Disaggregating proportional multistate lifetables by population heterogeneity to estimate intervention impacts on inequalities

Background Simulation models can be used to quantify the projected health impact of interventions. Quantifying heterogeneity in these impacts, for example by socioeconomic status, is important to understand impacts on health inequalities. We aim to disaggregate one type of Markov macro-simulation model, the proportional multistate lifetable, ensuring that under business-as-usual (BAU) the sum of deaths across disaggregated strata in each time step returns the same as the initial non-disaggregated model. We then demonstrate the application by deprivation quintiles for New Zealand (NZ), for: hypothetical interventions (50% lower all-cause mortality, 50% lower coronary heart disease mortality) and a dietary intervention to substitute 59% of sodium with potassium chloride in the food supply. Methods We developed a disaggregation algorithm that iteratively rescales mortality, incidence and case-fatality rates by time-step of the model to ensure correct total population counts were retained at each step. To demonstrate the algorithm on deprivation quintiles in NZ, we used the following inputs: overall (non-disaggregated) all-cause mortality & morbidity rates, coronary heart disease incidence & case fatality rates; stroke incidence & case fatality rates. We also obtained rate ratios by deprivation for these same measures. Given all-cause and cause-specific mortality rates by deprivation quintile, we derived values for the incidence, case fatality and mortality rates for each quintile, ensuring rate ratios across quintiles and the total population mortality and morbidity rates were returned when averaged across groups. The three interventions were then run on top of these scaled BAU scenarios. Results The algorithm exactly disaggregated populations by strata in BAU. The intervention scenario life years and health adjusted life years (HALYs) gained differed slightly when summed over the deprivation quintile compared to the aggregated model, due to the stratified model (appropriately) allowing for differential background mortality rates by strata. Modest differences in health gains (HALYs) resulted from rescaling of sub-population mortality and incidence rates to ensure consistency with the aggregate population. Conclusion Policy makers ideally need to know the effect of population interventions estimated both overall, and by socioeconomic and other strata. We demonstrate a method and provide code to do this routinely within proportional multistate lifetable simulation models and similar Markov models.

Variation in US Drug Overdose Mortality Within and Between Hispanic/Latine Subgroups: A Disaggregation of National Data

This study examined differences across Latine heritage groups (i.e., Mexican, Puerto Rican, Cuban, Dominican, Central American, South American) in rates of US drug overdose mortality. The study utilized 2015-2019 mortality data from the National Center for Health Statistics for 29,137 Hispanic individuals who died of drug overdose. Using population estimates from the American Community Survey, age-standardized drug overdose mortality rates were calculated by specific Latine heritage and sex, nativity, educational attainment, and geographic region. Standardized rate ratios (SRRs), incidence rate ratios (IRRs) from negative binomial regression models, and 95% Confidence Intervals (CIs) were calculated, and multiple imputation was used for missing Latine heritage group in select models. Drug overdose mortality rates in the Puerto Rican heritage population were more than three times as high as in the Mexican heritage population (IRR 3.61 [95% CI 3.02-4.30] in unadjusted model; IRR 3.70 [95% CI 3.31-4.15] in model adjusting for age, sex, nativity, educational attainment, and region; SRR 3.23 [95% CI, 3.15-3.32] in age-standardized model with missing Hispanic heritage imputed). Higher age-standardized rates of drug overdose mortality were observed in males than females across all Latine groups, yet the magnitude of the sex differential varied by Latine heritage. The relationship between drug overdose mortality and nativity differed by Latine heritage; in all groups except Puerto Rican, overdose mortality rates were significantly higher in the US-born than those not US-born. In contrast, overdose mortality rates were significantly lower in US-born Puerto Ricans than in Puerto Ricans who were not US-born (e.g., born in Puerto Rico; SRR, 0.84 [95% CI 0.80-0.88]). The relationship between drug overdose mortality and educational attainment (for ages 25+) also varied between Latine groups. The diverse subgroups comprising the US Latine population vary not only in rates of drug overdose mortality, but also in demographic risk factors for fatal drug overdose.

Sex disparities in COVID-19 mortality vary considerably across time: The case of New York State

In order to characterize how sex disparities in COVID-19 mortality evolved over time in New York State (NY), we analyzed sex-disaggregated data from the US Gender/Sex COVID-19 Data Tracker from March 14, 2020 to August 28, 2021. We defined six different time periods and calculated mortality rates by sex and mortality rate ratios, both cumulatively and for each time period separately. As of August 28, 2021, 19 227 (44.2%) women and 24 295 (55.8%) men died from COVID-19 in NY. 72.7% of the cumulative difference in the number of COVID-19 deaths between women and men was accrued between March 14 and May 4, 2020. During this period, the COVID-19 mortality rate ratio for men compared to women was 1.56 (95% CI: 1.52-1.61). In the five subsequent time periods, the corresponding ratio ranged between 1.08 (0.98-1.18) and 1.24 (1.15-1.34). While the cumulative mortality rate ratio of men compared to women was 1.34 (1.31-1.37), the ratio equals 1.19 (1.16-1.22) if deaths during the initial COVID-19 surge are excluded from the analysis. This article shows that in NY the magnitude of sex disparities in COVID-19 mortality was not stable across time. While the initial surge in COVID-19 mortality was characterized by stark sex disparities, these were greatly attenuated after the introduction of public health controls.

Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs

<i>Objective:</i> There is mounting evidence regarding the cardiovascular (CV) benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) and glucagon like peptide-1 receptor agonists (GLP-1RAs) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their utilization. <p> </p> <p><i>Research Design and Methods:</i> We used the nationwide Veterans Affairs (VA) healthcare system dataset from January 1, 2020 to December 31, 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1RA and the facility-level variation in their utilization. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1RA in patients with ASCVD and T2DM. </p> <p> </p> <p><i>Results:</i> Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received SGLT2i while 8.0% of patients received GLP-1RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10^th-90^th percentile) facility-level rates were 14.92% (9.31%-22.50%) for SGLT2i and 10.88% (4.44%-17.07%) for GLP-1RA. There was significant facility level variation among SGLT2-Is utilization - MRR_unadjusted (95% CI):1.41 (1.35-1.47) and MRR_adjusted (95% CI): 1.55 (1.46 – 1.63). Similar facility level variation was observed for utilization of GLP-1 RA – MRR_unadjusted (95% CI):1.34 (1.29-1.38) and MRR_adjusted(95% CI): 1.78 (1.65 – 1.90).</p> <p> </p> <p><i>Conclusions:</i> Overall utilization rates of SGLT2i and GLP-1RA among eligible patients are low with significantly higher residual facility-level variation in utilization of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients. </p>

Trends in the Incidence of New‐Onset Hypertensive Disorders of Pregnancy Among Rural and Urban Areas in the United States, 2007 to 2019

Background Hypertensive disorders of pregnancy are growing public health problems that contribute to maternal morbidity, mortality, and future risk of cardiovascular disease. Given established rural‐urban differences in maternal cardiovascular health, we described contemporary trends in new‐onset hypertensive disorders of pregnancy in the United States. Methods and Results We conducted a serial, cross‐sectional analysis of 51 685 525 live births to individuals aged 15 to 44 years from 2007 to 2019 using the Centers for Disease Control and Prevention Natality Database. We included gestational hypertension and preeclampsia/eclampsia in individuals without chronic hypertension and calculated the age‐adjusted incidence (95% CI) per 1000 live births overall and by urbanization status (rural or urban). We used Joinpoint software to identify inflection points and calculate rate of change. We quantified rate ratios to compare the relative incidence in rural compared with urban areas. Incidence (95% CI) of new‐onset hypertensive disorders of pregnancy increased from 2007 to 2019 in both rural (48.6 [48.0–49.2] to 83.9 [83.1–84.7]) and urban (37.0 [36.8–37.2] to 77.2 [76.8–77.6]) areas. The rate of annual increase in new‐onset hypertensive disorders of pregnancy was more rapid after 2014 with greater acceleration in urban compared with rural areas. Rate ratios (95% CI) comparing incidence of new‐onset hypertensive disorders of pregnancy in rural and urban areas decreased from 1.31 (1.30–1.33) in 2007 to 1.09 (1.08–1.10) in 2019. Conclusions Incidence of new‐onset hypertensive disorders of pregnancy doubled from 2007 to 2019 with persistent rural‐urban differences highlighting the need for targeted interventions to improve the health of pregnant individuals and their offspring.

Comparison of Natural and BNT162b2 Vaccine-induced Immunity, with and without an Enhancer or Booster Dose, on the Risk of COVID-19-Related Hospitalization in Israel

Introduction: With the COVID-19 pandemic ongoing, accurate assessment of population immunity and the effectiveness of booster and enhancer vaccines is critical. Methods We compare COVID-19-related hospitalization incidence rate ratios, adjusted for potential demographic, clinical and health-seeking-behavior confounders, in 2,412,755 individuals (235,552,274 person-days), across four exposures: 2 BNT162b2 doses, 5 or more months prior ("non-recent vaccine immunity"); 3 BNT162b2 doses (“boosted vaccine immunity”); previous COVID-19, with or without a subsequent BNT162b2 dose (“natural immunity” and “enhanced natural immunity” respectively). Results Compared with non-recent vaccine immunity, COVID-19-related hospitalization incidence rate ratios are 11% (9%-13%) for boosted vaccine immunity, 34% (23%-50%) for natural immunity and 25% (17%-39%) for enhanced natural immunity. Conclusion We demonstrate that natural immunity (enhanced or not) provides better protection against COVID-19-related hospitalization than non-recent vaccine immunity, but less protection than that attained from booster vaccination. Additionally, our results suggest that vaccinating individuals with natural immunity further enhances their protection.

Utilization Rates of SGLT2 Inhibitors and GLP-1 Receptor Agonists and Their Facility-Level Variation Among Patients With Atherosclerotic Cardiovascular Disease and Type 2 Diabetes: Insights From the Department of Veterans Affairs

<i>Objective:</i> There is mounting evidence regarding the cardiovascular (CV) benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) and glucagon like peptide-1 receptor agonists (GLP-1RAs) among patients with atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes (T2DM). There is paucity of data assessing real-world practice patterns for these drug classes. We aimed to assess utilization rates of these drug classes and facility-level variation in their utilization. <p> </p> <p><i>Research Design and Methods:</i> We used the nationwide Veterans Affairs (VA) healthcare system dataset from January 1, 2020 to December 31, 2020 and included patients with established ASCVD and T2DM. Among these patients, we assessed the use of SGLT2i and GLP-1RA and the facility-level variation in their utilization. Facility-level variation was computed using median rate ratios (MRR), a measure of likelihood that two random facilities differ in use of SGLT2i and GLP-1RA in patients with ASCVD and T2DM. </p> <p> </p> <p><i>Results:</i> Among 537,980 patients with ASCVD and T2DM across 130 VA facilities, 11.2% of patients received SGLT2i while 8.0% of patients received GLP-1RA. Patients receiving these cardioprotective glucose-lowering drug classes were on average younger and had a higher proportion of non-Hispanic Whites. Overall, median (10^th-90^th percentile) facility-level rates were 14.92% (9.31%-22.50%) for SGLT2i and 10.88% (4.44%-17.07%) for GLP-1RA. There was significant facility level variation among SGLT2-Is utilization - MRR_unadjusted (95% CI):1.41 (1.35-1.47) and MRR_adjusted (95% CI): 1.55 (1.46 – 1.63). Similar facility level variation was observed for utilization of GLP-1 RA – MRR_unadjusted (95% CI):1.34 (1.29-1.38) and MRR_adjusted(95% CI): 1.78 (1.65 – 1.90).</p> <p> </p> <p><i>Conclusions:</i> Overall utilization rates of SGLT2i and GLP-1RA among eligible patients are low with significantly higher residual facility-level variation in utilization of these drug classes. Our results suggest opportunities to optimize their use to prevent future adverse cardiovascular events among these patients. </p>

Increasing Incidence of Juvenile Idiopathic Arthritis: A Trend Over 31 Years in Southern Sweden

Background The reported incidence of juvenile idiopathic arthritis (JIA) varies from studies around the world, depending on patient collection techniques, geographic region, and time. Our aim was to study the mean annual incidence of juvenile arthritis in a population-based setting using two regional cohorts of children diagnosed with juvenile chronic arthritis (JCA) and JIA over a period of 31 years.Findings The study population was 651 children diagnosed 1980-2010. The mean annual incidence over the period was 9.9 per 100,000 children, with a range from 4.2 per 100,000 in 1980 to 17.1 per 100,000 children in 2010. When comparing incidence rate between the decade of diagnosis using rate ratios, there is a significant difference with diagnosis 1980-1989 as comparator.Conclusions We show a statistically significant increase in the incidence of JIA over three decades in a population-based cohort of children with juvenile arthritis.

Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study

Background Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously. Methods In this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions. Results There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively. Conclusions Video-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support. Trial registration The larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.

Exploring factors influencing patient mortality and loss to follow-up in two paediatric hospital wards in Zamfara, North-West Nigeria, 2016–2018

Introduction Child mortality has been linked to infectious diseases, malnutrition and lack of access to essential health services. We investigated possible predictors for death and patients lost to follow up (LTFU) for paediatric patients at the inpatient department (IPD) and inpatient therapeutic feeding centre (ITFC) of the Anka General Hospital (AGH), Zamfara State, Nigeria, to inform best practices at the hospital. Methods We conducted a retrospective cohort review study using routinely collected data of all patient admissions to the IPD and ITFC with known hospital exit status between 2016 and 2018. Unadjusted and adjusted rate ratios (aRR) and respective 95% confidence intervals (95% CI) were calculated using Poisson regression to estimate the association between the exposure variables and mortality as well as LTFU. Results The mortality rate in IPD was 22% lower in 2018 compared to 2016 (aRR 0.78; 95% CI 0.66–0.93) and 70% lower for patients coming from lead-affected villages compared to patients from other villages (aRR 0.30; 95% CI 0.19–0.48). The mortality rate for ITFC patients was 41% higher during rainy season (aRR 1.41; 95% CI 1.2–1.6). LTFU rates in ITFC increased in 2017 and 2018 when compared to 2016 (aRR 1.6; 95% CI 1.2–2.0 and aRR 1.4; 95% CI 1.1–1.8) and patients in ITFC had 2.5 times higher LTFU rates when coming from a lead-affected village. Conclusions Our data contributes clearer understanding of the situation in the paediatric wards in AGH in Nigeria, but identifying specific predictors for the multifaceted nature of mortality and LTFU is challenging. Mortality in paediatric patients in IPD of AGH improved during the study period, which is likely linked to better awareness of the hospital, but still remains high. Access to healthcare due to seasonal restrictions contributes to mortalities due to late presentation. Increased awareness of and easier access to healthcare, such as for patients living in lead-affected villages, which are still benefiting from an MSF lead poisoning intervention, decreases mortalities, but increases LTFU. We recommend targeted case audits and qualitative studies to better understand the role of health-seeking behaviour, and social and traditional factors in the use of formal healthcare in this part of Nigeria and potentially similar settings in other countries.