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Background: Home‐based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in‐home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model. Methods: This prospective cohort study enrolled older adults in home‐based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30‐day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR). Results: We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76–86 years, with 3–5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06–1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48–1.18) or 30‐day readmissions (IRR 1.32, 95% CI 0.49–3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001). Conclusion: Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations. [ABSTRACT FROM AUTHOR]

Objective: To describe differences in clinical and demographic characteristics between patients with episodic migraine (EM) or chronic migraine (CM) and determine the effect of migraine subtype on patient‐reported outcome measures (PROM). Background: Prior studies have characterized migraine in the general population. While this provides a basis for our understanding of migraine, we have less insight into the characteristics, comorbidities, and outcomes of migraine patients who present to subspecialty headache clinics. These patients represent a subset of the population that bears the greatest burden of migraine disability and are more representative of migraine patients who seek medical care. Valuable insights can be gained from a better understanding of CM and EM in this population. Methods: We conducted a retrospective observational cohort study of patients with CM or EM seen in the Cleveland Clinic Headache Center between January 2012 and June 2017. Demographics, clinical characteristics, and patient‐reported outcome measures (3‐Level European Quality of Life 5‐Dimension [EQ‐5D‐3L], Headache Impact Test‐6 [HIT‐6], Patient Health Questionnaire‐9 [PHQ‐9]) were compared between groups. Results: Eleven thousand thirty‐seven patients who had 29,032 visits were included. More CM patients reported being on disability 517/3652 (14.2%) than EM patients 249/4881 (5.1%) and had significantly worse mean HIT‐6 (67.3 ± 7.4 vs. 63.1 ± 7.4, p < 0.001) and median [interquartile range] EQ‐5D‐3L (0.77 [0.44–0.82] vs. 0.83 [0.77–1.00], p < 0.001), and PHQ‐9 (10 [6–16] vs. 5 [2–10], p < 0.001). Conclusions: There are multiple differences in demographic characteristics and comorbid conditions between patients with CM and EM. After adjustment for these factors, CM patients had higher PHQ‐9 scores, lower quality of life scores, greater disability, and greater work restrictions/unemployment. [ABSTRACT FROM AUTHOR]

Objectives: To compare clinical characteristics among outpatient headache clinic patients who do and do not self‐report visiting the emergency department for headache. Background: Headache is the fourth most common reason for emergency department visits, compromising 1%–3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self‐report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization. Methods: This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self‐reported questionnaires. Associations between self‐reported emergency department utilization and demographics, clinical characteristics, and patient‐reported outcome measures (PROMs: Headache Impact Test [HIT‐6], headache days per month, current headache/face pain, Patient Health Questionnaire‐9 [PHQ‐9], Patient‐Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated. Results: Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self‐reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78–0.85] per decade), Black patients (vs. White patients) (1.47 [1.26–1.71]), Medicaid (vs. private insurance) (1.50 [1.29–1.74]), and worse area deprivation index (1.04 [1.02–1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT‐6 (1.35 [1.30–1.41] per 5‐point increase), higher (worse) PHQ‐9 (1.14 [1.09–1.20] per 5‐point increase), and lower (worse) PROMIS‐GH Physical Health T‐scores (0.93 [0.88–0.97]) per 5‐point increase. Conclusion: Our study identified several characteristics associated with self‐reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department. [ABSTRACT FROM AUTHOR]

Purpose: The Modified Low Back Pain Disability Questionnaire (MDQ) is a commonly used tool to assess functioning of patients with low back pain (LBP). Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) was suggested as an alternative platform to assess LBP patient-reported health. We sought to map between the MDQ and PROMIS Physical Function (PROMIS-PF) and Pain Interference (PROMIS-PI) scales using multiple methods.Methods: In a retrospective analysis of LBP patients seen at Cleveland Clinic 11/14/18-12/11/19, T-scores from each PROMIS scale were mapped to MDQ total score individually and together. MDQ item and total scores were mapped to each PROMIS scale. Linear regression as well as linear and equipercentile equating were used. Split sample internal validation using root mean squared error (RMSE), mean absolute error (MAE), and correlations were used to assess accuracy of mapping equations.Results: 13585 patients completed the three scales. In the derivation cohort, average age was 59.0 (SD = 15.8); 53.3% female and 82.9% white. Average MDQ total, PROMIS-PF, and PROMIS-PI T-scores were 40.3 (SD = 19.0), 37.2 (SD = 7.6), and 62.9 (SD = 7.2), respectively. For estimating MDQ total scores, methods that used both PROMIS-PF and PROMIS-PI had closest estimated means, lowest RMSE and MAE, and highest correlations. For estimating each of PROMIS-PF and PROMIS-PI T-scores, the best performing method was equipercentile equating using the MDQ items.Conclusions: We created and internally validated maps between MDQ and PROMIS-PF and PROMIS-PI using linear regression, linear and equipercentile equating. Our equations can be used by researchers wishing to translate scores between these scales. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to test the reliability of the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" mobility and activity short forms between patients and therapist proxies. As a secondary aim, reliability was examined when patients completed their self-report before versus after the therapist evaluation. Methods Patients being seen for an initial physical therapist (N = 70) or occupational therapist (N = 71) evaluation in the acute care hospital completed the "6-Clicks" mobility short form (if a physical therapist evaluation) or activity short form (if an occupational therapist evaluation). Whether patients completed their self-assessment before or after the evaluation was randomized. Patient- and therapist-rated "6-Clicks" raw scores were converted to AM-PAC T-scores for comparison. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland–Altman plots, and agreement was assessed with weighted kappa values. Results The ICCs for the "6-Clicks" mobility and daily activity short forms were 0.57 (95% CI = 0.42–0.69) and 0.45 (95% CI = 0.28–0.59), respectively. For both short forms, reliability was higher when the patient completed the self-assessment after versus before the therapist evaluation (ICC = 0.67, 95% CI = 0.47–0.80 vs ICC = 0.50, 95% CI = 0.26–0.67 for the mobility short form; and ICC = 0.52, 95% CI = 0.29–0.70 vs ICC = 0.34, 95% CI = 0.06–0.56 for the activity short form). Conclusion Reliability of the "6-Clicks" total scores was moderate for both the mobility and activity short forms, though higher for the mobility short form and when patients' self-report occurred after the therapist evaluation. Impact Reliability of the AM-PAC "6-Clicks" short forms is moderate when comparing scores from patients with those of therapists responding as proxies. The short forms are useful for measuring participants' function in the acute care hospital; however, it is critical to recognize limitations in reliability between clinician- and patient-reported AM-PAC scores when evaluating longitudinal change and recovery. [ABSTRACT FROM AUTHOR]

Objectives: Research has indicated proxies overestimate symptoms on patients' behalves, however it is unclear whether patients and proxies agree on meaningful change across domains over time. The objective of this study is to assess patient-proxy agreement over time, as well as agreement on identification of meaningful change, across 10 health domains in patients who underwent acute rehabilitation following stroke. Methods: Stroke patients were recruited from an ambulatory clinic or inpatient rehabilitation unit, and were included in the study if they were undergoing rehabilitation. At baseline and again after 30 days, patients and their proxies completed PROMIS Global Health and eight domain-specific PROMIS short forms. Reliability of patient-proxy assessments at baseline, follow-up, and the change in T-score was evaluated for each domain using intra-class correlation coefficients (ICC(2,1)). Agreement on meaningful improvement or worsening, defined as 5+ T-score points, was compared using percent exact agreement. Results: Forty-one patient-proxy dyads were included in the study. Proxies generally reported worse symptoms and functioning compared to patients at both baseline and follow-up, and reported less change than patients. ICCs for baseline and change were primarily poor to moderate (range: 0.06 (for depression change) to 0.67 (for physical function baseline)), and were better at follow-up (range: 0.42 (for anxiety) to 0.84 (for physical function)). Percent exact agreement between indicating meaningful improvement versus no improvement ranged from 58.5–75.6%. Only a small proportion indicated meaningful worsening. Conclusions: Patient-proxy agreement across 10 domains of health was better following completion of rehabilitation compared to baseline or change. Overall change was minimal but the majority of patient-proxy dyads agreed on meaningful change. Our study provides important insight for clinicians and researchers when interpreting change scores over time for questionnaires completed by both patients and proxies. [ABSTRACT FROM AUTHOR]

Purpose: Type 2 diabetes-related polyneuropathy (DPN) is associated with increased vascular events and mortality, but determinants and outcomes of pain in DPN are poorly understood. We sought to examine the effect of neuropathic pain on vascular events and mortality in patients without DPN, DPN with pain (DPN + P), and DPN without pain (DPN-P).Methods: A retrospective cohort study was conducted within a large health system of adult patients with type 2 diabetes from January 1, 2009 through December 31, 2016. Using an electronic algorithm, patients were classified as no DPN, DPN + P, or DPN-P. Primary outcomes included number of vascular events and time to mortality. Independent associations with DPN + P were evaluated using multivariable negative binomial and Cox proportional hazards regression models, adjusting for demographics, socioeconomic characteristics, and comorbidities.Results: Of 43 945 patients with type 2 diabetes (age 64.6 ± 14.0 years; 52.1% female), 13 910 (31.7%) had DPN: 9104 DPN + P (65.4%) vs 4806 DPN-P (34.6%). Vascular events occurred in 4538 (15.1%) of no DPN patients, 2401 (26.4%) DPN + P, and 1006 (20.9%) DPN-P. After adjustment, DPN + P remained a significant predictor of number of vascular events (incidence rate ratio [IRR] = 1.55, 95% CI, 1.29-1.85), whereas no DPN was protective (IRR = 0.70, 95% CI, 0.60-0.82), as compared to DPN-P. Compared to DPN-P, DPN + P was also a significant predictor of mortality (hazard ratio = 1.42, 95% CI, 1.25-1.61).Conclusions: Our study found a significant association between pain in DPN and an increased risk of vascular events and mortality. This observation warrants longitudinal study of the risk factors and natural history of pain in DPN. [ABSTRACT FROM AUTHOR]

Objectives: To examine the accuracy of general health cross-walk tables in a clinical sample of patients with spine disorders. Published tables (Schalet BD, Rothrock NE, Hays RD, et al. Linking physical and mental health summary scores from the Veterans RAND 12-Item Health Survey (VR-12) to the PROMIS(®) Global Health Scale. J Gen Intern Med 2015;30:1524-30) link scores from the Veterans RAND 12-Item Health Survey (VR-12) to the 10-Item Patient-Reported Outcome Measurement Information System (PROMIS), a global health scale metric for both mental (GMH) and physical (GPH) summary scores.Methods: We assessed the accuracy of administered PROMIS and VR-12 scores with scores predicted by cross-walks in 4606 adult patients seen in a spine clinic from October 2015 to 2016. Accuracy of linking scores was evaluated using Pearson correlation, intraclass correlation coefficients, and mean and SD of score differences. Bland-Altman plots were used to graphically assess the levels of agreement. The consistency in scores' discrimination across levels of pain severity, depression, and other patient characteristics was assessed. Bootstrap methods estimated linking precision across varying sample sizes.Results: Actual and cross-walked PROMIS scores showed moderate correlation (ICC(3,1): GMH 0.73; GPH 0.81), with Bland-Altman plots suggesting smaller differences between scores in patients with lower and higher general health. Significant discrimination between patient subgroups was demonstrated reliably by both actual and estimated scores. Bootstrapped resamples indicated adequate precision for 200 patients (95% confidence interval for mean difference: GMH -1.38 to 0.60; GPH 0.39 to 1.93).Conclusions: VR-12 and PROMIS global health scores can be accurately linked within a sample of patients with spine disorders; nevertheless, bias is high and precision is low for linking on the patient level. Linked scores at the group level for more than 200 patients can be used in comparative effectiveness research and for comparing results across studies. [ABSTRACT FROM AUTHOR]

Background: When considering an asymptomatic inguinal hernia, surgeons must weigh the risks of watchful waiting against the risk of operative complications. Laparoscopy offers the benefit of reduced postoperative pain, which, for appropriate surgical candidates, may strengthen the case for repair. This study compares general and disease-specific quality of life following totally extraperitoneal (TEP) laparoscopic inguinal hernia repair (LIHR) of asymptomatic and symptomatic hernias.Methods: We summarize prospective data from 387 patients who underwent TEP LIHR between 2009 and 2015 by four surgeons at a single institution. Asymptomatic individuals were identified by pain scores of zero at preoperative clinic visits. Validated quality of life (QOL) measurements were administered preoperatively and at 3 weeks, 6 months, and 1-year postop. Comparisons were made using Chi-square test, t test, or Mann-Whitney U test. Changes over time were assessed using longitudinal mixed effects models.Results: A cohort of 79 asymptomatic cases were compared to 308 symptomatic individuals. The asymptomatic cohort had larger median hernia defects (2.5 vs 2 cm, p < 0.01), was older (mean 63.0 vs 58.9 years, p = 0.03), included fewer indirect hernias (57.7 vs 74.9%, p < 0.01), took pain medication for fewer days (mean 1.2 ± 1.5 vs 2.2 ± 3.0 days, p = 0.02), returned to baseline activities of daily living earlier (median 3 vs 5 days, p < 0.01), and reported decreased postoperative pain (p = 0.02). There was no significant difference in general QOL. There was one recurrence in the asymptomatic group and were two in the symptomatic cohort.Conclusions: Asymptomatic individuals undergoing TEP LIHR reported less postoperative pain, returned to baseline activities, and discontinued pain medication sooner than symptomatic patients. These results are encouraging and may inform patient-centered discussions about asymptomatic hernia repair. [ABSTRACT FROM AUTHOR]

Background. Functional impairment is common in people with chronic liver disease (CLD), and improvement is expected following liver transplantation (LT). The Six-Minute Walk Test (6MWT) is an objective measure of functional performance. Objective. The aims of this study were: (1) to evaluate the feasibility of 6MWT performance after LT, (2) to compare post-LT 6MWT performance over time between patients with and without CLD, (3) to determine when post-LT 6MWT performance approaches expected values, and (4) to investigate predictors of poor 6MWT performance. Methods. The 6MWT was performed by 162 consecutive ambulatory participants (50 healthy controls, 62 with CLD, 50 with LT). Sex, age, and body mass index were used to predict expected 6MWT performance. Chi-square testing, analysis of variance, and Pearson coefficients compared percentage of predicted 6-minute walk distance (%6MWD) across groups. Multivariable mixed models assessed predictors of improvement. Results. The participants' mean age was 53.5 years (SD = 13.0), 39.5% were female, and 39.1% were nonwhite. At 1-month post-LT, only 52% of all LT recipients met the inclusion criteria for 6MWT performance. Mean %6MWD values for female participants improved from 49.8 (SD = 22.2) at 1 month post-LT to 90.6 (SD = 12.8) at 1 year post-LT (P-C0001), which did not differ statistically from the CLD group (X=95.9, SD= 15.6) or the control group (X=95.6, SD=18.0) (P=.58). However, at 1-year post-LT, mean %6MWD values for male participants (X=80.4, SD = 19.5) remained worse than for both the CLD group (X=93.3, SD = 13.7) and the control group (X=91.9, SD = 14.3) (P=.O3). Six-Minute Walk Test performance was directly correlated with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical component score (r=.51, P<.01) and was inversely correlated with nonalcoholic steato-hepatitis(r=-.52, P<.01) and diabetes (r= -.48, P<.05). In multivariate analysis adjusted for age and sex, hepatitis C independently predicted 6MWT improvement (estimated β=698, standard error=27.6, P=.01). Limitations. A significant proportion of patients evaluated for enrollment were excluded due to level of illness early after LT (n=99, 47.4%). Thus, sampling bias occurred in this study toward patients without significant postoperative complications. Conclusions. The 6MWT is a simple test of physical functioning but may be difficult to apply in LT recipients. The 6MWT performance improved following LT but was lower than expected, suggesting a low level of fitness up to 1 year following LT. [ABSTRACT FROM AUTHOR]

The efficacy of mandatory medically supervised preoperative weight loss (MPWL) prior to bariatric surgery continues to be a controversial topic. The purpose of this observational study was to assess the efficacy of a MPWL program in a single institution, which mandated at least 10% excess body weight loss before surgery, by comparing outcomes of patients undergoing primary bariatric surgery with and without a compulsory preoperative weight loss regimen. We analyzed our database of 757 patients who underwent primary bariatric surgery between March 2008 and January 2015. Patients were placed into two cohorts based on their participation in a MPWL program requiring at least 10% excess weight loss (EWL) prior to surgery. Patients were evaluated at 3, 6, 12, and 24 months after surgery for weight loss, comorbidity resolution, and the occurrences of hospital readmissions. A total of 717 patients met the inclusion criteria of whom 465 underwent surgery without a preoperative weight loss requirement and 252 participated in the MPWL program. One year after surgery, 67.1% of non-participants and 62.5% of MPWL participants showed a resolution of at least one of five associated comorbidities (p = 0.45). Non-participants showed an average of 58.6% EWL, while MPWL participants showed 59.1% EWL at 1 year postoperatively (p = 0.84). Readmission rates, excluding those which were ulcer-related, at 30 days (3.4 vs. 6.40%, p = 0.11) and 90 days (9.9 vs. 7.5%, p = 0.29) postoperatively were not significantly different between the non-participants and MPWL patients, respectively. A mandatory preoperative weight loss program prior to bariatric surgery did not result in significantly greater %EWL or comorbidity resolution 1 year after surgery compared to patients not required to lose weight preoperatively. Additionally, the program did not result in significantly lower 30- or 90-day readmission rates for these patients. The value of a MPWL program must be weighed against the potential loss of bariatric surgery candidates. Patients who fail to lose 10% excess weight preoperatively are thus ineligible for a procedure from which they would otherwise benefit. Our data suggest these patients will have similar positive outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine whether statin intake affects nephrolithiasis risk, and whether higher lipid levels correlate with stone risk. Dyslipidemia is a known independent risk factor for urolithiasis, and emerging evidence suggests common biological pathways. Previous work has suggested that statins protect against new stone formation, but these findings have not been verified by other investigators.Methods: We queried our Institution's Electronic Data Warehouse for all patients who were newly diagnosed with hyperlipidemia between 2009 and 2011, and had never taken a statin drug. These patients' clinical outcomes were followed until 2015, to assess whether they had been newly prescribed statins and whether they had developed symptomatic urolithiasis. Patient demographics, stone risk factors, prescription data, and serum lipid values were collected.Results: A total of 101,259 patients met inclusion criteria, 47.8% of whom received a statin prescription during the study period. Patients prescribed statins were significantly older, had a greater likelihood of osteoporosis, hemiplegia, immobility, and more likely to take a thiazide diuretic. Patients without a history of urolithiasis who were started on statin therapy were significantly less likely to develop new stones than patients not taking statins. This protective effect was even greater in patients with a history of stone disease. Lipid parameters (low-density lipoprotein, triglyceride, cholesterol) were lower in the statin-treated group, suggesting overall compliance with these medications.Conclusion: Our data confirm previous work that statins protect against urinary stone formation; however, the underlying mechanism seems to be distinct from statins' lipid-lowering effect. [ABSTRACT FROM AUTHOR]

Background: The lack of long-term data on quality of life after groin hernia repair presents a challenge in setting patients' postoperative expectations. This study aimed to describe quality of life outcomes after laparoscopic totally extraperitoneal groin hernia repair with a minimum of 2 years follow-up.Study Design: We prospectively evaluated 293 patients who had laparoscopic totally extraperitoneal groin hernia repair in an IRB-approved study. The Short-Form 36-item Health Survey (version 2), Surgical Outcomes Measurement System, and Carolinas Comfort Scale were administered pre- and postoperatively. Pairwise comparisons using nonparametric Wilcoxon signed rank test were made between time points.Results: Mean patient age was 56 ± 15 years and 93% were male; 80% of patients presented with painful hernias and 15% of hernias were recurrent. Mean operative time was 43 ± 16 minutes. No operative complications occurred. Mean duration of narcotic pain medication use was 2.5 ± 3.4 days, and daily activities were resumed and return to work occurred 5.4 ± 4.4 days and 5.4 ± 3.9 days post operation, respectively. Recurrence rate was 2%. The Short-Form 36-item Health Survey outcomes improved from baseline for domains of Physical Functioning, Role Limitations due to Physical Health, and Pain at 2 years post operation; Surgical Outcomes Measurement System outcomes improved for domains of Pain Impact on Quality of Life, Body Image, and Patient Satisfaction (p ≤ 0.05). The percentage of patients reporting no or mild but not bothersome symptoms on the Carolinas Comfort Scale at 2 years post operation for sensation of mesh, pain, and movement limitations were 98%, 95%, and 97%, respectively.Conclusions: Measuring both general and procedure-specific quality of life, patients' perceptions of health status improved significantly 2 years after laparoscopic totally extraperitoneal groin hernia repair. [ABSTRACT FROM AUTHOR]