scholarly journals 688. Marginal Structure Models to Estimate the Effect of Cytomegalovirus Infection on Hospitalization Among Children Undergoing Allogeneic Hematopoietic Cell Transplantation

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S397-S398
Author(s):  
Yun Li ◽  
Arman Oganisian ◽  
Craig L K Boge ◽  
Molly Hayes ◽  
Alexander Newman ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Generalized Estimating Equations ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Causal Effect ◽  
Time Varying ◽  
Cmv Infection ◽  
Research Support ◽  
Post Transplant ◽  
Cmv Reactivation

Abstract Background Children receiving an allogeneic hematopoietic cell transplant (HCT) are at risk for cytomegalovirus (CMV) infection in the post-transplant period, necessitating routine surveillance for CMV. Some patients will not have CMV detected while others will have intermittent or persistent CMV detection. Prior analyses assessing the association of CMV infection on hospitalization in the post-transplant period have been limited by methods that did not consider the time-varying nature of the exposure (CMV reactivation) and its confounders or aim to obtain causal effect estimates. We aimed to assess the causal effect of CMV reactivation on hospitalization using a causal modeling approach. The Effect of CMV Infection on Hospitalization Using Generalized Estimating Equations and Marginal Structural Models Methods A cohort of allogeneic HCT patients transplanted at Children’s Hospital of Philadelphia January 2004–April 2017 was assembled and followed for 100 days after transplant. Eligible patients included those under CMV surveillance, defined as having ≥2 CMV whole blood polymerase chain reaction tests in the first month after HCT. All information was abstracted from medical charts. The association of CMV reactivation on the rate of hospitalization was estimated using traditional generalized estimating equations and repeated using a marginal structural model that accounted for time-varying exposure, confounders and non-random drop-out and obtained effects with causal interpretations. Results The study cohort included 340 pediatric allogeneic HCT recipients under CMV surveillance testing. 46.5% were female and the median age was 9 (range: 0 to 26). The CMV infection rate was 33.9%, with a median time to CMV detection of 23.5 days (range: 4-100). CMV infection was common in Donor+/Recipient+ (58.9%) and Donor-/Recipient+ (34.6%) patients. A traditional model estimates an additional week of CMV infection was associated with a 22% increase in average weekly hospitalization (Incidence rate ratio: 1.22, 95%: 1.12 -1.34). A marginal structure model estimates an additional week of CMV infection is associated with 3% increase in average weekly hospitalization incidence (Incidence rate ratio: 1.03, 95%: 0.91-1.16). Conclusion Our research showed the effect of CMV on hospitalization diminished after properly considering the time-varying nature of the CMV infection status and its confounders. Disclosures Brian T. Fisher, DO, MPH, MSCE, Astellas (Advisor or Review Panel member)Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Azithromycin distribution and childhood mortality in compliance-related subgroups in Niger: complier average causal effect and spillovers in a cluster-randomized, placebo-controlled trial

2021 ◽  
Author(s):  
Kieran S O’Brien ◽  
Ahmed M Arzika ◽  
Ramatou Maliki ◽  
Abdou Amza ◽  
Farouk Manzo ◽  
...  
Keyword(s):  
Incidence Rate ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Causal Effect ◽  
Controlled Trial ◽  
Effect Analysis ◽  
Intention To Treat ◽  
Average Causal Effect ◽  
Cluster Randomized ◽  
Complier Average Causal Effect

Abstract Background Biannual azithromycin distribution to children 1–59 months old reduced all-cause mortality by 18% [incidence rate ratio (IRR) 0.82, 95% confidence interval (CI): 0.74, 0.90] in an intention-to-treat analysis of a randomized controlled trial in Niger. Estimation of the effect in compliance-related subgroups can support decision making around implementation of this intervention in programmatic settings. Methods The cluster-randomized, placebo-controlled design of the original trial enabled unbiased estimation of the effect of azithromycin on mortality rates in two subgroups: (i) treated children (complier average causal effect analysis); and (ii) untreated children (spillover effect analysis), using negative binomial regression. Results In Niger, 594 eligible communities were randomized to biannual azithromycin or placebo distribution and were followed from December 2014 to August 2017, with a mean treatment coverage of 90% [standard deviation (SD) 10%] in both arms. Subgroup analyses included 2581 deaths among treated children and 245 deaths among untreated children. Among treated children, the incidence rate ratio comparing mortality in azithromycin communities to placebo communities was 0.80 (95% CI: 0.72, 0.88), with mortality rates (deaths per 1000 person-years at risk) of 16.6 in azithromycin communities and 20.9 in placebo communities. Among untreated children, the incidence rate ratio was 0.91 (95% CI: 0.69, 1.21), with rates of 33.6 in azithromycin communities and 34.4 in placebo communities. Conclusions As expected, this analysis suggested similar efficacy among treated children compared with the intention-to-treat analysis. Though the results were consistent with a small spillover benefit to untreated children, this trial was underpowered to detect spillovers.

scholarly journals SARS-CoV-2 Transmission in Alberta, British Columbia, and Ontario, Canada, January 1-July 6, 2020

2020 ◽  
Author(s):  
Isaac Chun-Hai Fung ◽  
Yuen Wai Hung ◽  
Sylvia K. Ofori ◽  
Kamalich Muniz-Rodriguez ◽  
Po-Ying Lai ◽  
...  
Keyword(s):  
British Columbia ◽  
Incidence Rate ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Reproduction Number ◽  
Time Varying ◽  
Rate Ratios

Objective: To investigate COVID-19 epidemiology in Alberta, British Columbia and Ontario, Canada. Methods: We calculated the incidence rate ratio (January 1-July 6, 2020) between the 3 provinces, and estimated time-varying reproduction number, Rt, starting from March 1, using EpiEstim package in R. Results: Using British Columbia as a reference, the incidence rate ratios in Alberta and Ontario are 3.1 and 4.3 among females, and 3.4 and 4.0 among males. In Ontario, Rt fluctuated ~1 in March, reached values >1 in early and mid-April, then dropped <1 in late April and early May. Rt rose to ~1 in mid-May and then remained <1 from late May through early July. In British Columbia, Rt dropped <1 in early April, but it increased towards the end of April. Rt <1 in May while it fluctuated around 1.0 in June and early July. In Alberta, Rt > 1 in March; Rt dropped in early April and rose again in late April. In much of May, Rt <1, but Rt increases in early June and fluctuates ~1 since mid-June. Conclusions: Rt wavering around 1.0 indicated that three provinces of Canada have managed to achieve limited onward transmission of SARS-CoV-2 as of early July 2020.

scholarly journals 568. Healthcare Cost and Length of Stay for Cytomegalovirus (CMV) Infection-Related Hospitalizations in Allogeneic Hematopoietic Cell Transplant (allo-HCT) recipients: A Multicenter Analysis

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S348-S349
Author(s):  
Fareed Khawaja ◽  
Kathleen Mullane ◽  
Lynn El Haddad ◽  
Joseph Sassine ◽  
Ella Ariza Heredia ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Healthcare Cost ◽  
Median Duration ◽  
Resource Use ◽  
Cell Transplant ◽  
Cmv Infection ◽  
Research Support ◽  
Post Transplant ◽  
Cmv Reactivation ◽  
Research Grant

Abstract Background CMV reactivation is associated with significant morbidity and mortality in allo-HCT recipients and could be a resource intensive condition to manage. Limited data are available on the economic ramification of CMV reactivation in allo-HCT. Therefore, we aimed to examine healthcare cost and length of hospital stay (LOS) among allo-HCT recipients treated for CMV infection. Methods We performed a retrospective cohort study that included 56 consecutive allo-HCT recipients who were diagnosed with CMV infection within 100 days post-transplant and admitted to two medical centers, University of Texas MD Anderson Cancer Center and University of Chicago, Department of Infectious Disease between January 2016 and December 2017. CMV-related hospitalization was determined as an inpatient admission with or for CMV reactivation within 100 days post-transplant. Data were limited to only the first CMV-related hospitalization. Descriptive statistics were reported on patient characteristics, first CMV-related hospitalization and costs. Results Most patients were 40 years or older (64%), female (55%), Caucasian (66%), CMV seropositive recipients (87%), received a matched unrelated donor HCT (49%) and had a myeloablative or reduced intensity conditioning regimen (65%) (Figure 1). The median duration of CMV episode was 40 days. Seventy-one percent of the patients were treated with foscarnet for CMV infection. Acute kidney injury was the most frequent CMV treatment-related complication (67%) followed by myelosuppression (55%) and end-stage renal disease (36%). Of 56 encounters, 16% required admission to intensive care unit with a median duration of 9 days. The median length of stay for hospitalization was 23 days and healthcare cost for CMV-related hospitalization was $71,840. The median hospitalization cost and LOS varied by reason for hospitalizations, type of anti-CMV therapy and treatment-related complications (Figure 2). Figure 1. Baseline characteristics, CMV episodes, outcomes, and cost. Figure 2. CMV Outcomes among allo-HCT recipients Conclusion Our study showed even a single episode of CMV-related hospitalization led to significant resource use and hospitalization costs. This study highlights the need for interventions to prevent of CMV-related hospitalization, thereby reducing associated cost and resource use. Disclosures Kathleen Mullane, DO, Pharm D, FIDSA, FAST, MERCK (Advisor or Review Panel member, Research Grant or Support, Speaker’s Bureau) Ella Ariza Heredia, MD, Merck Sharp & Dohme (Grant/Research Support)Oxford Immunotec (Grant/Research Support) Yuexin Tang, PhD, Merck and Co., Inc. (Employee) Amit D. Raval, PhD, Merck and Co., Inc (Employee) Roy F. Chemaly, MD, MPH, FACP, FIDSA, Chimerix (Consultant, Research Grant or Support)Clinigen (Consultant)Merck (Consultant, Research Grant or Support)Novartis (Research Grant or Support)Oxford Immunotec (Consultant, Research Grant or Support)Shire/Takeda (Research Grant or Support)Viracor (Research Grant or Support)

Inflammatory Bowel Disease and Risk of Major Bleeding During Anticoagulation for Venous Thromboembolism

2021 ◽  
Author(s):  
Susanna Scharrer ◽  
Christian Primas ◽  
Sabine Eichinger ◽  
Sebastian Tonko ◽  
Maximilian Kutschera ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Venous Thromboembolism ◽  
Incidence Rate ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Fatal Bleeding ◽  
Adjusted Incidence Rate ◽  
Inflammatory Bowel ◽  
Adjusted Incidence

Abstract Background Little is known about the bleeding risk in patients with inflammatory bowel disease (IBD) and venous thromboembolism (VTE) treated with anticoagulation. Our aim was to elucidate the rate of major bleeding (MB) events in a well-defined cohort of patients with IBD during anticoagulation after VTE. Methods This study is a retrospective follow-up analysis of a multicenter cohort study investigating the incidence and recurrence rate of VTE in IBD. Data on MB and IBD- and VTE-related parameters were collected via telephone interview and chart review. The objective of the study was to evaluate the impact of anticoagulation for VTE on the risk of MB by comparing time periods with anticoagulation vs those without anticoagulation. A random-effects Poisson regression model was used. Results We included 107 patients (52 women, 40 with ulcerative colitis, 64 with Crohn disease, and 3 with unclassified IBD) in the study. The overall observation time was 388 patient-years with and 1445 patient-years without anticoagulation. In total, 23 MB events were registered in 21 patients, among whom 13 MB events occurred without anticoagulation and 10 occurred with anticoagulation. No fatal bleeding during anticoagulation was registered. The incidence rate for MB events was 2.6/100 patient-years during periods exposed to anticoagulation and 0.9/100 patient-years during the unexposed time. Exposure to anticoagulation (adjusted incidence rate ratio, 3.7; 95% confidence interval, 1.5-9.0; P = 0.003) and ulcerative colitis (adjusted incidence rate ratio, 3.5; 95% confidence interval, 1.5-8.1; P = 0.003) were independent risk factors for MB events. Conclusion The risk of major but not fatal bleeding is increased in patients with IBD during anticoagulation. Our findings indicate that this risk may be outweighed by the high VTE recurrence rate in patients with IBD.

scholarly journals Secrets of the hospital underbelly: abundance of antimicrobial resistance genes in hospital wastewater reflects hospital antimicrobial use and inpatient length of stay

2019 ◽  
Author(s):  
Meghan R. Perry ◽  
Bram van Bunnik ◽  
Luke McNally ◽  
Bryan Wee ◽  
Patrick Munk ◽  
...  
Keyword(s):  
Antimicrobial Resistance ◽  
Length Of Stay ◽  
Incidence Rate ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Clinical Activity ◽  
Hospital Wastewater ◽  
Antimicrobial Consumption ◽  
Gene Abundance ◽  
Class Level

ABSTRACTIntroductionHospital wastewater is a potential major source of antimicrobial resistance (AMR). This study uses metagenomics to ask how abundances of AMR genes in hospital wastewater are related to clinical activity.MethodsSewage was collected over a 24-hour period from multiple wastewater collection points representing different specialties within a tertiary hospital site and simultaneously from community sewage works. High throughput shotgun sequencing was performed using Illumina HiSeq4000. AMR gene abundances were correlated to hospital antimicrobial usage (AMU), data on clinical activity and resistance prevalence in clinical isolates.FindingsMicrobiota and AMR gene composition varied between each collection point and overall AMR gene abundance was higher in hospital wastewater than in community influent. The composition of AMR genes correlated with microbiota composition (Procrustes analysis, p=0.002). Increased antimicrobial consumption at a class level was associated with higher AMR gene abundance within that class in wastewater (incidence rate ratio 2.80, C.I. 1.2-6.5, p=0.016). Prolonged average patient length of stay was associated with higher total AMR gene abundance in wastewater (incidence rate ratio 2.05, C.I. 1.39-3.01, p=0.0003). AMR gene abundance at a class level within hospital wastewater did not reflect resistance patterns in the 181 clinical isolates grown from hospital inpatients over the time of wastewater sampling.ConclusionsHospital antimicrobial consumption and patient length of stay are important drivers of AMR gene outflow into the environment. Using metagenomics to identify the full range of AMR genes in hospital wastewater could represent a useful surveillance tool to monitor hospital AMR gene outflow and guide environmental policy on AMR.

scholarly journals Cytomegalovirus Reactivation in Hematopoietic Stem Cell Transplant Recipients in High Endemic Population

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 23-24
Author(s):  
Muhammad Farhan ◽  
Qamar Un Nisa Chaudhry ◽  
Syed Kamran Mahmood ◽  
Tariq Ghafoor ◽  
Raheel Iftikhar ◽  
...  
Keyword(s):  
Risk Factors ◽  
Stem Cell ◽  
Viral Load ◽  
High Viral Load ◽  
Transplant Recipients ◽  
Cmv Infection ◽  
Hematopoietic Stem ◽  
Post Transplant ◽  
Endemic Population ◽  
Cmv Reactivation

Background: Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). It causes end-organ disease, multi-organ dysfunction syndrome, graft failure, increased susceptibility to infections and GVHD. According to the published western data greatest risk of CMV infection is the seropositivity of the recipient, however, in a high endemic population where seropositivity is up to 100%, risk factors for CMV reactivation are different and are analyzed in this study. Methods: It is a prospective descriptive study performed at Armed Forces Bone Marrow Transplant Center, Rawalpindi, Pakistan from January 2017 to March 2020. Consecutive patients who underwent allogeneic HSCT during this period were enrolled. All patients were prospectively monitored for CMV reactivation by weekly or two weekly CMV DNA quantitative PCR, from engraftment till day 100 post-transplant. CMV infection was diagnosed on detection of more than 200 copies/ml on PCR. Threshold for starting preemptive antiviral therapy was kept at 2000 copies/ml. Patients with past history of CMV infection, those who expired before day 14 post-transplant or those with less than 70% of required CMV tests were not included in the study. Factors associated with CMV reactivation, outcome of antiviral therapy and effect of CMV on post-transplant survival were studied. Results: Out of 319 transplants during this period, 230 patients fulfilled the inclusion criteria. Of these, 197 were HLA matched sibling, 18 were matched family donor and 15 were haploidentical transplants. There were 163 males and 67 females. Median age at transplant was 9.5 years (0.5-53). Eighty-three transplants were done in thalassemia, 55 in aplastic anemia, 14 in Fanconi anemia, 27 in acute leukemias, 8 in CML, 9 in MDS, 12 in HLH and 22 in other hematological disorders. All the patients and donor were CMV IgG seropositive when tested before transplantation. CMV reactivation was seen in 152 out of 230 patients (66.1%). Of 152, 95 patients had CMV viral load more than 2000 copies/ml and required antiviral treatment. Median time to reactivation since transplant was 35 days (13-90). In multivariate analysis using binary regression, risk factors for high viral load CMV reactivation included steroid administration (p=0.009), recipient age less than 10 years (p=0.003) and haploidentical transplant (p=0.048). No statistically significant association was found with the use of ATG, GVHD, underlying disease, ABO blood group or gender mismatch. Survival analysis using cox regression showed significant impact of high viral load CMV reactivation on post-transplant survival. Event-free survival (EFS) with and without CMV reactivation was 70.5 % and 89.7% respectively (p=0.004) and overall survival (OS) was 80.0 % and 97.4 % with and without CMV reactivation respectively (p=0.002). Valganciclovir was given in 89 patients and 6patients were treated with ganciclovir. Mean time to clear viremia was 19.8±9 days. Myelosuppression was seen in 41% of patients treated with valganciclovir. Renal impairment was seen in 25% of patients treated with valganciclovir. One patient had resistant disease. One patient had CMV pneumonia and she recovered. One patient died of suspected CMV pneumonia Conclusion: CMV reactivation was seen in 66.1% of the transplant recipients, this is higher compared to the western world due to high CMV seropositivity is this region. Steroids administration in post-transplant period significantly increase the risk of CMV reactivation. Preemptive therapy with valganciclovir effectively treats CMV reactivation. Viral threshold for treatment should be decided considering the regional endemicity. CMV adversely effects the transplant outcome in terms of EFS and OS. Disclosures No relevant conflicts of interest to declare.

Accelerometer-Measured Daily Steps, Physical Function, and Subsequent Fall Risk in Older Women: The Objective Physical Activity and Cardiovascular Disease in Older Women Study

2021 ◽  
pp. 1-11
Author(s):  
Benjamin T. Schumacher ◽  
John Bellettiere ◽  
Michael J. LaMonte ◽  
Kelly R. Evenson ◽  
Chongzhi Di ◽  
...  
Keyword(s):  
Physical Function ◽  
Older Women ◽  
Incidence Rate ◽  
Fall Risk ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Steps Per Day ◽  
Falls In Older Adults ◽  
Adjusted Incidence Rate ◽  
Adjusted Incidence

Steps per day were measured by accelerometer for 7 days among 5,545 women aged 63–97 years between 2012 and 2014. Incident falls were ascertained from daily fall calendars for 13 months. Median steps per day were 3,216. There were 5,473 falls recorded over 61,564 fall calendar-months. The adjusted incidence rate ratio comparing women in the highest versus lowest step quartiles was 0.71 (95% confidence interval [0.54, 0.95]; ptrend across quartiles = .01). After further adjustment for physical function using the Short Physical Performance Battery, the incidence rate ratio was 0.86 ([0.64, 1.16]; ptrend = .27). Mediation analysis estimated that 63.7% of the association may be mediated by physical function (p = .03). In conclusion, higher steps per day were related to lower incident falls primarily through their beneficial association with physical functioning. Interventions that improve physical function, including those that involve stepping, could reduce falls in older adults.

Thirteen-Year Trends in Cardiovascular Risk in Men and Women with Chronic Coronary Syndrome

2021 ◽  
Author(s):  
Kevin Kris Warnakula Olesen ◽  
Esben Skov Jensen ◽  
Christine Gyldenkerne ◽  
Morten Würtz ◽  
Martin Bødtker Mortensen ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Incidence Rate ◽  
Cardiac Death ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Men And Women ◽  
Coronary Syndrome ◽  
Adjusted Incidence Rate ◽  
Artery Disease ◽  
Adjusted Incidence

Abstract Aims To examine combined and sex-specific temporal changes in risks of adverse cardiovascular events and coronary revascularization in patients with chronic coronary syndrome undergoing coronary angiography. Methods We included all patients with stable angina pectoris and coronary artery disease examined by coronary angiography in Western Denmark from 2004 to 2016. Patients were stratified by examination year interval: 2004-2006, 2007-2009, 2010-2012, and 2013-2016. Outcomes were two-year risk of myocardial infarction, ischemic stroke, cardiac death, and all-cause death estimated by adjusted incidence rate ratios using patients examined in 2004-2006 as reference. Results A total of 29,471 patients were included, of whom 70% were men. The two-year risk of myocardial infarction (2.8% versus 1.9%, adjusted incidence rate ratio 0.65, 95% CI 0.53-0.81), ischemic stroke (1.8% versus 1.1%, adjusted incidence rate ratio 0.48, 95% CI 0.37-0.64), cardiac death (2.1% versus 0.9%, adjusted incidence rate ratio 0.38, 95% CI 0.29-0.51), and all-cause death (5.0% versus 3.6%, adjusted incidence rate ratio 0.65, 95% CI 0.55-0.76) decreased from the first examination interval (2004-2006) to the last examination interval (2013-2016). Coronary revascularizations also decreased (percutaneous coronary intervention: 51.6% versus 42.5%; coronary artery bypass grafting: 24.6% versus 17.5%). Risk reductions were observed in both men and women, however, women had a lower absolute risk. Conclusion The risk for adverse cardiovascular events decreased substantially in both men and women with chronic coronary syndrome from 2004 to 2016. These results most likely reflect the cumulative effect of improvements in the management of chronic coronary artery disease.

Abstract 3: Impact of Financial Incentives on Variation in Use of Cardiac Imaging Tests

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Vinay Kini ◽  
Fenton McCarthy ◽  
Sheeva Rajaei ◽  
Paul Heidenreich ◽  
Peter Groeneveld
Keyword(s):  
Incidence Rate ◽  
Geographic Variation ◽  
Cardiac Imaging ◽  
Rate Ratio ◽  
Incidence Rate Ratio ◽  
Patient Characteristics ◽  
Administrative Claims ◽  
Matched Cohort ◽  
Health Administration ◽  
Local Practice

Background: Rapid growth and geographic variation in the provision of cardiac imaging tests have led to concerns about overuse due to fee-for-service (FFS) incentives. The degree to which FFS incentives may influence rates of cardiac imaging over and above patient characteristics and local practice styles is unknown. Objectives: To examine overall rates, degree of geographic variation, and correlation in use of echocardiography (ECHO) among veterans who primarily use services provided by the Veterans Health Administration (VA - a fixed budget health system without significant FFS incentives), versus veterans who use FFS Medicare. Design: We analyzed administrative claims from VA and Medicare of veterans with heart failure over the age of 65 from 2007-2010. Veterans were assigned to the VA or Medicare cohort according to the volume of services (procedures, hospitalizations, and visits) received within each system. The analysis was restricted to 34 major metropolitan service areas (MSAs). Rates of ECHO in the overall cohort and in a propensity-matched cohort were compared using multilevel mixed effects regression models adjusted for patient-level characteristics. Mean adjusted rates for each MSA according to cohort were tested for correlation and difference in variance. Results: The Medicare cohort included 364,413 veterans (mean age 77 years) and the VA cohort included 15,330 veterans (mean age 76 years). The Medicare cohort had a significantly higher adjusted rate of ECHO use compared to the VA cohort (1.09 versus 0.28 ECHOs per person-year, incidence rate ratio 4.23 [95% CI 4.12 to 4.34], p<.001). The higher rate persisted in the propensity-matched cohort of 14,889 pairs (Medicare incidence rate ratio 1.98 [95% CI 1.92 to 2.04], p<.001). Variance of the mean adjusted use of imaging across MSAs was greater in the Medicare cohort than the VA cohort (0.14 versus 0.02, p<.001). There was modest correlation in geographic variation between cohorts (r = 0.56, p<.001, Figure 1). Conclusions: ECHO rates and degree of variation were significantly higher in the Medicare cohort than the VA cohort in both overall and propensity-matched analyses, with modest regional correlation. ECHO utilization rates may be strongly influenced by payment system despite differences in patient characteristics and local practice styles.

scholarly journals Educational and health outcomes of children treated for asthma: Scotland-wide record linkage study of 683 716 children

2019 ◽  
Vol 54 (3) ◽  
pp. 1802309 ◽  
Author(s):  
Michael Fleming ◽  
Catherine A. Fitton ◽  
Markus F.C. Steiner ◽  
James S. McLay ◽  
David Clark ◽  
...  
Keyword(s):  
Health Outcomes ◽  
Incidence Rate ◽  
Rate Ratio ◽  
Hospital Admissions ◽  
Incidence Rate Ratio ◽  
Educational Interventions ◽  
Linkage Study ◽  
Increased Risk ◽  
Educational Need ◽  
Psychosocial Morbidity

BackgroundThe global prevalence of childhood asthma is increasing. The condition impacts physical and psychosocial morbidity; therefore, wide-ranging effects on health and education outcomes are plausible.MethodsLinkage of eight Scotland-wide databases, covering dispensed prescriptions, hospital admissions, maternity records, death certificates, annual pupil census, examinations, school absences/exclusions and unemployment, provided data on 683 716 children attending Scottish schools between 2009 and 2013. We compared schoolchildren on medication for asthma with peers, adjusting for sociodemographic, maternity and comorbidity confounders, and explored effect modifiers and mediators.ResultsThe 45 900 (6.0%) children treated for asthma had an increased risk of hospitalisation, particularly within the first year of treatment (incidence rate ratio 1.98, 95% CI 1.93–2.04), and increased mortality (HR 1.77, 95% CI 1.30–2.40). They were more likely to have special educational need for mental (OR 1.76, 95% CI 1.49–2.08) and physical (OR 2.76, 95% CI 2.57–2.95) health reasons, and performed worse in school exams (OR 1.11, 95% CI 1.06–1.16). Higher absenteeism (incidence rate ratio 1.25, 95% CI 1.24–1.26) partially explained their poorer attainment.ConclusionsChildren with treated asthma have poorer education and health outcomes than their peers. Educational interventions that mitigate the adverse effects of absenteeism should be considered.

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