on key elements of safe prescribing: allergies, current medications, or contraindicating clinical conditions or symptoms. Agreement in information between clinical and evaluation assessment was summarized as a binary variable. Factors associated with the assessment agreement variable were explored using univariate and multivariate analysis. The secondary evaluation measures were recall of and adherence to instructions for taking medication, time-from-diagnosis-to-treatment, and acceptability of the web-based service.ResultsAll web-based service users, resident in the London Boroughs of Lambeth and Southwark with a positive chlamydia diagnosis, who were eligible for and chose postal treatment between February 15, 2017, and October 24, 2017, were invited to participate in this service evaluation. Of 321 eligible users, 62.0% (199) participated. A total of 27.6% (55/199) users completed the clinical assessment via SMS text message, 40.7% (81/199) users via telephone, and 31.7% (63/199) users via a secure web form. Those who were assessed for prescription via SMS text message were less likely to have an agreement in safe prescribing information than those assessed via telephone (adjusted odds ratio [aOR] 0.22, 95% CI 0.08-0.61; P=.004). We found no statistically significant difference in odds of agreement between the web form and telephone assessment (aOR 0.50, 95% CI 0.17-1.43; P=.20). Median time-to-treatment was 4 days (IQR 3-5.5). In addition, 99.0% (196/199) of users reported understanding remote communication, and 89.9% (178/198) would use the service again.ConclusionsPostal treatment is an acceptable and rapid treatment option for uncomplicated genital chlamydia. Clinical assessment via SMS text message before remote prescription may not be accurate or sufficient. As health care is delivered via the web, strategies that support safe remote prescribing are increasingly important, as is their evaluation, which should be robust and carefully considered.

Association of Bariatric Surgery With Risk of Fracture in Patients With Severe Obesity

Given the complex relationship between body mass index, body composition, and bone density and the correlative nature of the studies that have established the prevailing notion that higher body mass indices may be protective against osteopenia and osteoporosis and, therefore, fracture, the absolute risk of fracture in patients with severe obesity who undergo either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) compared with those who do not undergo bariatric surgery is unknown. To assess the rates of fractures associated with obesity and compare rates between those who do not undergo bariatric surgery, those who undergo RYGB, and those who undergo SG. In this retrospective multicenter cohort study of Medicare Standard Analytic Files derived from Medicare parts A and B records from January 2004 to December 2014, patients classified as eligible for bariatric surgery using the US Centers of Medicare & Medicaid criteria who either did not undergo bariatric surgery or underwent RYGB or SG were exactly matched in a 1:1 fashion based on their age, sex, Elixhauser Comorbidity Index, hypertension, smoking status, nonalcoholic fatty liver disease, hyperlipidemia, type 2 diabetes, osteoporosis, osteoarthritis, and obstructive sleep apnea status. Data were analyzed from November to December 2019. RYGB or SG. The primary outcome measured in this study was the odds of fracture overall based on exposure to bariatric surgery. Secondary outcomes included the odds of type of fracture (humerus, radius or ulna, pelvis, hip, vertebrae, and total fractures) based on exposure to bariatric surgery. A total of 49 113 patients were included and were equally made up of 16 371 bariatric surgery-eligible patients who did not undergo weight loss surgery, 16 371 patients who had undergone RYGB, and 16 371 patients who had undergone SG. Each group consisted of an equal number of 4109 men (25.1%) and 12 262 women (74.9%) and had an equal distribution of ages, with 11 780 patients (72.0%) 64 years or younger, 4230 (25.8%) aged 65 to 69 years, 346 (2.1%) aged 70 to 74 years, and 15 (0.1%) aged 75 to 79 years. Patients undergoing RYGB were found to have no significant difference in odds of fractures compared with bariatric surgery-eligible patients who did not undergo surgery. Patients undergoing undergone SG were found to have decreased odds of fractures of the humerus (odds ratio [OR], 0.57; 95% CI, 0.45-0.73), radius or ulna (OR, 0.38; 95% CI, 0.25-0.58), hip (OR, 0.49; 95% CI, 0.33-0.74), pelvis (OR, 0.34; 95% CI, 0.18-0.64), vertebrae (OR, 0.60; 95% CI, 0.48-0.74), or fractures in general (OR, 0.53; 95% CI, 0.46-0.62). Compared with patients undergoing SG, patients undergoing RYGB had a significantly greater risk of total fractures (OR, 1.79; 95% CI, 1.55-2.06) and humeral fractures (OR, 1.60; 95% CI, 1.24-2.07). In this cohort study, bariatric surgery was associated with a reduced risk of fracture in bariatric surgery-eligible patients. Sleeve gastrectomy might be the best option for weight loss in patients in which fractures could be a concern, as RYGB may be associated with an increased fracture risk compared with SG.

Delayed Radical Prostatectomy is Not Associated with Adverse Oncologic Outcomes: Implications for Men Experiencing Surgical Delay Due to the COVID-19 Pandemic.

The 2019 novel Coronavirus (COVID-19) pandemic has forced many health care organizations to divert efforts and resources to emergent patient care, delaying many elective oncologic surgeries. We investigated an association between delay in radical prostatectomy and oncologic outcomes. This is a retrospective review of men with intermediate and high risk prostate cancer in the National Cancer Database undergoing radical prostatectomy from 2010 to 2016. Immediate radical prostatectomy was defined as radical prostatectomy within 3 months of diagnosis, while delayed radical prostatectomy was analyzed in 3-month intervals up to 12 months. Multivariable logistic regression models were fit to test for associations between levels of delayed radical prostatectomy and outcomes of interest (adverse pathology, upgrading on radical prostatectomy, node positive disease and post-radical prostatectomy secondary treatments) compared with men undergoing immediate radical prostatectomy. We identified 128,062 men with intermediate and high risk prostate cancer treated with radical prostatectomy. After adjustment, we did not appreciate a significant difference in odds of adverse pathology, upgrading, node positive disease or post-radical prostatectomy secondary treatments between men treated with immediate radical prostatectomy and any level of delay up to 12 months. Subgroup analysis of men with Grade Group 4 and 5 prostate cancer did not demonstrate an association between delayed radical prostatectomy and worse oncologic outcomes. In the National Cancer Database delayed radical prostatectomy was not associated with early adverse oncologic outcomes at radical prostatectomy. These results may provide reassurance to patients and urologists balancing care in the current pandemic.

Influence of bedspacing on outcomes of hospitalised medicine service patients: a retrospective cohort study

BackgroundSpecialty wards cohort hospitalised patients to improve outcomes and lower costs. When demand exceeds capacity, patients overflow and are “bedspaced” to alternate wards. Some studies have demonstrated that bedspacing among...

Real-world risk of new-onset inflammatory bowel disease among patients with psoriasis exposed to interleukin 17 inhibitors

Informationon the real-world risk of inflammatory bowel disease (IBD) among patients with psoriasis exposed to interleukin-17 inhibitor (IL-17i) is limited. To compare IBD risk in patients with psoriasis with and without IL-17i exposure. Retrospective cohort analysis of patients with psoriasis with and without IL-17i exposure identified by using electronic health records data. Primary outcomes were 6-month and 1-year IBD incidence. Crude 6-month IBD incidence was 0.16% (3/1821) among patients with psoriasis exposed to any IL-17i, 0.24% (3/1246) among those exposed to secukinumab alone, and 0.11% (239/213,060) among those unexposed. Crude 1-year IBD incidence was 0.27% (5/1821) among IL-17i-exposed patients with psoriasis, 0.32% (4/1246) among those exposed to secukinumab alone, and 0.19% (412/213,060) among those unexposed. In adjusted analysis, there was no significant difference in odds of developing IBD at 6months (odds ratio, 1.42; 95% confidence interval, 0.45-4.43) and 1year (odds ratio, 1.37; 95% confidence interval, 0.57-3.33) between exposed and unexposed patients with psoriasis. Similarly, there was no significant difference in odds of developing IBD at 6months and 1year between secukinumab-exposed and -unexposed patients with psoriasis. Analysis may have been limited by the low number of outcome events. The incidence of IBD among patients with psoriasis exposed to IL-17i is low, and therisk appears similar to that for unexposed patients with psoriasis.

Abstract WMP94: Temporal Trends in Racial, Age, and Sex-Specific Utilization of Decompressive Hemicraniectomy Among Acute Ischemic Stroke Patients in the United States

Background: The aim of this study is to evaluate current trends in racial, age, and sex-specific utilization of decompressive hemicraniectomy (HC) in acute ischemic stroke (AIS) patients in the United States over the last decade. Methods: All adult patients with a diagnosis of AIS were identified from the 2004-2015 Nationwide Inpatient Sample (weighted N=4,792,428) using International Classification of Diseases Ninth revision (ICD-9) codes. Proportion of patients undergoing HC in various age, race, and sex groups were ascertained using ICD-9 procedural codes. Temporal trends were mapped by year in order to track changes in utilization over time. Analysis of utilization disparities and trends within age, sex, and race subgroups was conducted via multivariate logistic regression. Results: Of all eligible AIS patients from 2004-2015, 0.25% underwent HC (.08 in 2004 to .46 in 2015). Increased utilization over time was seen in both men (.13 to .57) and women (.08 to .54), with women showing comparable odds of utilization to men [OR: 0.95 (95% CI: .87-1.04, p=0.27)]. Similarly, increased utilization trends were seen in all age groups (Figure 1) with the highest rates in the 18-39 subgroup (1.41%). Compared to trends in this younger subgroup (.43 to 2.12), patients aged 60-79 experienced a similar overall increase but at lower utilization rates (.06 to .37). Compared to white patients in multivariate models, blacks did not show significant differences in odds of HC [1.09 (.96-1.24, p=0.20)], while patients from Hispanic [1.25 (1.03-1.51, p=0.02)] and other [1.26 (1.04-1.52, p=0.02)] race-ethnic groups showed increased odds. Conclusions: From 2004-2015, hemicraniectomy rates have seen substantial increases in all age, sex, and race groups. The increasing rates of hemicraniectomies among those over age 60 suggest that there has been at least partial acceptance of DESTINY 2 study results.

Early Treatment Uptake and Cost Burden of Hepatitis C Therapies Among Newly Diagnosed Hepatitis C Patients with a Particular Focus on HIV Coinfection.

Despite the high efficacy and safety associated with direct-acting antivirals (DAAs), access to HCV treatment has been frequently restricted because of the high DAA drug costs. To (1) compare HCV treatment initiation rates between HCV monoinfected and HCV/HIV coinfected patients before (pre-DAA period) and after (post-DAA period) all-oral DAAs became available; and to (2) estimate the HCV treatment costs for payers and patients. A retrospective analysis of the MarketScan® Databases (2009-2016) was conducted for newly diagnosed HCV patients. Multivariable logistic regression was used to estimate the odds ratio (OR) of initiating HCV treatments during the pre-DAA and post-DAA periods. Kruskal-Wallis test was used to compare drug costs for dual, triple and all-oral therapies. A total of 15,063 HCV patients [382 (2.5%) HIV coinfected] in the pre-DAA period and 14,896 [429 (2.9%) HIV coinfected] in the post-DAA period were included. HCV/HIV coinfected patients had lower odds of HCV treatment uptake compared to HCV monoinfected patients during the pre-DAA period [OR, 0.59; 95% confidence interval (CI), 0.45-0.78], but no significant difference in odds of HCV treatment uptake was observed during the post-DAA period (OR, 1.08; 95% CI, 0.87-1.33). From 2009 to 2016, average payers' treatment costs (dual, $20,820; all-oral DAAs, $99,661; p < 0.001) as well as average patients' copayments (dual, $593; all-oral DAAs $933; p < 0.001) increased significantly. HCV treatment initiation rates increased, especially among HCV/HIV coinfected patients, from the pre-DAA to the post-DAA period. However, payers' expenditures per course of therapy saw an almost fivefold increase and patients' copayments increased by 55%.

Obesity Paradox in the Burn Patient.

Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this "Obesity Paradox" has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and BMI classifications (underweight <18.5 kg/m2, normal 18.5 to 24.9 kg/m2, overweight 25-29.9 kg/m2, obesity class I 30 to 34.9 kg/m2, obesity class II 35 to 39.9 kg/m2, and extreme obesity >40 kg/m2). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio of 0.856 (95% confidence interval [CI] 0.767 to 0.956). When adjusted for total BSA (TBSA), being obesity class I was associated with an adjusted odds ratio of mortality of 0.0166 (95% CI 0.000332 to 0.833). The adjusted odds ratio for mortality for underweight patients was 4.13 (95% CI 0.416 to 41.055). There was no statistically significant difference in odds of mortality between the normal and overweight BMI categories. In conclusion, the obesity paradox exists in burn care: further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients.

645 Black and White Patients With Inflammatory Bowel Disease Demonstrate Similar Biologic Use Patterns With Medicaid Insurance

INTRODUCTION: Prior studies have indicated that significant disparities exist when comparing black and white patients with inflammatory bowel disease (IBD), including increased emergency department visits and difficulty accessing specialists for Crohn's disease (CD) and ulcerative colitis (UC). The primary objective of this study was to compare any use of IBD-specific therapies among black and white patients with Medicaid Insurance, where race is self-reported at enrollment and patients have uniform insurance coverage. Among patients with CD who underwent surgery, we also aimed to evaluate postoperative therapies. METHODS: We performed a retrospective cohort study, analyzing data from the Medicaid Analytic Extract from four states (CA, GA, NC, and TX) between 2007 and 2014. We compared the use of IBD-specific therapies between black and white patients with IBD, including specific analyses of postoperative therapy among patients with CD. We performed bivariate analyses and multivariable logistic regression, adjusting for potential confounders. RESULTS: We identified 14,735 patients with IBD [4,672 black race (32%), 8,277 CD (58%)]. Among all 14,375 patients, 64% received at least one IBD-specific medication. Black patients were significantly more likely to receive therapy with an immunomodulator (20% vs. 15%, P &lt; 0.001), an anti-tumor necrosis alpha (anti-TNF) therapy (23% vs. 18%, P &lt; 0.001), combination therapy with an anti-TNF and an immunomodulator (4% vs. 3%, P &lt; 0.001) and prednisone (43% vs. 38%, P &lt; 0.001, Table 1). In multivariable analysis, there was no significant difference in odds of anti-TNF use by race for CD [adjusted Odds Ratio (aOR) 1.13, 95% Confidence Interval (CI): 0.99-1.28] or UC (aOR 1.12, 95% CI: 0.96-1.32, Table 2). Black patients with CD were more likely to receive combination therapy (aOR 1.50, 95% CI: 1.15-1.96). Among 398 patients undergoing surgery for CD, black patients received earlier postoperative therapy with an anti-TNF (median 94 days vs. 132 days, P = 0.023) and azathioprine (median 53 days vs. 92 days, P = 0.024), with no significant difference noted in use of methotrexate in the post-operative period. CONCLUSION: In patients with Medicaid Insurance, where access to IBD-specific therapy should be similar for all individuals, there was no significant disparity by race in the utilization of IBD-specific therapies. Access to comparable insurance benefits may aid significantly in resolving apparent healthcare disparities.

Does time matter? cross–sectional evaluation of mhealth program enrollment duration on healthy behaviors among key populations in Lomé

Context: Key populations (KP) in Togo, including men who have sex with men and female sex workers, experience disproportionately high rates of HIV prevalence. In response to this situation, USAID/West Africa and FHI360 established the PACTE–VIH regional HIV/AIDS project, which utilized mobile health (mHealth) to send reminders to enrolled participants on ways to reduce the risk of HIV infection. While mHealth programs are known to be effective in improving HIV–related health behavior outcomes, the role of length of time enrolled in a mHealth program is not well understood. Methods: To assess whether there was a relationship between time enrolled in the PACTE–VIH mHealth program and adoption of HIV prevention behavior, we use data from an operations research study conducted in Lomé, Togo, in 2016 with 1005 KP and employ logistic regression analysis. Results: The odds of adopting prevention behaviors were higher with each additional month enrolled in the program (OR: 1.62; 95% CI 1.19–2.20). Fully adjusted (age and marital status) logistic regression models demonstrated no significant difference in odds of adopting prevention behavior between enrollment times of less than six months and any category greater than six months. Conclusion: Time does matter for adoption of HIV prevention behaviors. However, more studies are needed to better understand what length of time enrolled in a program truly affects behavioral outcomes.

Length of Stay and Disposition of Patients Undergoing Elective Spine Surgery in Maryland: Impact of the Global Budget Revenue Program

Abstract INTRODUCTION The State of Maryland implemented an All-Payer Global Budget Revenue (GBR) program in 2014. The policy shifted hospital reimbursement from diagnosis related groups (DRG) to set annual budgets prior to each fiscal year with the goal of reducing cost and utilization while improving patient outcomes. No studies have evaluated the impact on patients undergoing spine surgery, a growing population that can exhibit high costs. METHODS A retrospective review was conducted utilizing the Maryland Health Services Cost Review Commission Public use dataset to evaluate differences in hospital length of stay (LOS), 30 d readmissions, and disposition locations of patients undergoing elective spine surgery at hospitals under the GBR Program in Maryland from 2012 to 2018. Hierarchical regression modeling was used to evaluate the outcomes prior to and following policy implementation. Outcomes included mean LOS, odds of readmission, and the relative risk of discharge to home with home health care (HHC) or rehabilitation (Rehab) compared to home. Covariates included sex, age, race, complexity, and mortality risk. RESULTS A total of 31 068 records of elective spine surgery from 2012 to 2018 were identified. There was a statistically significant decrease in readmission rates following implementation of the global budget program, 2.57% to 2.02% P = .001. However, when clustering on hospitals, there was no significant difference in odds of readmission following policy implementation, Adjusted OR 0.76 (95% CI 0.48, 1.22). There was a statistically significant increase in the ratio of relative risks of discharge to HHC or Rehab comparing the period following policy implementation to before was 1.62 (95% CI 1.17, 2.23) and 2.07 (95% CI 1.38, 3.12), respectively. CONCLUSION A preliminary analysis demonstrates no change in hospital utilization, but an increase in risk of being discharged with ancillary services or to rehabilitation among spine fusion patients following policy implementation. Further analysis is warranted to determine changes in trends to inform future policies.

Safety of Intra-articular Hyaluronic Acid Injections in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis.

BackgroundSome controversy exists regarding the safety of intra-articular hyaluronic acid (IAHA) in the management of osteoarthritis (OA).ObjectiveThe objective of this study was to re-assess the safety profile of IAHA in patients with OA, through a comprehensive meta-analysis of randomized, placebo-controlled trials.MethodsA comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with IAHA in patients with OA were eligible for inclusion. Authors and/or study sponsors were contacted to obtain the full report of AEs. The primary outcomes were overall severe and serious AEs, as well as the following MedDRA System Organ Class (SOC)-related AEs: gastrointestinal, cardiac, vascular, respiratory, nervous system, skin and subcutaneous tissue disorders, musculoskeletal, renal and urinary disorders, infections and infestations, and hypersensitivity reaction.ResultsDatabase searches initially identified 1481 records. After exclusions according to the selection criteria, 22 studies were included in the qualitative synthesis, and nine studies having adequate data were ultimately included in the meta-analysis. From the studies excluded according to the pre-specified selection criteria, 21 with other pharmacological OA treatments permitted during the trials were a posteriori included in a parallel qualitative synthesis, from which eight studies with adequate data were finally included in a parallel meta-analysis. Since this meta-analysis was designed to assess safety, the exclusion criterion on concomitant anti-OA medication was crucial. However, due to the high number of studies that allowed mainly concomitant oral non-steroidal anti-inflammatory drugs (NSAIDs), we decided to include them in a post hoc parallel analysis in order to compare the results from the two analyses. No statistically significant difference in odds was found between IAHA and placebo for all types of SOC-related disorders, except for infections and infestations, for which significantly lower odds were found with IAHA compared with placebo, both overall (odds ratio [OR] = 0.61, 95% confidence interval [CI] 0.40–0.93; I2 = 0%) and in studies without concomitant anti-OA medication (OR = 0.49, 95% CI 0.27–0.89). There were significant increased odds of reporting serious AEs with IAHA compared with placebo, both overall (OR = 1.78, 95% CI 1.21–2.63; I2 = 0%) and in studies with concomitant anti-OA medication (OR = 1.78, 95% CI 1.10–2.89), but not in studies without concomitant anti-OA medication (OR = 1.78, 95% CI 0.92–3.47).ConclusionsUsing the available data on studies without any concomitant anti-OA medication permitted during clinical trials, IAHA seems not to be associated with any safety issue in the management of OA. However, this evidence was associated with only a “low” to “moderate” certainty. A possible association with increased risk of serious AEs, particularly when used with concomitant OA medications, requires further investigation.Electronic supplementary materialThe online version of this article (10.1007/s40266-019-00657-w) contains supplementary material, which is available to authorized users.

93 The BMI Paradox in Burn Patients

Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this “BMI paradox” has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association/American College of Surgeons Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and the National Heart, Lung and Blood Institute(NIH) BMI classifications (underweight <18.5 kg/m2, normal 18.5–24.9 kg/m2, overweight 25–29.9 kg/m2, obesity class I 30–34.9 kg/m2, obesity class II 35–39.9 kg/m2 and extreme obesity >40 kg/m2). The mean BMI of inpatients treated for burns was 29.56 (SD 10.64). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio 0.82 (95% CI 0.71–0.96; p<0.01). When adjusted for total burn surface area, being in the obese class I rather than the normal classification was associated with an adjusted odds ratio of mortality of 0.032 (95% CI 0.0012 - 0.92; p<0.05), whereas having a BMI >40 kg/m2 had an odds ratio of 0.00. The adjusted odds ratio if underweight was 12.11 (95%CI 1.55–94.62; p<0.05). There was no statistically significant difference in odds of mortality between a normal and an overweight BMI. The “BMI paradox” exists in burn care. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients. Alters understanding of predictors of outcome.