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Background: The gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute. Objective: To characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity. Design, Setting, and Participants: This longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021. Main Measures: Monthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables. Key Results: The analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively). Conclusions: Increased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing. [ABSTRACT FROM AUTHOR]

To compare the outcomes of real-world patients who would have been eligible for asthma biologics to those who would not have been eligible. We used data from the OptumLabs Data Warehouse (OLDW) to categorize patients into eligible and ineligible groups based on clinical trials (n = 19 trials) used for Food and Drug Administration (FDA) approval. We then compared the change in the number of asthma exacerbations before and after biological initiation between the two groups. The percentage of people who would have been eligible for asthma biologic clinical trials ranged from 0–10.2%. The eligible group had a greater reduction in number of asthma exacerbations compared to the ineligible group based on eligibility criteria from 1 omalizumab trial (1.52, 95% CI 1.25, 1.8 in eligible vs. 0.47, 95% CI 0.43, 0.52 in ineligible) and from 1 dupilumab trial (1.6, 95% CI 0.92, 2.28 in eligible vs. 0.52, 95% CI 0.38, 0.65 ineligible). Notably, 15 of the 19 trials had fewer than 11 eligible people, limiting additional comparisons. Fewer than 1 in 10 people in the United States treated with asthma biologics would have been eligible to participate in the trial for the biologic they used. Where comparisons could be made, trial eligible people have a greater reduction in exacerbations. Supplemental data for this article is available online at https://doi.org/10.1080/02770903.2021.2010749. [ABSTRACT FROM AUTHOR]

Diabetes and its comorbidities are risk factors for severe, including fatal, COVID-19 disease.[1] Diabetes also requires regular monitoring, pharmacologic treatment, and access to medical care, all of which may have been disrupted during the COVID-19 pandemic. There is risk for misclassification of causes of death and underascertainment of diabetes when using causes of death to identify people with diabetes. However, all-cause mortality among people with diabetes increased 30% in 2020 compared to prior years, an excess of 438 deaths per 100,000 people with diabetes. [Extracted from the article]

Approximately half of all people with diabetes develop diabetic peripheral neuropathy (DPN) and half experience pain. Guidelines recommend pregabalin, gabapentin, and duloxetine (a selective norepinephrine and serotonin reuptake inhibitor [SNRI]) due to their demonstrated efficacy and safety. Topical analgesics, tricyclic anti-depressants (TCA), and anti-convulsants may also be used. Opioids are discouraged due to lack of effectiveness, risk of addiction, and safety concerns. To promote safe evidence-based pain management, we examined pain medication use by adults diagnosed with DPN between 2002-2019 in an integrated healthcare system across 5 states. We identified 13,815 adults with newly diagnosed DPN; mean age 66 (SD, 13) years, 42% female, 93% white, 29% insulin-treated. Overall, 56% received a pain medication from DPN diagnosis (1 month prior or continued from baseline) to 2 years later. Limiting to treatment pathways observed in ≥1% of cases, opioids were the most used 1st line medication, followed by gabapentin and others (Figure). Opioids and gabapentin were also the most prevalent 2nd line drugs. High rates of opioid use by patients with DPN, a life-long pain syndrome, are concerning particularly as safer effective treatment options are available. Further research is needed to identify drivers of opioid use and barriers to evidence-based alternatives, and develop interventions to improve DPN management in clinical practice. Disclosure: J. Fan: None. M.M. Jeffery: None. W. Hooten: None. N. Shah: None. R.G. McCoy: None. Funding: National Institutes of Health (K23DK114497) [ABSTRACT FROM AUTHOR]

Background: Little is known about adherence to asthma biologics.Research Question: Is adherence to inhaled corticosteroid (ICS) associated with subsequent asthma biologic adherence?Study Design and Methods: We analyzed individuals with asthma who started asthma biologics in the OptumLab Data Warehouse and used that data until October 2019. We calculated proportion days covered (PDC) for ICS ± long-acting β-agonists in the 6 months before and after asthma biologics were started and asthma biologic PDC for the first 6 months of use. We performed a multivariable analysis to identify factors associated with asthma biologic PDC ≥0.75, ICS PDC ≥0.75 during the 6-month period after asthma biologic were started, and achievement of a ≥50% reduction in asthma exacerbations during the first 6 months of asthma biologic use.Results: We identified 5,319 people who started asthma biologics. The mean PDC for asthma biologics was 0.76 (95% CI, 0.75-0.77) in the first 6 months after starting, higher than the mean PDCs for ICS in the 6 months before (0.44 [95% CI, 0.43-0.45]) and after (0.40 [95% CI, 0.39-0.40]) starting the asthma biologic. PDC ≥0.75 for ICS 6 months before index biologic use is associated with PDC for asthma biologics ≥0.75 (OR, 1.25; 95% CI, 1.10-1.43) and for ICS during the first 6 months of biologic use (OR, 9.93; 95% CI, 8.55-11.53). Neither ICS PDC ≥0.75 (OR, 0.92; 95% CI, 0.74-1.14) nor asthma biologic PDC ≥0.75 (OR, 1.15; 95% CI, 0.97-1.36) is associated with a statistically significant reduction in asthma exacerbations during the first 6 months of asthma biologic use among people with any exacerbation in the 6 months before first use.Interpretation: Adherence to asthma biologic is higher than to ICS and is associated with different factors. [ABSTRACT FROM AUTHOR]

Background The impact of ongoing efforts to decrease opioid use on patients with cancer remains undefined. Our objective was to determine trends in new and additional opioid use in patients with and without cancer. Methods This retrospective cohort study used data from Surveillance, Epidemiology, and End Results program–Medicare for opioid-naive patients with solid tumor malignancies diagnosed from 2012 through 2017 and a random sample of patients without cancer. We identified 238 470 eligible patients with cancer and further focused on 4 clinical strata: patients without cancer, patients with metastatic cancer, patients with nonmetastatic cancer treated with surgery alone ("surgery alone"), and patients with nonmetastatic cancer treated with surgery plus chemotherapy or radiation therapy ("surgery+"). We identified new, early additional, and long-term additional opioid use and calculated the change in predicted probability of these outcomes from 2012 to 2017. Results New opioid use was higher in patients with cancer (46.4%) than in those without (6.9%) (P  < .001). From 2012 to 2017, the predicted probability of new opioid use was more stable in the cancer strata (relative declines: 0.1% surgery alone; 2.4% surgery+; 8.8% metastatic cancer), than in the noncancer stratum (20.0%) (P  < .001 for each cancer to noncancer comparison). Early additional use declined among surgery patients (‒14.9% and ‒17.5% for surgery alone and surgery+, respectively) but was stable among patients with metastatic disease (‒2.8%, P  = .50). Conclusions Opioid prescribing declined over time at a slower rate in patients with cancer than in patients without cancer. Our study suggests important but tempered effects of the changing opioid climate on patients with cancer. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic resulted in unprecedented increases in mortality in the U.S. and worldwide. To better understand the impact of the COVID-19 pandemic on mortality in the state of Minnesota, U.S.A., we characterize the changes in the causes of death during 2020 (COVID-19 period), compared to 2018–2019 (baseline period), assessing for differences across ages, races, ethnicities, sexes, and geographic characteristics. Methods: Longitudinal population-based study using Minnesota death certificate data, 2018–2020. Using Poisson regression models adjusted for age and sex, we calculated all-cause and cause-specific (by underlying causes of death) mortality rates per 100,000 Minnesotans, the demographics of the deceased, and years of life lost (YLL) using the Chiang's life table method in 2020 relative to 2018–2019. Results: We identified 89,910 deaths in 2018–2019 and 52,030 deaths in 2020. The mean daily mortality rate increased from 123.1 (SD 11.7) in 2018–2019 to 144.2 (SD 22.1) in 2020. COVID-19 comprised 9.9% of deaths in 2020. Other categories of causes of death with significant increases in 2020 compared to 2018–2019 included assault by firearms (RR 1.68, 95% CI 1.34–2.11), accidental poisonings (RR 1.49, 95% CI 1.37–1.61), malnutrition (RR 1.48, 95% CI 1.17–1.87), alcoholic liver disease (RR, 95% CI 1.14–1.40), and cirrhosis and other chronic liver diseases (RR 1.28, 95% CI 1.09–1.50). Mortality rates due to COVID-19 and non-COVID-19 causes were higher among racial and ethnic minority groups, older adults, and non-rural residents. Conclusions: The COVID-19 pandemic was associated with a 17% increase in the death rate in Minnesota relative to 2018–2019, driven by both COVID-19 and non-COVID-19 causes. As the COVID-19 pandemic enters its third year, it is imperative to examine and address the factors contributing to excess mortality in the short-term and monitor for additional morbidity and mortality in the years to come. [ABSTRACT FROM AUTHOR]

Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions. The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type. The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774–1147 MMEs; posterior lumbar fusion: 717–1280 MMEs; circumferential lumbar fusion: 817–1271 MMEs; lumbar decompression/discectomy: 619–787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%–95%; anterior lumbar fusion: 87.5%–95.6%; circumferential lumbar fusion: 81.4%–96.5%; lumbar decompression/discectomy: 80.5%–91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid). In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery. [ABSTRACT FROM AUTHOR]

We sought to determine emergency medicine physicians' accuracy in designating patients' disposition status as "inpatient" or "observation" at the time of hospital admission in the context of Medicare's Two-Midnight rule and to identify characteristics that may improve the providers' predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians' disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers' awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy. [ABSTRACT FROM AUTHOR]

Introduction: While medically induced end-stage renal disease (m-ESRD) has been well-studied, outcomes in patients with surgically induced ESRD (s-ESRD) are unknown. We sought to quantitatively compare the non-oncological outcomes for s-ESRD and m-ESRD in a large, population-based cohort. Methods: Medicare patients >65 years old initiating hemodialysis were identified using the U.S. Renal Data System database (2000-2012). Metastatic cancer, prior transplant history, and nephrectomy for polycystic kidney disease were exclusion criteria. Patients were classified as having s-ESRD or m-ESRD based on hospital and physician claims for nephrectomy within a year preceding the onset of maintenance hemodialysis. Outcomes included non-cancer mortality (NCM), overall survival (OS), cardiovascular event (CVE), and renal transplantation. Time-to-event analyses were performed using Kaplan-Meier and cumulative incidence curves, and multivariable Cox and Fine-and-Crey regression models. Results: The cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD. Compared to m-ESRD patients, s-ESRD patients had a significantly lower five-year cumulative incidence of NCM (68% vs. 80%; p<0.001) and CVE (62% vs. 68%; p<0.001), with a correspondingly higher probability of OS (22% vs. 17%; pcO.OOl) and rate of renal transplantation (3.6% vs. 2.0%; p<0.001). On multivariable analyses, s-ESRD remained associated with lower risks of NCM (p<0.001) and CVE (pcO.OOl), improved OS (pcO.001), and higher chance of renal transplantation (pcO.001). Conclusions: While outcomes for s-ESRD appear more favorable than m-ESRD, s-ESRD is still associated with a substantial risk of NCM and CVE, and a low incidence of renal transplantation in Medicare patients >65 years old. These non-oncological outcomes are worth considering in patients potentially facing postoperative ESRD. [ABSTRACT FROM AUTHOR]

Background: Hospital readmission is common among patients with diabetes. Some readmissions, particularly for hypoglycemia and hyperglycemia, may be avoidable with better care transitions and post-discharge management.Objective: To ascertain the most common reasons and risk factors for readmission among adults with diabetes, with specific consideration of severe dysglycemia.Design: Retrospective analysis of data from the OptumLabs Data Warehouse, an administrative data set of commercially insured and Medicare Advantage beneficiaries across the U.S.Participants: Adults ≥18 years of age with diabetes, discharged from a hospital between January 1, 2009, and December 31, 2014 (N = 342,186).Main Measures: Principal diagnoses and risk factors for 30-day unplanned readmissions, subset as being for severe dysglycemia vs. all other causes.Key Results: We analyzed 594,146 index hospitalizations among adults with diabetes: mean age 68.2 years (SD, 13.0), 52.9% female, and 67.8% white. The all-cause 30-day readmission rate was 10.8%. Heart failure was the most common cause for index hospitalization (5.5%) and readmission (8.9%). Severe dysglycemia accounted for 2.6% of index hospitalizations (48.1% hyperglycemia, 50.4% hypoglycemia, 1.5% unspecified) and 2.5% of readmissions (38.3% hyperglycemia, 61.0% hypoglycemia, 0.7% unspecified). Younger patient age, severe dysglycemia at index or prior hospitalization, and the Diabetes Complications Severity Index (DCSI) were the strongest risk factors predisposing patients to severe dysglycemia vs. other readmissions. Prior episodes of severe dysglycemia and the DCSI were also independent risk factors for other-cause readmissions, irrespective of the cause of the index hospitalization.Conclusions: Adults with diabetes are hospitalized and readmitted for a wide range of health conditions, and hospitalizations for severe hypoglycemia and hyperglycemia remain common, with high rates of recurrence. Severe dysglycemia is most likely to occur among younger patients with multiple diabetes complications and prior history of such events. [ABSTRACT FROM AUTHOR]

Introduction: Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization. Methods: We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization. Results: We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT. Conclusion: CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT. [ABSTRACT FROM AUTHOR]

The article focuses on the rules introduced in medicaid coverage and the restrictions regarding opioid use. It talks about the risks associated with growing use of opioid in older adults in the population. It tells about the increase in the risks involved on the consumption of opioid with potentiators or drugs like benzodiazepines, gabapentinoids and non-benzodiazepine sedative hypnotics.

Background: The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care.Methods: We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients.Results: A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001).Conclusions: The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure. [ABSTRACT FROM AUTHOR]