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Background Electronic health records (EHRs) provide researchers with abundant sample sizes, detailed clinical data, and other advantages for performing high-quality observational health research on diverse populations. We review and demonstrate strategies for the design and analysis of cohort studies on neighborhood diversity and health, including evaluation of the effects of race, ethnicity, and neighborhood socioeconomic position on disease prevalence and health outcomes, using localized EHR data. Methods Design strategies include integrating and harmonizing EHR data across multiple local health systems and defining the population(s) of interest and cohort extraction procedures for a given analysis based on the goal(s) of the study. Analysis strategies address inferential goals, including the mechanistic study of social risks, statistical adjustment for differences in distributions of social and neighborhood-level characteristics between available EHR data and the underlying local population, and inference on individual neighborhoods. We provide analyses of local variation in mortality rates within Cuyahoga County, Ohio. Results When the goal of the analysis is to adjust EHR samples to be more representative of local populations, sampling and weighting are effective. Causal mediation analysis can inform effects of racism (through racial residential segregation) on health outcomes. Spatial analysis is appealing for large-scale EHR data as a means for studying heterogeneity among neighborhoods even at a given level of overall neighborhood disadvantage. Conclusions The methods described are a starting point for robust EHR-derived cohort analysis of diverse populations. The methods offer opportunities for researchers to pursue detailed analyses of current and historical underlying circumstances of social policy and inequality. Investigators can employ combinations of these methods to achieve greater robustness of results. Highlights EHR data are an abundant resource for studying neighborhood diversity and health. When using EHR data for these studies, careful consideration of the goals of the study should be considered in determining cohort specifications and analytic approaches. Causal mediation analysis, stratification, and spatial analysis are effective methods for characterizing social mechanisms and heterogeneity across localized populations.

Since its development, Singh’s 2003 Area Deprivation Index (ADI) has been routinely used by researchers to measure a global construct of neighborhood socioeconomic deprivation and to investigate how living in neighborhoods of different levels of socioeconomic deprivation affects individuals’ health. We empirically tested the ADI’s dimensionality, using 2013–2017 American Community Survey tract-level estimates (N = 73,056), and the stability of its performance across time and place. Factor analysis findings illuminated three distinct dimensions, the ADI-3, consisting of neighborhood financial strength, economic hardship and inequality, and educational attainment. The prior-assumed unidimensional ADI measure fails standard tests of construct validity. Findings from multigroup structural equation modeling across 2009 and 2017 and between New York and Minnesota suggest that the ADI performs with only partial stability across time and place. In order to most precisely understand the complex role of neighborhood socioeconomic position in health, public health researchers must integrate construct-valid and regionally and temporally relevant measures.

Using a multi-institutional EMR registry, we extracted housing status and evaluated the presence of several important comorbidities in order to describe the demographics and comorbidity burden of persons experiencing homelessness in northeast Ohio and compare this to non-homeless individuals of varying socioeconomic position. Of 1,974,766 patients in the EMR registry, we identified 15,920 (0.8%) as homeless, 351,279 (17.8%) as non-homeless and in the top quintile of area deprivation index (ADI), and 1,607,567 (81.4%) as non-homeless and in the lower four quintiles of area deprivation. The comorbidity burden was highest in the homeless population with depression (48.1%), anxiety (45.8%), hypertension (44.2%), cardiovascular disease (18.4%), and hepatitis (18.1%) among the most prevalent conditions. We conclude that it is possible to identify homeless individuals and document their comorbidity burden using a multi-institutional EMR registry, in order to guide future interventions to address the health of the homeless at the health-system and community level.

As broader geographic sharing is implemented in lung transplant allocation through the Composite Allocation Score (CAS) system, models predicting waitlist and posttransplantation survival will become more important in determining access to organs.How well do CAS survival models perform, and can discrimination performance be improved with alternative statistical models or machine learning approaches?Scientific Registry for Transplant Recipients (SRTR) data from 2015-2020 were used to build seven waitlist (WL) and data from 2010-2020 to build similar posttransplantation (PT) models. These included the (I) current lung allocation score (LAS)/CAS model; (II) re-estimated WL-LAS/CAS model; (III) model II incorporating nonlinear relationships; (IV) random survival forests model; (V) logistic model; (VI) linear discriminant analysis; and (VII) gradient-boosted tree model. Discrimination performance was evaluated at 1, 3, and 6 months on the WL and 1, 3, and 5 years posttransplantation. Area under the curve (AUC) values were estimated across subgroups.WL model performance was similar across models with the greatest discrimination in the baseline cohort (AUC 0.93) and declined to 0.87-0.89 for 3-month and 0.84-0.85 for 6-month predictions and further diminished for residual cohorts. Discrimination performance for PT models ranged from AUC 0.58-0.61 and remained stable with increasing forecasting times but was slightly worse for residual cohorts. WL and PT variability in AUC was greatest for individuals on Medicaid.Use of alternative modeling strategies and contemporary cohorts did not improve performance of models determining access to lung transplant.

ImportanceA recent National Academies of Sciences, Engineering, and Medicine study found that transplant outcomes varied greatly based on multiple factors, including race, ethnicity, and geographic location. They proposed a number of recommendations including studying opportunities to improve equity in organ allocation.ObjectiveTo evaluate the role of donor and recipient socioeconomic position and region as a mediator of observed racial and ethnic differences in posttransplant survival.Design, Setting, and ParticipantsThis cohort study included lung transplant donors and recipients with race and ethnicity information and a zip code tabulation area–defined area deprivation index (ADI) from September 1, 2011, to September 1, 2021, whose data were in the US transplant registry. Data were analyzed from June to December 2022.ExposuresRace, neighborhood disadvantage, and region of donors and recipients.Main Outcomes and MeasuresUnivariable and multivariable Cox proportional hazards regression were used to study the association of donor and recipient race with ADI on posttransplant survival. Kaplan-Meier method estimation was performed by donor and recipient ADI. Generalized linear models by race were fit, and mediation analysis was performed. Bayesian conditional autoregressive Poisson rate models (1, state-level spatial random effects; 2, model 1 with fixed effects for race and ethnicity, 3; model 2 excluding region; and 4: model 1 with fixed effects for US region) were used to characterize variation in posttransplant mortality and compared using ratios of mortality rates to the national average.ResultsOverall, 19 504 lung transplant donors (median [IQR] age, 33 [23-46] years; 3117 [16.0%] Hispanic individuals, 3667 [18.8%] non-Hispanic Black individuals, and 11 935 [61.2%] non-Hispanic White individuals) and recipients (median [IQR] age, 60 [51-66] years; 1716 [8.8%] Hispanic individuals, 1861 [9.5%] non-Hispanic Black individuals, and 15 375 [78.8%] non-Hispanic White individuals) were included. ADI did not mediate the difference in posttransplant survival between non-Hispanic Black and non-Hispanic White recipients; it mediated only 4.1% of the survival difference between non-Hispanic Black and Hispanic recipients. Spatial analysis revealed the increased risk of posttransplant death among non-Hispanic Black recipients may be associated with region of residence.Conclusions and RelevanceIn this cohort study of lung transplant donors and recipients, socioeconomic position and region of residence did not explain most of the difference in posttransplant outcomes among racial and ethnic groups, which may be due to the highly selected nature of the pretransplant population. Further research should evaluate other potentially mediating effects contributing to inequity in posttransplant survival.

Summary Literature exploration in PubMed on a large number of biomedical entities (e.g. genes, diseases or experiments) can be time-consuming and challenging, especially when assessing associations between entities. Here, we describe SimText, a user-friendly toolset that provides customizable and systematic workflows for the analysis of similarities among a set of entities based on text. SimText can be used for (i) text collection from PubMed and extraction of words with different text mining approaches, and (ii) interactive analysis and visualization of data using unsupervised learning techniques in an interactive app. Availability and implementation We developed SimText as an open-source R software and integrated it into Galaxy (https://usegalaxy.eu), an online data analysis platform with supporting self-learning training material available at https://training.galaxyproject.org. A command-line version of the toolset is available for download from GitHub (https://github.com/dlal-group/simtext) or as Docker image (https://hub.docker.com/r/dlalgroup/simtext/tags.). Supplementary information Supplementary data are available at Bioinformatics online.

Background The purpose of this study was to evaluate glenoid component position and radiolucency following anatomic total shoulder arthroplasty (TSA) using sequential 3-dimensional computed tomography (3D CT) analysis. Methods In a series of 152 patients (42 Walch A1, 16 A2, 7 B1, 49 B2, 29 B3, 3 C1, 3 C2, and 3 D glenoids) undergoing anatomic TSA with a polyethylene glenoid component, sequential 3D CT analysis was performed preoperatively (CT1), early postoperatively (CT2), and at a minimum 2-year follow-up (CT3). Glenoid component shift was defined as a change in component version or inclination of ≥3° from CT2 to CT3. Glenoid component central anchor peg osteolysis (CPO) was assessed at CT3. Factors associated with glenoid component shift and CPO were evaluated. Results Glenoid component shift occurred from CT2 to CT3 in 78 (51%) of the 152 patients. CPO was seen at CT3 in 19 (13%) of the 152 patients, including 15 (19%) of the 78 with component shift. Walch B2 glenoids with a standard component and glenoids with higher preoperative retroversion were associated with a higher rate of shift, but not of CPO. B3 glenoids with an augmented component and glenoids with greater preoperative joint-line medialization were associated with CPO, but not with shift. More glenoid component joint-line medialization from CT2 to CT3 was associated with higher rates of shift and CPO. A greater absolute change in glenoid component inclination from CT2 to CT3 and a combined absolute glenoid component version and inclination change from CT2 to CT3 were associated with CPO. Neither glenoid component shift nor CPO was associated with worse clinical outcomes. Conclusions Postoperative 3D CT analysis demonstrated that glenoid component shift commonly occurs following anatomic TSA, with increased inclination the most common direction. Most (81%) of the patients with glenoid component shift did not develop CPO. Longer follow-up is needed to determine the relationships of glenoid component shift and CPO with loosening over time. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To examine relationships between neighborhood socioeconomic disadvantage and outcomes following radical cystectomy (RC).A retrospective single institution study of consecutive RCs performed for bladder cancer between 2011 and 2019. Major complications, mortality and survival outcomes were compared using Cochran-Armitage or Kruskal-Wallis tests. Cox proportional hazards models were used for time-to-event analyses.A total of 906 patients were included in analysis. Overall 90-day mortality was 2.98% (27/906). Ninety-day mortality rates observed in the least (first) and most (fourth) disadvantaged ADI quartiles were 0% (0/115) and 6.5% (12/185), respectively. Patients from the fourth quartile demonstrated worse overall survival and recurrence free survival than those in the first quartile. ADI quartile was positively associated with muscle invasive (P = .0006) and node positive (P = .042) disease. ADI percentile was an independent predictor for 90-day mortality (adjusted OR: 1.022, CI: 1.004-1.04, P = .015).Higher rates of mortality and worse oncologic outcomes were observed for patients residing in the most disadvantaged quartile. ADI was associated with higher likelihood of 90-day mortality and may therefore be useful in patient counseling, risk stratification, and post-discharge management.

Background: Dysregulation of immunohematologic function (IHF) promotes cardiovascular disease and impairs protective responses to cancer and infection. A pragmatic method to identify those as risk due to IHF could improve the precision of preventive interventions and provide insight into the heterogeneity of immunologic capacity. We developed and validated a method to distill complete blood cell count data into distinct IHF profiles of prognostic relevance. Methods: We adapted latent profile analysis methods to simultaneously identify distinct groups of patients with respect to 10 immunohematologic indicators and regress time to all-cause mortality on this latent IHF profile. The model was developed using data from 30274 National Health and Nutrition Examination Survey participants and externally validated in 49851 outpatients in the Veterans Heath Administration (VHA) system and 44142 SARS-CoV-2 positive VHA patients. Findings: Ten distinct IHF profiles were identified. Profile 1, with relative mild pan-leukopenia in absence of red cell abnormalities, was associated with the best long term survival in each setting. Profiles 8-10, featuring anemia/anisocytosis especially in the setting of lymphopenia (Profiles 9-10) were associated with adjusted hazard ratio (HR) estimates of 1.76-2.62 for mortality across the three cohorts, compared to Profile 1. Profiles 6-7, featuring relative neutrophilia, were less common but also independently associated with mortality risk, especially after COVID-19 infection (Profile 7 HR [95% CI]: 2.51 [1.63 – 3.86]). The magnitude of adjusted risk conveyed by IHF profiles was greater than individual clinical risk factors (i.e., smoking, diabetes) or prevalent co-morbidities. Interpretation: Distinct immunohematologic endotypes can be identified during routine blood panels which project to mortality risk on par with a decade of life, additive to demographic and clinical factors. Applications that consider immunohematologic dysfunction may improve prevention of common fatal diseases, including COVID-19. Funding Information:This study was funded in part by The National Institute on Aging (R01AG055480; Dalton and Perzynski), the National Cancer Institute (U01CA260513; Zidar and Chan), and the United States Veteran Administration (COVID19-8900-05; Zidar). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veteran Affairs or the National Institutes of Health. Declaration of Interests: No conflict of interest exists between any of the authors and the contents of this paper. Ethics Approval Statement: The study was approved by the Institutional Review Board of the Louis Stokes Cleveland VAMC.

Electronic health records (EHRs) offer the potential to study large numbers of patients but are designed for clinical practice, not research. Despite the increasing availability of EHR data, their use in research comes with its own set of challenges. In this article, we describe some important considerations and potential solutions for commonly encountered problems when working with large-scale, EHR-derived data for health services and community-relevant health research. Specifically, using EHR data requires the researcher to define the relevant patient subpopulation, reliably identify the primary care provider, recognize the EHR as containing episodic (i.e., unstructured longitudinal) data, account for changes in health system composition and treatment options over time, understand that the EHR is not always well-organized and accurate, design methods to identify the same patient across multiple health systems, account for the enormous size of the EHR, and consider barriers to data access. Associations found in the EHR may be nonrepresentative of associations in the general population, but a clear understanding of the EHR-based associations can be enormously valuable to the process of improving outcomes for patients in learning health care systems. In the context of building 2 large-scale EHR-derived data sets for health services research, we describe the potential pitfalls of EHR data and propose some solutions for those planning to use EHR data in their research. As ever greater amounts of clinical data are amassed in the EHR, use of these data for research will become increasingly common and important. Attention to the intricacies of EHR data will allow for more informed analysis and interpretation of results from EHR-based data sets.

Since its development, Singh’s 2003 Area Deprivation Index (ADI) has been routinely used by researchers to measure a global construct of neighborhood socioeconomic deprivation and how living in neighborhoods of different levels of deprivation affects individuals’ health. We tested the ADI’s dimensionality and the stability of its performance across time and place. Factor analysis findings illuminated three distinct dimensions, the ADI-3, consisting of neighborhood financial strength, economic hardship and inequality, and educational attainment. The prior-assumed unidimensional ADI measure fails standard tests of construct validity. Findings from multigroup structural equation modeling across 2009 and 2017 and between New York and Minnesota suggest that the ADI performs with only partial stability across time and place. In order to most precisely understand the complex role of neighborhood socioeconomic position in health, public health researchers must integrate construct-valid and regionally- and temporally-relevant measures.

Objective: We sought to determine whether levels of individual leukocyte subsets (neutrophils, monocytes, and lymphocytes) and their post-procedural trajectory are related to survival after transcatheter aortic valve replacement (TAVR).Methods: We conducted a retrospective study of consecutive patients undergoing transfemoral TAVR in a large academic referral center (2012–2014). The association between baseline and 1-day post-TAVR change in leukocyte subsets and mortality were analyzed using Cox proportional hazards and Kaplan-Meier methods.Results: A total of 136 patients were included in this study. Overall, TAVR was associated with a modest increase in total leukocyte counts which was driven by increases in neutrophils and monocytes. In contrast, absolute lymphocyte counts (ALC) decreased sharply after TAVR (median difference −0.43 × 109/L, p

Sentinel lymph node biopsy is the gold standard for axillary staging in early-stage, clinically node-negative breast cancer, so it is paramount that this operation be both precise and accurate, because excessive sentinel lymph node removal increases morbidity, whereas understaging risks inadequate treatment. The goal of this study was to assess surgeon variation in the number of sentinel lymph nodes removed and the oncologic yield of sentinel lymph node biopsy for breast cancer.All patients in the Surveillance, Epidemiology, and End Results-Medicare database who underwent operative treatment for breast cancer from 2007-2011 were eligible for inclusion. Deidentified provider codes were used to track operations performed by individual surgeons. Only records in which an individual surgeon could be linked to a specific breast cancer operation were analyzed. The total number of sentinel lymph nodes removed and the number that were pathologically positive (oncologic yield) were recorded. Surgeon variation by T stage was analyzed using linear mixed-effects regression and logistic mixed-effects regression models.Query of the database identified 15,571 patients who met inclusion criteria, representing 2,478 providers. The mean number of sentinel lymph node procedures performed per provider per year was 1.3 (range 1-103). The lowest quartile of providers performed 1 or fewer sentinel lymph node procedures per year. The highest quartile of providers performed8 sentinel lymph node procedures per year. The average number of sentinel lymph node removed per operation increased with increasing T stage for all providers (P.001), including when N0 (P.001) and node-positive (P = .003) patients were evaluated separately. There was surgeon-associated variation in the number of sentinel lymph node removed for each T stage (P.001). In addition, there was surgeon-associated variation in the oncologic yield (sentinel lymph node positivity rate) by T stage (P.001).This study found surgeon-associated variation in axillary sentinel lymph node staging of breast cancer patients, which suggests the need to improve standardization of surgical practices to optimize the oncologic yield of these procedures and ensure accurate staging.

Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). The social vulnerability index (SVI) is an estimate of a neighborhood's potential for deleterious outcomes when faced with natural disasters or disease outbreaks. We sought to investigate the association of the SVI with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We linked census tract SVI with prevalence of census tract CVD risk factors (smoking, high cholesterol, diabetes, high blood pressure, low physical activity and obesity), and prevalence of CHD obtained from the behavioral risk factor surveillance system. We evaluated the association between SVI, its sub-scales, CVD risk factors and CHD prevalence using linear regression. Among 72,173 census tracts, prevalence of all cardiovascular risk factors increased linearly with SVI. A higher SVI was associated with a higher CHD prevalence (R

BACKGROUND: Nearly one-quarter of the approximately 400,000 reports to child protective services originating from non-mandated reporters come from neighbors. Understanding factors leading non-mandated reporters to contact authorities is important because if modifiable, they might serve as intervention targets to promote reporting of suspected maltreatment. OBJECTIVE: Investigate associations between neighbors’ reported responses to scenarios involving children in need, child/teen misbehavior, and suspected maltreatment with individual and neighborhood characteristics, including neighborhood collective efficacy, fear of victimization, and fear of retaliation. HYPOTHESIS: Increased collective efficacy would be associated with increased likelihood of neighbors taking action in response to the situation. PARTICIPANTS & SETTING: 400 caregivers of minors in Cleveland, OH, USA living in 20 census tracts. METHODS: Generalized linear mixed-effects modeling. RESULTS: Analyses adjusted for covariates confirmed our primary hypothesis: a 1-unit increase in the collective efficacy measure was associated with a 64% increase in the odds of neighbors taking action compared to doing nothing (odds ratio = 1.64, 95(th) percentile confidence interval 1.41-1.92). Also, participants with less than a high-school education had 36% greater odds of reporting their neighbors taking action compared to more educated participants. An interaction effect between participants’ fear of victimization in their neighborhood, but not fear of retaliation, was also observed: the effect of collective efficacy on the odds of neighbors taking action was substantially greater among residents expressing moderate and high fear of victimization. CONCLUSION: Enhancing collective efficacy may be an effective strategy for fostering community response to suspected child maltreatment and other situations of a child in need because it may catalyze a variety of positive responses to these situations.

Objectives We assessed characteristics that may predict outpatient appointment attendance in outpatient medical clinics among patients comorbid for serious mental illness (SMI) and type 2 diabetes (DM). Methods Baseline covariate data from 200 individuals with SMI-DM enrolled in a randomized controlled trial (RCT) were used to examine characteristics associated with electronic health record-identified clinic appointment attendance using a generalized estimating equations approach. The analyses evaluated the relationship between clinic attendance and potentially modifiable factors including disease knowledge, self-efficacy, social support, physical health, and mental health, as well as demographic information. Results Demographic and mental health characteristics were most associated with clinic attendance in adults with SMI-DM. Physical health was not associated with clinic attendance. Conclusions Information on clinical and demographic characteristics and factors potentially modifiable by psychological interventions may be useful in improving adherence to treatment among SMI-DM patients. It is our hope that clinicians and researchers will use these results to help tailor adherence-facilitating interventions among people at particular risk for poor engagement in care.

The Medicare Annual Wellness Visit (MWV) includes an assessment of health risks for older adults in the United States. Research suggests that neighborhood-level social inequality influences multiple health outcomes. We sought to examine the association between neighborhood socioeconomic position and older adults’ cognition, health management self-efficacy, and other health risks. We identified a cohort of 12,434 adults aged 65 and over from the NEOCARE Learning Health Registry who attended a routine MWV between 2011 and 2019. NEOCARE includes electronic health record and neighborhood data from 1999-2017 on over 3 million unique Northeast Ohio individuals. The study population was 60% White, 32% Black or African American, 64% female, and 90% non-Hispanic. Over 60% were ages 65-74, 29% 75-84, and 10% 85 years or older (range from 65 to 101). We used ANOVA and chi square tests to examine variation in health risks by quintile of census tract area deprivation index. Cognitive functioning differed across quintiles of area deprivation and Bonferroni-corrected tests indicated that adults in the most socioeconomically disadvantaged neighborhoods had lower average cognitive screening scores as compared to older adults in less disadvantaged areas (F=53.50, df=4, n=12,204, p

In epidemiology, gerontology, human development and the social sciences, age-period-cohort (APC) models are used to study the variability in trajectories of change over time. A well-known issue exists in simultaneously identifying age, period and birth cohort effects, namely that the three characteristics comprise a perfectly collinear system. That is, since age = period-cohort, only two of these effects are estimable at a time. In this paper, we introduce an alternative framework for considering effects relating to age, period and birth cohort. In particular, instead of directly modeling age in the presence of period and cohort effects, we propose a risk modeling approach to characterize age-related risk (i.e., a hybrid of multiple biological and sociological influences to evaluate phenomena associated with growing older). The properties of this approach, termed risk-period-cohort (RPC), are described in this paper and studied by simulations. We show that, except for pathological circumstances where risk is uniquely determined by age, using such risk indices obviates the problem of collinearity. We also show that the size of the chronological age effect in the risk prediction model associates with the correlation between a risk index and chronological age and that the RPC approach can satisfactorily recover cohort and period effects in most cases. We illustrate the advantages of RPC compared to traditional APC analysis on 27496 individuals from NHANES survey data (2005-2016) to study the longitudinal variability in depression screening over time. Our RPC method has broad implications for examining processes of change over time in longitudinal studies.

Background: Low back pain may arise from disorders of the sacroiliac joint in up to 30% of patients. Radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint has been shown to be a safe and efficacious strategy. Objectives: We aimed to develop a new RFA technique to relieve low back pain secondary to sacroiliac joint disorders. Study Design: Methodology development with validation through prospective observational non-randomized trial (PONRT). Setting: Academic multidisciplinary health care system, Ohio, USA. Methods: We devised a guide-block to facilitate accurate placement of multiple electrodes to simultaneously ablate the L5 dorsal ramus and lateral branches of the S1, S2, and S3 dorsal rami. This was achieved by bipolar radiofrequency ablation (b-RFA) to create a strip lesion from the lateral border of the base of the sacral superior articular process (L5-S1 facet joint) to the lateral border of the S3 sacral foramen. We applied this technique in 31 consecutive patients and compared the operating time, x-ray exposure time and dose, and clinical outcomes with patients (n = 62) who have been treated with the cooled radiofrequency technique. Patients’ level of pain relief was reported as < 50%, 50 – 80%, and > 80% pain relief at one, 3, 6, and 12 months after the procedure. The relationship between RFA technique and duration of pain relief was evaluated using interval-censored multivariable Cox regression. Results: The new technique allowed reduction of operating time by more than 50%, x-ray exposure time and dose by more than 80%, and cost by more than $1,000 per case. The percent of patients who achieved > 50% pain reduction was significantly higher in the b-RFA group at 3, 6, and 12 months follow-up, compared to the cooled radiofrequency group. No complications were observed in either group. Limitations: Although the major confounding factors were taken into account in the analysis, use of historical controls does not balance observed and unobserved potential confounding variables between groups so that the reported results are potentially confounded. Conclusion: Compared to the cooled radiofrequency ablation (c-RFA) technique, the new b-RFA technique reduced operating time by more than 50%, decreased x-ray exposure by more than 80%, and cut the cost by more than $1000 per case. The new method was associated with significantly improved clinical outcomes despite the limitations of the study design. Thus this new technique appeared to be safe, efficacious, and cost-effective. Key words: Sacroiliac joint pain, sacroiliac joint, low back pain, radiofrequency ablation (RFA), bipolar radiofrequency ablation (b-RFA), cooled radiofrequency ablation (c-RFA), cost-effectiveness

BACKGROUND While substantial practice variation in coronary revascularization has been described and deviation from clinical practice guidelines has been associated with worse outcomes, the degree to which this is driven by flawed decision making and/or appropriate deviation associated with comorbid conditions is unknown. We evaluated heterogeneity in procedure use, and the extent to which hospital-level practice variation is related to surgical mortality. METHODS We analyzed data on 554,563 inpatients undergoing either percutaneous coronary intervention or coronary artery bypass grafting at 391 centers in 6 states. Procedure-specific risk models were developed based on demographics and comorbidities, allowing for differential effects of comorbidities for each sex. For each patient, the revascularization procedure that minimized predicted probability of inhospital mortality was designated as the model-preferred procedure.Hospital-level discordance rates-the proportion of cases in each hospital for which the opposite from the model-preferred procedure was performed-were calculated. Hierarchical linear models were used to analyze the relationship between HDRs and hospital-level risk-standardized mortality ratios (RSMRs). RESULTS Comorbidities and demographics alone explained between 68% and 86% of overall variation in inhospital mortality (corresponding C-statistics of 0.84-0.93). The mean (SD) HDR was 26.3% (9.6%). There was a positive independent association between HDRs and inhospital mortality, with a 10% increase in HDR associated with an 11% increase in RSMR (P

Study Objective To determine the number of difficult airway (DA) carts required based on the number of anesthetising locations and patients risk of DA. Design Binomial distributions. Setting and Patients Various hypothetical settings and patient cohorts. Interventions and Measurements Binomial distributions were used to calculate the number of distinct combinations of DAs by number of anesthetising locations assuming an average risk of 10%. The ‘at least' number of DAs was calculated using cumulative probabilities of having exactly two plus more than 2 DAs up to the total number of simultaneously started anesthetising locations o r until the cumulative probability exceeds the 50% threshold, therefore being more likely than not. Main Results The probability of encountering concurrent DAs increases as the number of simultaneously started anesthetising locations increases. For at least 2 concurrent DAs, the probability first exceeds 50% at 17 locations. The corresponding thresholds for at least 3 and 4 concurrent DAs, are 27 and 37 locations respectively. The probability of at least 2 concurrent DAs will exceed 50% when approximately 17 anesthetising sites are started simultaneously and a 10% worst case risk is assumed. Conclusions With continuing resource constraints, proper planning of human and capital resources for DAs needs to be addressed without compromising patient safety. It is recommended that every block of 15–20 sites be equipped with a DA cart, that anaesthesia groups develop and rehearse DA algorithms with available equipment, and that preoperative anaesthesia clinics be used to identify DA therefore providing logistical leverage.

Models of successful aging underscore the critical role of external social resources in older adults’ health and well-being. Neighborhood socioeconomic position is known to influence health, but little is known about the linkages between neighborhood conditions, social relationships and health among older adults. We identified a cohort of 12,434 adults (aged 65+) who attended a Medicare Annual Wellness Visit from the NEOCARE Learning Health Registry. NEOCARE includes electronic health record (EHR) and neighborhood data from 1999-2017 on over 3 million unique Northeast Ohio individuals. The study population was 60% White, 32% Black or African American, 64% female, and 90% non-Hispanic. Over 60% were ages 65-74, 29% 75-84, and 10% 85 years or older (range from 65 to 101). We used ANOVA and chi square tests to examine variation in social support by quintile of the census tract area deprivation index. Compared to those in less disadvantaged neighborhoods, older adults in more disadvantaged neighborhoods were more likely to report needing help with care needs (Bonferroni-corrected x2=95.21, df=4, n=8,967, p

The contemporary scientific community places a growing emphasis on the reproducibility of research. The projects R package is a free, open-source endeavor created in the interest of facilitating reproducible research workflows. It adds to existing software tools for reproducible research and introduces several practical features that are helpful for scientists and their collaborative research teams. For each individual project, it supplies an intuitive framework for storing raw and cleaned study data sets, and provides script templates for protocol creation, data cleaning, data analysis and manuscript development. Internal databases of project and author information are generated and displayed, and manuscript title pages containing author lists and their affiliations are automatically generated from the internal database. File management tools allow teams to organize multiple projects. When used on a shared file system, multiple researchers can harmoniously contribute to the same project in a less punctuated manner, reducing the frequency of misunderstandings and the need for status updates.

Background The use of hyperoncotic albumin (HA) for shock resuscitation is controversial given concerns about its cost, effectiveness, and potential for nephrotoxicity. We evaluated the association between early exposure to hyperoncotic albumin (within the first 48 h of onset of shock) and acute organ dysfunction in post-surgical patients with shock. Methods This retrospective, cohort study included 11,512 perioperative patients with shock from 2009 to 2012. Shock was defined as requirement for vasopressors to maintain adequate mean arterial pressure and/or elevated lactate (> 2.2 mmol/L). Subsets of 3600 were selected after propensity score and exact matching on demographics, comorbidities, and treatment variables (> 30). There was a preponderance of cardiac surgery patients. Proportional odds logistic regression, multivariable logistic regression or Cox proportional hazard regression models measured association between hyperoncotic albumin and acute kidney injury (AKI), hepatic injury, ICU days, and mortality. Results Hyperoncotic albumin-exposed patients showed greater risk of acute kidney injury compared to controls (OR 1.10, 95% CI 1.04, 1.17. P = 0.002), after adjusting for imbalanced co-variables. Within matched patients, 20.3%, 2.9%, and 4.4% of HA patients experienced KDIGO stages 1–3 AKI, versus 19.6%, 2.5%, and 3.0% of controls. There was no difference in hepatic injury (OR 1.16; 98.3% CI 0.85, 1.58); ICU days, (HR 1.05; 98.3% CI 1.00, 1.11); or mortality, (OR 0.88; 98.3% CI 0.64, 1.20). Conclusions Early exposure to hyperoncotic albumin in postoperative shock appeared to be associated with acute kidney injury. There did not appear to be any association with hepatic injury, mortality, or ICU days. The clinical and economic implications of this finding warrant further investigation.

Age-Period-Cohort (APC) models in gerontology can be used to understand time-varying events that account for variability in patient care and health outcome trajectories. Age effects have been thought of as the consequences of growing older; period effects as the consequences of general influences that vary through time or epoch; and cohort effects as the consequences of being born in a given year or birth cohort. APC models are often criticized for inability to independently estimate age, period, and cohort effects, since age = period + cohort presents a model identification problem. Bell and Jones (2014) have criticized the efficiency of current proposed solutions and recommended that an investigator performing APC analyses choose which two among the three APC effects are most interesting to study. We propose a novel method for APC analyses for including functions of all three effects. We model period and cohort along with an internal risk score based on age and other risk factors relevant to predicting the outcome of interest. We exclude period and cohort in the internal risk score model. The resulting risk index contains information about an age effect, but is not linearly dependent with period and cohort. A necessary condition is 0.05 ≤ |ρ| ≤ 0.95, where ρ is the correlation between age and the risk index. We illustrate these “risk-period-cohort” methods using individual level data in electronic health records over a 15-year period in a sample of 49,609 adults with type 2 diabetes with an outcome of time until an ASCVD event.

Background The association between preinduction blood pressure (BP) and postoperative outcomes after noncardiac surgery is poorly understood. Whether this association depends on the presence of risk factors for poor cardiovascular outcomes remains unclear. Accordingly, we evaluated the association between preinduction BP and its different components; isolated systolic hypertension (ISH) and wide pulse pressure (WPP), and postoperative complications in patients with and without revised cardiac risk index (RCRI) components. Methods We analysed consecutive patients undergoing elective noncardiac surgery at Cleveland Clinic. Separate analyses were undertaken for patients with and without any RCRI components. Preinduction BP was assessed both continuously and according to hypertension stages. Logistic regression was used to assess the association between the BP values and composite of in-hospital mortality as well as cardiovascular, renal, and neurologic morbidity. We considered the following potential confounding factors in our analysis; year of surgery, age, sex, race, BMI, and American College of Cardiology/American Heart Association surgical procedure risk classification. Results Of 58 276 patients, 10 512 had one or more RCRI components. For those with no RCRI, no significant relationship was found between preinduction BP and outcome after adjustment for confounders. For patients with RCRI, the adjusted incidence was the greatest among those with normal preinduction SBP and DBP of less than 70 mmHg. Among patients with preinduction DBP greater than 75 mmHg, risk rose slightly with increasing SBP. However, we found no association between preinduction hypertension stages, ISH, or WPP and the composite outcome in patients with and without RCRI. Conclusion Preinduction low DBP less than 70 mmHg or SBP greater than 160 mmHg and not ISH, nor WPP were associated with an increased risk of postoperative complications in noncardiac surgery patients with one or more RCRI components.

Using an observational cohort analysis, the authors studied the predictive accuracy of the Pooled Cohort Equations Risk Model of the American College of Cardiology and American Heart Association in...

Immuno-hematologic function (IHF) is increasingly being recognized as a central component of health status in older age. In this study, we sought to identify homogeneous IHF profiles regarding their relationship to all-cause mortality. We then studied the distribution of these profiles among individuals over age 65. We used data on 30,828 NHANES participants, including 10 baseline complete blood count with differential components [e.g., lymphocytes, leukocytes, red cell distribution width (RDW)] and all-cause mortality. We used latent profile analysis (LPA) to simultaneously optimize intra-cluster homogeneity on CBC components and inter-cluster survival differences. LPA (using MPlus 8.2) allowed for the empirical comparison of different solutions based on goodness-of-fit criteria. After LPA model convergence, a 9-class solution balanced goodness-of-fit criteria and interpretability of the resulting classes. The largest 3 classes accounted for 83.7% of the sample, with classes 1, 2 and 3 comprising 32.1%, 28.6% and 23.6%. Class 2 had lower lymphocytes, monocytes, neutrophils and platelets relative to classes 1 and 3. Survival rates were different between classes 1 and 2 (Cox model hazard ratio, HR=0.85; P=0.012) and 2 vs 3 (HR=1.18; P=0.001). The remaining 6 classes, which generally shared in common characteristics of higher RDW and lower hemoglobin, also were involved with significant survival differences. Multinomial logistic regression revealed that, among the subset of 7,173 participants over 65, older age was significantly associated with membership in class 1 relative to classes 2 (P

Recently, van Walraven developed a weighted summary score (VW) based on the 30 comorbidities from the Elixhauser comorbidity system. One of the 30 comorbidities, cardiac arrhythmia, is currently excluded as a comorbidity indicator in administrative datasets such as the Nationwide Inpatient Sample (NIS), prompting us to examine the validity of the VW score and its use in the NIS.Using data from the 2009 Maryland State Inpatient Database, we derived weighted summary scores to predict in-hospital mortality based on the full (30) and reduced (29) set of comorbidities and compared model performance of these and other comorbidity summaries in 2009 NIS data.Weights of our derived scores were not sensitive to the exclusion of cardiac arrhythmia. When applied to NIS data, models containing derived summary scores performed nearly identically (c statistics for 30 and 29 variable-derived summary scores: 0.804 and 0.802, respectively) to the model using all 29 comorbidity indicators (c=0.809), and slightly better than the VW score (c=0.793). Each of these models performed substantially better than those based on a simple count of Elixhauser comorbidities (c=0.745) or a categorized count (0, 1, 2, or ≥ 3 comorbidities; c=0.737).The VW score and our derived scores are valid in the NIS and are statistically superior to summaries using simple comorbidity counts. Researchers wishing to summarize the Elixhauser comorbidities with a single value should use the VW score or those derived in this study.

Intrathecal drug delivery systems represent an important component of interventional strategies for refractory chronic pain syndromes. Continuous intrathecal administration of opioids results in higher subarachnoid drug concentrations, improved pain scores, and less frequent side effects when compared with systemic opioid administration. Substantial costs arise at the time of surgical implantation and at revision for battery depletion or treatment of a complication. Despite current widespread use, the real-world longevity and cost of implanted intrathecal pumps (ITP) has not been fully quantified.Patients with an ITP implanted at Cleveland Clinic Pain Management Center between January 1998 and December 2012 were included. ITP longevity was calculated as the time between implant and explant for depletion of the system's battery. Using the 2013 fee schedule of the Centers for MedicareMedicaid Services, the daily cost of having a functioning ITP was calculated. The costs of office visits for pump refills and the cost of intrathecal medications were not included, nor were the possible savings due to decreased utilization of alternate medical services.Three hundred sixty-five patients had 559 pumps implanted. Postlaminectomy syndrome was the most common indication (40%). The median system longevity for all pumps was 5.4 years (97.5% confidence interval: [5.0, 5.8]), including pumps extracted prematurely, as well as those that reached the elective replacement interval. The median ITP longevity was 5.9 years (95% confidence interval: [5.6, 6.1]) for pumps explanted for end of battery life. The median system cost per day was $10.46. The median cost per day of pumps explanted for end of battery life was $9.26, versus $44.59 for pumps explanted prematurely due to complications.Overall, the cohort experienced an increased incidence of pump-related complications and a device longevity that was within the range of the manufacturer's anticipated lifespan. Increasing the lifespan of the ITP and improving patient selection have the potential to significantly improve the cost-effectiveness of intrathecal therapy.

Nutrition-related policy, system, and environmental (PSE) interventions such as farmers' markets have been recommended as effective strategies for promoting healthy diet for chronic disease prevention. Tools are needed to assess community readiness and capacity factors influencing successful farmers' market implementation among diverse practitioners in different community contexts. We describe a multiphase consensus modeling approach used to develop a diagnostic tool for assessing readiness and capacity to implement farmers' market interventions among public health and community nutrition practitioners working with low-income populations in diverse contexts. Modeling methods included the following: phase 1, qualitative study with community stakeholders to explore facilitators and barriers influencing successful implementation of farmers' market interventions in low-income communities; phase 2, development of indicators based on operationalization of qualitative findings; phase 3, assessment of relevance and importance of indicators and themes through consensus conference with expert panel; phase 4, refinement of indicators based on consensus conference; and phase 5, pilot test of the assessment tool. Findings illuminate a range of implementation factors influencing farmers' market PSE interventions and offer guidance for tailoring intervention delivery based on levels of community, practitioner, and organizational readiness and capacity.

Cardiovascular disease affects 1 in 3 patients and remains the leading cause of death in the United States.(1) Severe elevation of low-density lipoprotein cholesterol (LDL-C) levels is a modifiable risk factor for developing premature cardiovascular disease, and elevation levels of 190 mg/dL or greater (to convert LDL-C values to millimoles per liter, multiply by 0.0259) may indicate a monogenic etiology such as familial hypercholesterolemia.(2) Treatment with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors or statins is recommended (class IA) for all adults 21 years or older with an LDL-C of 190 mg/dL or greater. Statin treatment appears to reduce mortality and result in cost savings for health systems.(3,4) Therefore, we sought to examine rates of statin prescription in patients screened for dyslipidemia to identify treatment gaps in a real-world contemporary setting.

We previously found lymphopenia to have important prognostic relevance, especially when accompanied by bone marrow dysregulation. Immunohematologic dysfunction (IHD, co-existent lymphopenia and anisocytosis) was strongly associated with increased all-cause mortality, but whether IHD is associated

NEW-ONSET acute kidney injury (AKI) occurs in approximately 1 to 7% of patients having noncardiac surgery depending on the classification of AKI.1,2 It is associated with increased cost, prolonged hospitalization, and worsened morbidity and mortality.3–7 Postoperative patients requiring new renal replacement therapy have an especially high risk of dying.8,9 Perioperative fluid management can be a major determinant of postoperative kidney function.10 Hypovolemia is associated with increases in morbidity and mortality,11 whereas excessive fluid administration can provoke hemodynamic deterioration, pulmonary complications, or tissue edema.12–14 Maintaining physiologic perioperative intravascular volume is thus desirable.11–15 Much evidence suggests that guiding fluid therapy to optimal stroke volume, for example with esophageal Doppler ultrasonography, improves outcome.5,16,17 Nearly all randomized evaluations of goal-directed fluid management used colloids for fluid optimization, most often a hydroxyethyl starch (HES) solution. Low-molecular-weight HES, though, increased the risk of AKI and mortality in recent large randomized trials,18,19 conclusions that are supported by systematic reviews.20–22 However, these studies largely focused on critically ill patients (i.e., sepsis and major trauma) who were given large volumes of HES. But unlike critical care patients who are often given high-dose HES over prolonged periods, surgical patients are typically given smaller amounts over just a few hours. It remains unknown whether the adverse effects of HES observed in critically ill patients apply to routine surgical patients. We therefore evaluated the association between intraoperative HES administration and postoperative kidney function after noncardiac surgery. Specifically, we tested the primary hypothesis that intra-operative HES (Hextend; Hospira Inc., Lake Forest, IL) administration increases the risk of new-onset postoperative kidney injury as defined by Acute Kidney Injury Network criteria.23 Secondarily, we tested the hypotheses that: (1) cumulative intraoperative HES volume is independently associated with risk of new-onset postoperative kidney injury; (2) the relationship between HES use and AKI depends on baseline AKI risk; (3) in-hospital mortality is greater in patients given intraoperative HES; and (4) 90-day mortality is greater in patients given intraoperative HES.

Background: Ultrasound guidance for continuous femoral perineural catheters may be supplemented by electrical stimulation through a needle or through a stimulating catheter. The authors tested the primary hypothesis that ultrasound guidance alone is noninferior on both postoperative pain scores and opioid requirement and superior on at least one of the two. Second, the authors compared all interventions on insertion time and incremental cost. Methods: Patients having knee arthroplasty with femoral nerve catheters were randomly assigned to catheter insertion guided by: (1) ultrasound alone (n = 147); (2) ultrasound and electrical stimulation through the needle (n = 152); or (3) ultrasound and electrical stimulation through both the needle and catheter (n = 138). Noninferiority between any two interventions was defined for pain as not more than 0.5 points worse on a 0 to 10 verbal response scale and for opioid consumption as not more than 25% greater than the mean. Results: The stimulating needle group was significantly noninferior to the stimulating catheter group (difference [95% CI] in mean verbal response scale pain score [stimulating needle vs. stimulating catheter] of −0.16 [−0.61 to 0.29], P < 0.001; percentage difference in mean IV morphine equivalent dose of −5% [−25 to 21%], P = 0.002) and to ultrasound-only group (difference in mean verbal response scale pain score of −0.28 [−0.72 to 0.16], P < 0.001; percentage difference in mean IV morphine equivalent dose of −2% [−22 to 25%], P = 0.006). In addition, the use of ultrasound alone for femoral nerve catheter insertion was faster and cheaper than the other two methods. Conclusion: Ultrasound guidance alone without adding either stimulating needle or needle/catheter combination thus seems to be the best approach to femoral perineural catheters.

Objectives To elucidate the differences in clinical practice between the USA and Japan in major types of uro-oncological surgery by a head-to-head comparison of national databases in the two countries. Methods We compared variations in surgical modality, length of stay, total charges, caseload centralization, transfusion incidence, and in-hospital mortality between the two countries for four major types of uro-oncological surgery (radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy) in 2011. Additionally, the chronological changes in surgical modalities were investigated for 2009–11. The national estimates were based on data from the Japanese Diagnosis Procedure Combination database and the US National Inpatient Sample. Results For radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy, minimally-invasive surgery accounted for 24.2% versus 70.2%, 0% versus 14.0%, 50.7% versus 30.7% and 50.2% versus 30.5%, respectively, in Japan versus the USA in 2011. Although minimally-invasive surgery has become increasingly frequent in both countries, the major procedures were robot-assisted surgery in the USA and laparoscopic surgery in Japan. The USA was generally characterized by a slightly younger age at operation, far higher hospital volume, a shorter length of stay, higher charges and less use of transfusion than Japan. Conclusions The findings suggest substantial differences between the USA and Japan regarding clinical practices in uro-oncological surgery. Standing at the beginning of robotic surgery era in Japan, the precise recognition of these differences will aid a proper understanding of clinical practices.

Background: Perioperative myocardial infarction (PMI) is a major surgical complication that is costly and causes much morbidity and mortality. Diagnosis and treatment of PMIs have evolved over time. Many treatments are expensive but may reduce ancillary expenses including the duration of hospital stay. The time-dependent economic impact of novel treatments for PMI remains unexplored. The authors thus evaluated absolute and incremental costs of PMI over time and discharge patterns. Methods: Approximately 31 million inpatient discharges were analyzed between 2003 and 2010 from the California State Inpatient Database. PMI was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Propensity matching generated 21,637 pairs of comparable patients. Quantile regression modeled incremental charges as the response variable and year of discharge as the main predictor. Time trends of incremental charges adjusted to 2012 dollars, mortality, and discharge destination was evaluated. Results: Median incremental charges decreased annually by $1,940 (95% CI, $620 to $3,250); P < 0.001. Compared with non-PMI patients, the median length of stay of patients who experienced PMI decreased significantly over time: yearly decrease was 0.16 (0.10 to 0.23) days; P < 0.001. No mortality differences were seen; but over time, PMI patients were increasingly likely to be transferred to another facility. Conclusions: Reduced incremental cost and unchanged mortality may reflect improving efficiency in the standard management of PMI. An increasing fraction of discharges to skilled nursing facilities seems likely a result from hospitals striving to reduce readmissions. It remains unclear whether this trend represents a transfer of cost and risk or improves patient care.