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Overuse of diagnostic testing in the hospital setting contributes to high healthcare costs, yet the drivers of diagnostic overuse in this setting are not well-understood. If financial incentives play an important role in perpetuating hospital-level diagnostic overuse, then hospitals with favorable payer mixes might be more likely to exhibit high levels of diagnostic intensity.To apply a previously developed hospital-level diagnostic intensity index to characterize the relationship between payer mix and diagnostic intensity.Cross-sectional analysis SUBJECTS: Acute care hospitals in seven states MAIN MEASURES: We utilized a diagnostic intensity index to characterize the level of diagnostic intensity at a given hospital (with higher index values and tertiles signifying higher levels of diagnostic intensity). We used two measures of payer mix: (1) a hospital's ratio of discharges with Medicare and Medicaid as the primary payer to those with a commercial insurer as the primary payer, (2) a hospital's disproportionate share hospital ratio.A 5-fold increase in the Medicare or Medicaid to commercial insurance ratio was associated with an adjusted odds ratio of 0.24 (95% CI 0.16-0.36) of being in a higher tertile of the intensity index. A ten percentage point increase in the disproportionate share hospital ratio was associated with an adjusted odds ratio of 0.56 (95% CI 0.42-0.74) of being in a higher intensity index tertile.At the hospital level, a favorable payer mix is associated with higher diagnostic intensity. This suggests that financial incentives may be a driver of diagnostic overuse.

STUDY OBJECTIVES: To determine whether there was evidence of circadian or sleep-regulatory dysfunction in sighted individuals with non–24-hour sleep-wake rhythm disorder. METHODS: Three sighted individuals with signs and/or symptoms of non–24-hour sleep-wake rhythm disorder were studied. Thirty-five- to 332-day laboratory and home-based assessments of sleep-wake and circadian timing, endogenous circadian period, photic input to the circadian pacemaker, and/or circadian and sleep-wake–dependent regulation of sleep were conducted. RESULTS: No evidence of circadian dysfunction was found in these individuals. Instead, sleep-wake timing appeared to dissociate from the circadian timing system, and/or self-selected sleep-wake and associated light/dark timing shifted the circadian pacemaker later, rather than the circadian pacemaker determining sleep-wake timing. CONCLUSIONS: These findings suggest that the etiology of this disorder may be light- and/or behaviorally induced in some sighted people, which has implications for the successful treatment of this disorder. CITATION: Emens JS, St Hilaire MA, Klerman EB, et al. Behaviorally and environmentally induced non–24-hour sleep-wake rhythm disorder in sighted patients. J Clin Sleep Med. 2022;18(2):453–459.

Background Post-hospitalization transition interventions remain a priority in preventing rehospitalization. However, not all patients referred for readmission prevention interventions receive them. We sought to 1) define patient characteristics associated with non-receipt of readmission prevention interventions (among those eligible for them), and 2) determine whether these same patient characteristics are associated with hospital readmission at the state level. Methods We used state-wide data from the Maryland Health Services Cost Review Commission to determine patient-level factors associated with state-wide readmissions. Concurrently, we conducted a retrospective analysis of discharged patients referred to receive 1 of 3 post-discharge interventions between January 2013 and July 2019—a nurse transition guide, post-discharge phone call, or follow-up appointment in our post-discharge clinic—to determine patient-level factors associated with not receiving the intervention. Multivariable generalized estimating equation logistic regression models were used to calculate the odds of not accepting or not receiving the interventions. Results Older age, male gender, black race, higher expected readmission rate, and lower socioeconomic status were significantly associated with 30-day readmission in hospitalized Maryland patients. Most of these variables (age, sex, race, payer type [Medicaid or non-Medicaid], and socioeconomic status) were also associated with non-receipt of intervention. Conclusions We found that many of the same patient-level characteristics associated with the highest readmission risk are also associated with non-receipt of readmission reduction interventions. This highlights the paradox that patients at high risk of readmission are least likely to accept or receive interventions for preventing readmission. Identifying strategies to engage hard-to-reach high-risk patients continues to be an unmet challenge in readmission prevention.

Evidence suggests that an apixaban-based strategy to treat acute venous thromboembolism (VTE) in patients with End-Stage Kidney Disease (ESKD) may be safer than a warfarin-based strategy. Apixaban has an additional advantage of not requiring bridging with heparin which often necessitates long hospitalizations for patients with ESKD. We sought to determine if an apixaban-based strategy is associated with less healthcare utilization than a warfarin-based strategy.We employed a new-user, active-comparator retrospective cohort study using inverse probability of treatment weights (IPTW) to adjust for confounding demographic and clinical variables. Patients with ESKD newly initiated on either apixaban or warfarin for an acute VTE between 2014 and 2018 in the United States Renal Data System were included. Outcomes were presence of index hospitalization, length of index hospitalization, total hospital days, total hospital days excluding index hospitalization, total emergency department (ED) visits that did not result in hospitalization, and total skilled nursing facility days.At six months, patients who received apixaban were less likely to have an index hospitalization, had a shorter index hospitalization (median of 4.0 vs 8.0 days, p 0.001), and had fewer total hospital days. The IPTW and index year-adjusted incidence rate ratios of total hospital days at one, three, and six months were 0.83 (95 % confidence intervals (CI) 0.79-0.86), 0.84 (95 % CI 0.81-0.88), and 0.88 (95 % CI 0.83-0.92) for apixaban compared to warfarin.Among patients with ESKD and VTE, resource utilization for an apixaban-based strategy appears to be lower than for a warfarin-based strategy.

Patients with end-stage kidney disease (ESKD) are at significantly increased risk for both thrombosis and bleeding relative to those with normal renal function. The optimal therapy of venous thromboembolism (VTE) in patients with ESKD is unknown.To compare the safety and effectiveness of apixaban relative to warfarin in patients with ESKD and acute VTE.New-user, active-comparator retrospective United States population-based cohort with inverse probability of treatment weighting, using the United States Renal Data System data from 2014 to 2018. We included adults with ESKD on hemodialysis or peritoneal dialysis who were newly initiated on apixaban or warfarin for an acute VTE.The coprimary outcomes were major bleeding, recurrent VTE, and all-cause mortality within 6 months of anticoagulant initiation. Secondary outcomes were intracranial hemorrhage and gastrointestinal bleeding. The primary analyses were based on intent-to-treat defined by the first drug received and accounted for competing risks of death. Sensitivity analyses included varied follow-up time, as-treated analyses, and dose-specific apixaban subgroups.The apixaban and warfarin cohorts included 2302 and 9263 patients, respectively. Apixaban was associated with a lower risk of major bleeding (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.70-0.94), intracranial bleeding (HR 0.69, 95% CI 0.48-0.98), and gastrointestinal bleeding (HR 0.82, 95% CI 0.69-0.96). Recurrent VTE and all-cause mortality were not significantly different between the groups.Apixaban was associated with a lower risk of bleeding relative to warfarin when used to treat acute VTE in patients with ESKD on dialysis.

BACKGROUND: Bedrest is toxic for inpatients and consumer grade physical activity monitors offer an economical solution to monitor patient ambulation. But these devices may not be accurate in debilitated hospitalized patients who frequently ambulate very slowly. OBJECTIVE: To determine whether measures of physical capacity can help identify inpatients for whom wearable physical activity monitors may accurately measure step count. METHODS: Prospective observational study of 54 adult inpatients with acute neurological diagnoses. Patients were assessed using 2 physical capacity assessments (Activity Measure for Post-Acute Care Inpatient Mobility Short Form [AM-PAC IMSF] and Katz Activities of Daily Living [ADL] scale). They also completed a 2-minute walk test (2MWT) wearing a consumer grade physical activity monitor. RESULTS: The wearable activity monitor recorded steps (initiated) in 33 (61%) of the inpatients, and for 94% of inpatients with gait speeds >0.43 m/s. Physical capacity assessments correlated well with gait speed, AM-PAC IMSF r = 0.7, and Katz ADL r = 0.6, p 45) and Katz ADL (>5) cutoff scores identified inpatients for whom physical activity monitors initiated with a sensitivity of 94 and 91%, respectively. CONCLUSIONS: Physical capacity assessments, such as AM-PAC, and Katz ADL, may be a useful and feasible screening strategy to help identify inpatients where wearable physical activity monitors can measure their mobility.