High-dose opioid utilization and mortality among individuals initiating hemodialysis

Abstract Background Individuals undergoing hemodialysis in the United States frequently report pain and receive three-fold more opioid prescriptions than the general population. While opioid use is appropriate for select patients, high-dose utilization may contribute to an increased risk of death due to possible accumulation of opioid metabolites. Methods We studied high-dose opioid utilization (≥120 morphine milligram equivalents [MME] per day) among adults initiating hemodialysis in the United States between 2007 and 2014 using national registry data. We calculated the cumulative incidence (%) of high-dose utilization and depicted trends in the average percentage of days individuals were exposed to opioids. We used adjusted Cox proportional hazards models to identify which opioid doses were associated with mortality. Results Among 327,344 adults undergoing hemodialysis, the cumulative incidence of high-dose utilization was 14.9% at 2 years after initiating hemodialysis. Among patients with ≥1 opioid prescription during follow-up, the average percentage of days exposed to high-dose utilization increased from 13.9% in 2007 to 26.1% in 2014. Compared to 0MME per day, doses < 60MME were not associated with an increased risk of mortality, but high-dose utilization was associated with a 1.63-fold (95% CI, 1.57, 1.69) increased risk of mortality. The risk of mortality associated with opioid dose was highest in the first year after hemodialysis initiation. Conclusions The risk of mortality associated with opioid utilization among individuals on hemodialysis increases as doses exceed 60MME per day and is greatest during periods of high-dose utilization. Patients and clinicians should carefully weigh the risks and benefits of opioid doses exceeding 60MME per day.

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Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region

The American Surgeon ◽

10.1177/0003134820960063 ◽

2020 ◽

pp. 000313482096006

Author(s):

William Q. Duong ◽

Areg Grigorian ◽

Cyrus Farzaneh ◽

Jeffry Nahmias ◽

Theresa Chin ◽

...

Keyword(s):

United States ◽

The United States ◽

Trauma Patients ◽

Improvement Program ◽

Trauma Outcomes ◽

Risk Of Death ◽

Hospital Access ◽

Risk Of Mortality ◽

Sex Disparities ◽

Male Patients

Objectives Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States. Methods The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma. Results Most trauma patients were treated in the South (n = 522 388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, P < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, P < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions. Discussion This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.

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Older Adults in the United States and COVID-19: A Qualitative Study of Perceptions, Finances, Coping, and Emotions

Frontiers in Public Health ◽

10.3389/fpubh.2021.660536 ◽

2021 ◽

Vol 9 ◽

Author(s):

R. Turner Goins ◽

Elizabeth Anderson ◽

Hannah Minick ◽

Heather Daniels

Keyword(s):

Mental Health ◽

United States ◽

Older Adults ◽

News Media ◽

Emotional Health ◽

The United States ◽

Stress Appraisal ◽

Risk Of Death ◽

Increased Risk ◽

Precautionary Measures

Introduction: Older adults have the poorest coronavirus (COVID-19) prognosis with the highest risk of death due to complications, making their COVID-19 experiences particularly important. Guided by the stress-appraisal-coping theoretical model, we sought to understand COVID-related perceptions and behaviors of older adults residing in the United States.Materials and Methods: We used convenience sampling to recruit persons with the following inclusion criteria: Aged ≥ 65 years, English fluency, and U.S. residency. Semi structured in-depth interviews were conducted remotely and audio recorded between April 25, 2020 and May 7, 2020. Interviews were professionally transcribed with a final study sample of 43. A low-inference qualitative descriptive design was used to provide a situated understanding of participants' life experiences using their naturalistic expressions.Results: The mean age of participants was 72.4 ± 6.7. Slightly over half were female (55.8%), 90.6% were White, and 18.6% lived alone. The largest percentages of participants resided in a rural area (27.9%) or small city (25.6%). We identified four themes, including (1) risk perception, (2) financial impact, (3) coping, and (4) emotions. Most participants were aware of their greater risk for poor COVID-19 outcomes but many did not believe in their increased risk. Financial circumstances because of the pandemic varied with largely no financial impacts, while others reported negative impacts and a few reported positive impacts. Coping was problem- and emotion-focused. Problem-focused coping included precautionary efforts and emotion-focused coping included creating daily structure, pursuing new and/or creative activities, connecting with others in new ways, and minimizing news media exposure. Overall, emotional health was negatively affected by the pandemic although some participants reported positive emotional experiences.Conclusions: Perceiving themselves as high risk for COVID-19 complications, older adults used precautionary measures to protect themselves from contracting the virus. The precautionary measures included social isolation, which can negatively affect mental health. Older adults will need to be resourceful and draw on existing resources to cope, such as engaging in creative activities and new strategies to connect with others. Our findings underscore the importance of the preservation of mental health during extended periods of isolation by taking advantage of low-to-no-cost existing resources.

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370. Comparing Trends and Outcomes among HIV-Infected vs. HIV Uninfected Patients with Tuberculosis: A 5-Year Experience Within the Florida Department of Health in Hillsborough County

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.443 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S194-S194

Author(s):

Shylah M Moore-Pardo ◽

Anteneh Addisu ◽

Tea Reljic ◽

Sadaf Aslam ◽

Beata Casanas

Keyword(s):

United States ◽

The United States ◽

Homeless Persons ◽

Sputum Smear ◽

Foreign Born ◽

Female Ratio ◽

Risk Of Death ◽

Increased Risk ◽

The Difference ◽

Hiv Negative

Abstract Background Although the rate of tuberculosis (TB) has significantly declined in the United States, elimination has plateaued. Florida is one of the states with the greatest number of cases. The majority of cases occur in foreign-born individuals. Human immunodeficiency virus (HIV) is also a major contributor. HIV-TB coinfection leads to reciprocal interactions with significant clinical impact. We aim to compare the risk factors, clinical findings, and outcomes among HIV-infected vs. HIV uninfected patients. Methods A retrospective cohort study of TB cases over a 5 year period (2012–2017) was conducted. All patients with HIV co-infection with age- and gender-matched HIV negative controls were included. The diagnosis of TB was made via clinical, microbiological, radiological, and/or PCR based methods. SPSS was used for statistical data analysis. Results A total of 411 TB cases were identified and 66 patients (33 HIV-infected plus 33 HIV un-infected) were eligible for inclusion. The median age was 49 years (range 22–70). The male to female ratio was 21:12 and 50% of patients had TB symptoms; the rest had abnormal imaging or lab finding. Cases were confirmed via positive sputum smear, culture, or PCR (Figures 1–3). Only 11 patients were lost to follow-up, thus 83.3% completed therapy. A total of 5 persons died (Table 1). Conclusion The rate of HIV-TB coinfection in the United States was 5.3% in 2018; higher among injection drugs users, homeless persons, inmates, and alcoholics. In our study, the rate of HIV-TB coinfection was slightly higher (8%). The difference was not statistically significant in regards to foreign born, homelessness, and incarceration. Only 3 patients admitted to injection drug use and 9 used alcohol (all HIV negative). Traditionally, HIV-TB coinfected patients have extra-pulmonary TB with higher rates of negative sputum and are at increased risk of death. In our cohort, the difference was statistically significant (P = 0.009) only for cavitary TB (predominated in HIV un-infected) but no difference in outcomes was observed between the two groups. These findings suggest changing trends in HIV-TB coinfection which may be partly related to our setting and demographics but may be attributed to better access to care and antiretroviral therapy at large. Disclosures All authors: No reported disclosures.

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Increased Risk of Death for Patients on the Waitlist for Liver Transplant Residing at Greater Distance From Specialized Liver Transplant Centers in the United States

Transplantation Journal ◽

10.1097/tp.0000000000001387 ◽

2016 ◽

Vol 100 (10) ◽

pp. 2146-2152 ◽

Cited By ~ 14

Author(s):

Luca Cicalese ◽

Ali Shirafkan ◽

Kristofer Jennings ◽

Daria Zorzi ◽

Cristiana Rastellini

Keyword(s):

United States ◽

Liver Transplant ◽

The United States ◽

Risk Of Death ◽

Increased Risk

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Discrepancies in Written Versus Calculated Durations in Opioid Prescriptions: Pre-Post Study (Preprint)

10.2196/preprints.16199 ◽

2019 ◽

Author(s):

Benjamin H Slovis ◽

John Kairys ◽

Bracken Babula ◽

Melanie Girondo ◽

Cara Martino ◽

...

Keyword(s):

The United States ◽

Opioid Use ◽

Duration Of Treatment ◽

Record System ◽

Opioid Prescription ◽

Increased Risk ◽

The Us ◽

Control And Prevention ◽

Opioid Medications

BACKGROUND The United States is in the midst of an opioid epidemic. Long-term use of opioid medications is associated with an increased risk of dependence. The US Centers for Disease Control and Prevention makes specific recommendations regarding opioid prescribing, including that prescription quantities should not exceed the intended duration of treatment. OBJECTIVE The purpose of this study was to determine if opioid prescription quantities written at our institution exceed intended duration of treatment and whether enhancements to our electronic health record system improved any discrepancies. METHODS We examined the opioid prescriptions written at our institution for a 22-month period. We examined the duration of treatment documented in the prescription itself and calculated a duration based on the quantity of tablets and doses per day. We determined whether requiring documentation of the prescription duration affected these outcomes. RESULTS We reviewed 72,314 opioid prescriptions, of which 16.96% had a calculated duration that was greater than what was documented in the prescription. Making the duration a required field significantly reduced this discrepancy (17.95% vs 16.21%, <i>P</i><.001) but did not eliminate it. CONCLUSIONS Health information technology vendors should develop tools that, by default, accurately represent prescription durations and/or modify doses and quantities dispensed based on provider-entered durations. This would potentially reduce unintended prolonged opioid use and reduce the potential for long-term dependence.

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Sociodemographic Profile and Outcomes of Patients with Non-Diffuse Large B-Cell Lymphoma (non-DLBCL) Treated at Minority-Predominant Facilities in the United States

Blood ◽

10.1182/blood-2018-99-119976 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4868-4868

Author(s):

Vivek Kumar ◽

Taimur Sher ◽

Vivek Roy ◽

Prakash Vishnu ◽

Anne M Hazen ◽

...

Keyword(s):

Multivariate Analysis ◽

B Cell Lymphoma ◽

The United States ◽

Racial Minorities ◽

Risk Of Death ◽

Risk Of Mortality ◽

Increased Risk ◽

Race Ethnicity ◽

Facility Level ◽

The Impact

Abstract Background: Racial disparities in outcomes of cancer patients have been reported. Access to comprehensive cancer centers is associated with improved overall survival (OS) but racial/ethnic minorities may have a disparate access to such care. While the impact of treatment facility volume on outcomes has been evaluated, outcomes of centers with minority-predominant patient population have not been studied. We compared demographic profiles, facility level data and OS of patients treated at minority-predominant facilities to facilities that treated predominantly non-Hispanic Whites (NHW) with non-DLBCL. Methods: The National Cancer Database (NCDB) was used to identify all non-DLBCL patients diagnosed between 2004 and 2015. "Minority-treating facilities" were defined as facilities in the top decile by proportion for initial treatment of non-Hispanic African-Americans (NHAA), Hispanics and other races. We performed univariate and multivariate analyses to compare sociodemographic and clinical factors influencing outcomes between minority treating and non-minority treating facilities. A subgroup analysis stratified by race/ethnicity was also conducted to study the effect of treating facilities on the outcome of NHWs and minorities separately. Results: Of 1339 total facilities, 123 (9.1%) qualified as minority treating. Of 207,239 eligible patients in NCDB, 18,719 (9.03%) received treatment at the minority-treating facilities and of these, 11,190 (~60%) belonged to the minority races. Overall, 4.5% (6,988/156,664) NHWs and 30% (11,190/37,639) minorities received treatment at the minority-treating facilities. Several demographic and facility level characteristics were significantly different among the patients treated at minority-treating facilities as compared to non-minority treating facilities. Overall, significantly higher number of patients in minority-treating hospitals had lower income and education, had Medicaid coverage or lack of insurance. The OS of patients in minority treating facilities was significantly worse as compared to non-minority facilities (Figures). On multivariate analysis, patients who received treatment at minority-treating facilities were at 10% (HR=1.10, 95% CI: 1.06-1.14 p<0.001) higher risk of mortality as compared to those treated at the non-minority treating facilities. On multivariate analysis, NHAA (30% increased risk) and 'other races' (9% increased risk) were at significantly higher risk of mortality as compared to the NHW (Table 2). To study the effect of treatment at minority-treating facilities on OS among the patients of same race/ethnicity group, a multivariate analysis was also run separately for NHW and racial minorities. The NHWs who received treatment at minority-treating facilities were at 13% higher risk of death (HR=1.13, 95% CI: 1.08-1.19 p<0.001) as compared to NHWs who were treated at non-minority treating facilities. Similarly, the racial minorities who received treatment at minority treating facilities were at 8% higher risk of death (HR=1.08, 95% CI: 1.03-1.19 p=0.003) as compared to those who received treatment at the nonminority treating facilities. Conclusions:Outcomes of patients who received treatment at minority treating facilities was significantly worse than those at non-minority treating facilities. This was true for NHWs and racial minorities separately as well. Several demographic and facility level characteristics were significantly different in the two groups however OS remained worse after adjusting for them. Causes of poor outcomes at minority-treating facilities must be analyzed to mitigate them and improve outcomes for all. Figure. Figure. Disclosures Ailawadhi: Takeda: Consultancy; Celgene: Consultancy; Amgen: Consultancy; Janssen: Consultancy; Pharmacyclics: Research Funding.

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Secondary organic aerosol association with cardiorespiratory disease mortality in the United States

Nature Communications ◽

10.1038/s41467-021-27484-1 ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

Havala O. T. Pye ◽

Cavin K. Ward-Caviness ◽

Ben N. Murphy ◽

K. Wyat Appel ◽

Karl M. Seltzer

Keyword(s):

United States ◽

Secondary Organic Aerosol ◽

Carbon Sources ◽

Organic Aerosol ◽

The United States ◽

County Level ◽

Risk Of Death ◽

Predictive Algorithms ◽

Increased Risk ◽

The U.S

AbstractFine particle pollution, PM2.5, is associated with increased risk of death from cardiorespiratory diseases. A multidecadal shift in the United States (U.S.) PM2.5 composition towards organic aerosol as well as advances in predictive algorithms for secondary organic aerosol (SOA) allows for novel examinations of the role of PM2.5 components on mortality. Here we show SOA is strongly associated with county-level cardiorespiratory death rates in the U.S. independent of the total PM2.5 mass association with the largest associations located in the southeastern U.S. Compared to PM2.5, county-level variability in SOA across the U.S. is associated with 3.5× greater per capita county-level cardiorespiratory mortality. On a per mass basis, SOA is associated with a 6.5× higher rate of mortality than PM2.5, and biogenic and anthropogenic carbon sources both play a role in the overall SOA association with mortality. Our results suggest reducing the health impacts of PM2.5 requires consideration of SOA.

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Implications of the Opioid Crisis for the American Disability Community

Rehabilitation Research Policy and Education ◽

10.1891/re-19-25 ◽

2020 ◽

Vol 34 (4) ◽

pp. 265-274

Author(s):

Mykal J. Leslie ◽

Kathleen Sheppard-Jones ◽

Malachy L. Bishop

Keyword(s):

United States ◽

Rehabilitation Counseling ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Use ◽

Research Education ◽

Opioid Crisis ◽

Increased Risk ◽

The Relationship

PurposeThe profession of rehabilitation counseling has long been responsive to emerging disabilities. To date, however, the profession's attention and response to the ongoing opioid crisis in the United States has been incommensurate with the scope and detriment of opioids and opioid use disorder (OUD) on Americans with disabilities. The opioid crisis, including the overuse, abuse, and overdose rates associated with prescription and illegal opioids, affects people of all ages and backgrounds. However, people with disabilities are at increased risk for developing OUDs, and they experience greater barriers to OUD treatment than people without disabilities.MethodThis article describes the origins and development of this crisis, the relationship between disability and increased risk for OUD, and the barriers to treatment that exist. We then evaluate the role of rehabilitation counseling, including the need for further action in advocacy, research, education, and policy.Results and ConclusionsThroughout this article, we encourage a more urgent and concerted response than seems to be the case presently.

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Costs and Mortality Associated With Multidrug-Resistant Healthcare-Associated Acinetobacter Infections

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2016.145 ◽

2016 ◽

Vol 37 (10) ◽

pp. 1212-1218 ◽

Cited By ~ 16

Author(s):

Richard E. Nelson ◽

Marin L. Schweizer ◽

Eli N. Perencevich ◽

Scott D. Nelson ◽

Karim Khader ◽

...

Keyword(s):

United States ◽

Incidence Rate ◽

Cumulative Incidence ◽

The United States ◽

Multidrug Resistant ◽

Risk Of Mortality ◽

Payer Perspective ◽

Using Data ◽

Healthcare Associated ◽

The Cost

BACKGROUNDOur objective was to estimate the per-infection and cumulative mortality and cost burden of multidrug-resistant (MDR) Acinetobacter healthcare-associated infections (HAIs) in the United States using data from published studies.METHODSWe identified studies that estimated the excess cost, length of stay (LOS), or mortality attributable to MDR Acinetobacter HAIs. We generated estimates of the cost per HAI using 3 methods: (1) overall cost estimates, (2) multiplying LOS estimates by a cost per inpatient-day ($4,350) from the payer perspective, and (3) multiplying LOS estimates by a cost per inpatient-day from the hospital ($2,030) perspective. We deflated our estimates for time-dependent bias using an adjustment factor derived from studies that estimated attributable LOS using both time-fixed methods and either multistate models (70.4% decrease) or matching patients with and without HAIs using the timing of infection (47.4% decrease). Finally, we used the incidence rate of MDR Acinetobacter HAIs to generate cumulative incidence, cost, and mortality associated with these infections.RESULTSOur estimates of the cost per infection were $129,917 (method 1), $72,025 (method 2), and $33,510 (method 3). The pooled relative risk of mortality was 4.51 (95% CI, 1.10–32.65), which yielded a mortality rate of 10.6% (95% CI, 2.5%–29.4%). With an incidence rate of 0.141 (95% CI, 0.136–0.161) per 1,000 patient-days at risk, we estimated an annual cumulative incidence of 12,524 (95% CI, 11,509–13,625) in the United States.CONCLUSIONThe estimates presented here are relevant to understanding the expenditures and lives that could be saved by preventing MDR Acinetobacter HAIs.Infect Control Hosp Epidemiol 2016;1–7

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Discrepancies in Written Versus Calculated Durations in Opioid Prescriptions: Pre-Post Study

JMIR Medical Informatics ◽

10.2196/16199 ◽

2020 ◽

Vol 8 (3) ◽

pp. e16199

Author(s):

Benjamin H Slovis ◽

John Kairys ◽

Bracken Babula ◽

Melanie Girondo ◽

Cara Martino ◽

...

Keyword(s):

The United States ◽

Opioid Use ◽

Duration Of Treatment ◽

Record System ◽

Opioid Prescription ◽

Increased Risk ◽

The Us ◽

Control And Prevention ◽

Opioid Medications

Background The United States is in the midst of an opioid epidemic. Long-term use of opioid medications is associated with an increased risk of dependence. The US Centers for Disease Control and Prevention makes specific recommendations regarding opioid prescribing, including that prescription quantities should not exceed the intended duration of treatment. Objective The purpose of this study was to determine if opioid prescription quantities written at our institution exceed intended duration of treatment and whether enhancements to our electronic health record system improved any discrepancies. Methods We examined the opioid prescriptions written at our institution for a 22-month period. We examined the duration of treatment documented in the prescription itself and calculated a duration based on the quantity of tablets and doses per day. We determined whether requiring documentation of the prescription duration affected these outcomes. Results We reviewed 72,314 opioid prescriptions, of which 16.96% had a calculated duration that was greater than what was documented in the prescription. Making the duration a required field significantly reduced this discrepancy (17.95% vs 16.21%, P<.001) but did not eliminate it. Conclusions Health information technology vendors should develop tools that, by default, accurately represent prescription durations and/or modify doses and quantities dispensed based on provider-entered durations. This would potentially reduce unintended prolonged opioid use and reduce the potential for long-term dependence.

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