BackgroundFunctional limitations may be more common in middle-aged adults than previously recognized. However, there are few published data on the prevalence of activity limitations, and their association with multimorbidity, among adults 50 to 64 years old.ObjectiveTo describe the prevalence of activity limitations and the association with multimorbidity in middle-aged adults.DesignCross-sectional analysis of US population-based National Health and Nutrition Examination Survey (NHANES) 2011–2016.ParticipantsThe total number of community-dwelling NHANES participants aged 50–64 years old is 4217.Main MeasuresChronic conditions included hypertension, high cholesterol, diabetes mellitus, obesity, chronic kidney disease, cancer, stroke, coronary heart disease, heart failure, chronic obstructive pulmonary disease/asthma, arthritis, and depression. Activity limitations were defined as any difficulty within each of four International Classification of Functioning (ICF) domains: functional limitations (kneeling, carrying, standing, sitting, reaching, grasping, pulling), mobility (walking ¼ mile, climbing 10 steps), basic activities of daily living (BADLs; walking, transferring, eating, dressing), and instrumental activities of daily living (IADLs; finances, chores, cooking). We calculated prevalence ratios for activity limitations using generalized estimating equations.Key ResultsThe prevalence of functional limitations, mobility limitations, BADL difficulty, and IADL difficulty was 34%, 11%, 15%, and 17%, respectively. Seventy-two percent of participants had two or more chronic conditions; 23% had two, 18% had three, 15% had four, and 16% had five or more. Multivariable adjusted prevalence ratios (95% CI) for functional limitations among those with 2, 3, 4, and 5 or more chronic conditions, compared with 0–1 conditions, were 1.94 (1.43–2.63), 2.50 (1.93–3.23), 3.26 (2.48–4.27), and 4.54 (3.48–5.93), respectively (p trend?

BackgroundThe CHOICE care management intervention did not improve drinking relative to usual care (UC) for patients with frequent heavy drinking at high risk of alcohol use disorders. Patients with alcohol dependence were hypothesized to benefit most. We conducted preplanned secondary analyses to test whether the CHOICE intervention improved drinking relative to UC among patients with and without baseline DSM-IV alcohol dependence.MethodsA total of 304 patients reporting frequent heavy drinking from 3 VA primary care clinics were randomized (stratified by DSM-IV alcohol dependence, sex, and site) to UC or the patient-centered, nurse-delivered, 12-month CHOICE care management intervention. Primary outcomes included percent heavy drinking days (%HDD) using 28-day timeline follow-back and a “good drinking outcome” (GDO)—abstaining or drinking below recommended limits and no alcohol-related symptoms on the Short Inventory of Problems at 12 months. Generalized estimating equations binomial regression models (clustered on provider) with interaction terms between dependence and intervention group were fit.ResultsAt baseline, 59% of intervention and UC patients had DSM-IV alcohol dependence. Mean drinking outcomes improved for all subgroups. For participants with dependence, 12-month outcomes did not differ for intervention versus UC patients (%HDD 37% versus 38%, p?=?0.76 and GDO 16% versus 16%, p?=?0.77). For participants without dependence, %HDD did not differ between intervention (41%) and UC (31%) patients (p?=?0.12), but the proportion with GDO was significantly higher among UC participants (26% versus 13%, p?=?0.046). Neither outcome was significantly modified by dependence (interaction p values 0.19 for %HDD and 0.10 for GDO).ConclusionsAmong participants with frequent heavy drinking, care management had no benefit relative to UC for patients with dependence, but UC may have had benefits for those without dependence.Trial RegistrationClinicalTrials.gov NCT01400581.

BackgroundThe greater the severity of illness of a patient, the more likely the patient will have a poor hospital outcome. However, hospital-wide severity of illness scores that are simple, widely available, and not diagnosis-specific are still needed. Laboratory tests could potentially be used as an alternative to estimate severity of illness.ObjectiveTo evaluate the ability of hospital laboratory tests, as measures of severity of illness, to predict in-hospital mortality among hospitalized patients, and therefore, their potential as an alternative method to severity of illness risk adjustment.Designs and PatientsA retrospective cohort study among 38,367 adult non-trauma patients admitted to the University of Maryland Medical Center between November 2015 and November 2017 was performed. Laboratory tests (hemoglobin, platelet count, white blood cell count, urea nitrogen, creatinine, glucose, sodium, potassium, and total bicarbonate (HCO3)) were included when ordered within 24 h from the time of hospital admission. A multivariable logistic regression model to predict in-hospital mortality was constructed using a section of our cohort (n?=?21,003).Main MeasuresModel performance was evaluated using the c-statistic and the Hosmer-Lemeshow (HL) test. In addition, a calibration belt was constructed to determine a confidence interval around the calibration curve with the purpose of identifying ranges of miscalibration.Key ResultsPatient age and all laboratory tests predicted mortality with good discrimination (c?=?0.79). Patients with abnormal HCO3 levels or leukocyte counts at admission were twice as likely to die during their hospital stay as patients with normal results. A good model calibration and fit were observed (HL?=?13.9, p?=?0.18).ConclusionsAdmission laboratory tests are able to predict in-hospital mortality with good accuracy, providing an objective and widely accessible approach to severity of illness risk adjustment.

BackgroundThe Affordable Care Act and the introduction of accountable care organizations (ACOs) have increased the incentives for patients and providers to engage in preventive care, for example, through quality metrics linked to disease prevention. However, little is known about how ACOs deliver preventive care services.ObjectiveTo understand how Medicare ACOs provide preventive care services to their attributed patients.DesignMixed-methods study using survey data reporting Medicare ACO capabilities in patient care management and interviews with high-performing ACOs.ParticipantsACO executives completed survey data on 283 Medicare ACOs. These data were supplemented with 39 interviews conducted across 18 Medicare ACOs with executive-level leaders and associated clinical and managerial staff.Main MeasuresSurvey measures included ACO performance, organizational characteristics, collaboration experience, and capabilities in care management and quality improvement. Telephone interviews followed a semi-structured interview guide and explored the mechanisms used, and motivations of, ACOs to deliver preventive care services.Key ResultsMedicare ACOs that reported being comprehensively engaged in the planning and management of patient care - including conducting reminders for preventive care services - had more beneficiaries and had a history of collaboration experience, but were not more likely to receive shared savings or achieve high-quality scores compared to other surveyed ACOs. Interviews revealed that offering annual wellness visits and having a system-wide approach to closing preventive care gaps are key mechanisms used by high-performing ACOs to address patients’ preventive care needs. Few programs or initiatives were identified that specifically target clinically complex patients. Aside from meeting patient needs, motivations for ACOs included increasing patient attribution and meeting performance targets.ConclusionsACOs are increasingly motivated to deliver preventive care services. Understanding the mechanisms and motivations used by high-performing ACOs may help both providers and payers to increase the use of preventive care.

BackgroundOpioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care.ObjectiveTo determine whether patients taking chronic opioid therapy who experienced opioid tapers were at greater risk of subsequently terminating their care compared with those who were continued on their doses.DesignRetrospective cohort study of patients in a large, urban health system between 2008 and 2012 with 2 years of follow-up.ParticipantsAdult patients prescribed a stable baseline dose of chronic opioid therapy of at least 25 morphine milligram equivalents per day during a baseline year.Main MeasuresAn opioid taper during an exposure year, defined as a reduction in the average daily dose of at least 30% from the baseline dose in both of the two 6-month periods in the year following the baseline year. Opioid dose continuation was defined as any increase in dose, no change in dose, or any decrease up to 30% compared with baseline dose in the exposure year. The primary outcome was termination of care, defined as no outpatient encounters in the health system, in the year following the exposure year.Key ResultsOf 1624 patients on chronic opioid therapy, 207 (15.5%) experienced an opioid taper and 78 (4.8%) experienced termination of care. Compared with opioid dose continuation, opioid taper was significantly associated with termination of care (AOR 4.3 [95% CI 2.2–8.5]).ConclusionsOpioid taper is associated with subsequent termination of care. These findings invite caution and demonstrate the need to fully understand the risks and benefits of opioid tapers.

BackgroundLittle is known about patients who have caregiver proxies communicate with healthcare providers via portal secure messaging (SM). Since proxy portal use is often informal (e.g., sharing patient accounts), novel methods are needed to estimate the prevalence of proxy-authored SMs.Objective(1) Develop an algorithm to identify proxy-authored SMs, (2) apply this algorithm to estimate predicted proxy SM (PPSM) prevalence among patients with diabetes, and (3) explore patient characteristics associated with having PPSMs.DesignRetrospective cohort study.ParticipantsWe examined 9856 patients from Diabetes Study of Northern California (DISTANCE) who sent =?1 English-language SM to their primary care physician between July 1, 2006, and Dec. 31, 2015.Main MeasuresUsing computational linguistics, we developed ProxyID, an algorithm that identifies phrases frequently found in registered proxy SMs. ProxyID was validated against blinded expert categorization of proxy status among an SM sample, then applied to identify PPSM prevalence across patients. We examined patients’ sociodemographic and clinical characteristics according to PPSM penetrance, “none” (0%), “low” (=?0–50%), and “high” (=?50–100%).Key ResultsOnly 2.3% of patients had =?1 registered proxy-authored SM. ProxyID demonstrated moderate agreement with expert classification (??=?0.58); 45.7% of patients had PPSMs (40.2% low and 5.5% high). Patients with high percent PPSMs were older than those with low percent and no PPSMs (66.5 vs 57.4 vs 56.2 years, p?

BackgroundTo enhance the acute care delivery system, a comprehensive understanding of the patient’s perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary.MethodsWe conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses.ResultsNine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: “it’s urgent because it hurts,” and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: “my doctor said he was booked up and he instructed me to go to the ED.” The third domain was related to multiple advantages associated with ED care: “my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support.” In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers.ConclusionsIn this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.

BackgroundThe continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing =?90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers.ObjectivesWe evaluated prescribers’ specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination.DesignRetrospective cohort study.ParticipantsA cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015–2016.Main MeasuresPer prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination.Key ResultsFor 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed =?90 MME/day, discoordination accounted for a greater share of high-risk exposures—13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures.ConclusionLow-volume prescribers in the social network’s periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.

BackgroundThe National Quality Forum endorsed a 3-item Care Transitions Measure (CTM-3), part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, for evaluating hospital care transitions performance.ObjectiveTo explore whether CTM-3 scores are a suitable proxy for quality of transitional care.DesignRetrospective cohort study.ParticipantsA random sample of 48,384 adults discharged from medical or surgical wards in all 113 acute care hospitals in Alberta, Canada, between April 2011 and March 2016.Main MeasuresCTM-3 scores and their associations with all-cause emergency department (ED) visits or non-elective readmissions at 30 days, 3 months, and 12 months anywhere in the province.ResultsCTM-3 scores were significantly lower (all p?

ObjectivesScreening women for intimate partner violence (IPV) is increasingly expected in primary care, consistent with clinical prevention guidelines (e.g., United States Preventive Services Task Force). Yet, little is known about real-world implementation of clinical practices or contextual factors impacting IPV screening program success. This study identified successful clinical practices, and barriers to and facilitators of IPV screening program implementation in the Veterans Health Administration (VHA).DesignDescriptive, qualitative study of a purposeful sample of 11 Veterans Affairs Medical Centers (VAMCs) categorized as early and late adopters of IPV screening programs within women’s health primary care clinics. VAMCs were categorized based on performance measures collected by VHA operations partners.ParticipantsThirty-two administrators and clinician key informants (e.g., Women’s Health Medical Directors, IPV Coordinators, and physicians) involved in IPV screening program implementation decisions from six early- and five late-adopting sites nationwide.Main MeasuresParticipants reported on IPV screening and response practices, and contextual factors impacting implementation, in individual 1-h semi-structured phone interviews. Transcripts were analyzed using rapid content analysis with key practices and issues synthesized in profile summaries. Themes were identified and iteratively revised, utilizing matrices to compare content across early- and late-adopting sites.Key ResultsFive successful clinical practices were identified (use of two specific screening tools for primary IPV screening and secondary risk assessment, multilevel resource provision and community partnerships, co-location of mental health/social work, and patient-centered documentation). Multilevel barriers (time/resource constraints, competing priorities and mounting responsibilities in primary care, lack of policy, inadequate training, and discomfort addressing IPV) and facilitators (engaged IPV champions, internal and external supports, positive feedback regarding IPV screening practices, and current, national attention to violence against women) were identified.ConclusionsFindings advance national efforts by highlighting successful clinical practices for IPV screening programs and informing strategies useful for enhancing their implementation within and beyond the VHA, ultimately improving services and women’s health.

BackgroundConcerns exist about availability and access to psychiatric services in the USA. For Medicare beneficiaries, one impediment to psychiatric services is the extent to which psychiatrists have opted out of the Medicare program.ObjectiveThis study describes geographic variation in rates that psychiatrists opt out of Medicare, and assesses physician-level and geographic-level predictors of opt-out.DesignRetrospective cross-sectional analysis of data describing psychiatrists’ opt-out status as of March 2017 linked to data on psychiatrist location, psychiatrist characteristics (obtained from a comprehensive US physician database), and market area–level characteristics.Participants27,838 psychiatrists in the USAMain MeasuresWhether a psychiatrist had opted out of Medicare as of March 2017.Key ResultsOverall, 7.0% of psychiatrists (1940/27,838) opted out of Medicare as of March 2017. Opt-out rates varied substantially across states and within states. Physician-level factors independently associated with opt-out included: older age (psychiatrists >?65 years were 2.6 percentage points more likely to opt vs. psychiatrists

BackgroundHealthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients’ personal goals and factors associated with goal progress.ObjectiveTo describe high-need patients’ goals, and to identify factors associated with their goal progressDesignRetrospective cohort studyParticipantsA total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program.Main MeasuresTwo independent reviewers examined patients’ goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress.ResultsThe majority (n?=?72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1–0.9; p?=?0.03) and those living alone (aOR 0.4; 95% CI 0.1–1.0; p?=?0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p?=?0.02).ConclusionsAmong high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.

We report the case of a 55-year-old male who presented with several weeks of seizures, agitation, progressive confusion, and receptive aphasia. CSF showed a monocytic pleocytosis and tested positive for GABAB receptor autoantibodies. Pathological examination of an excisional mediastinal lymph node biopsy showed thymic small cell carcinoma, supporting a diagnosis of paraneoplastic limbic encephalitis (PLE). PLE is a subtype of limbic encephalitis and is associated with an array of autoantibodies. Neurologic symptoms related to PLE may precede the detection of the primary cancer. Recognition of the constellation of clinical features of limbic encephalitis should prompt initiation of diagnostic testing for this condition as well as evaluation for an underlying malignancy. A review of the literature reveals that this is the first case report of a patient with thymic small cell cancer presenting with PLE.