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IntroductionTo assess the within-class variation in kidney outcomes following initiation of sulfonylurea therapy.Research design and methodsWe used claims data of enrollees in commercial, Medicare Advantage, and traditional Medicare health plans between 2014 and 2021 to emulate a target trial including adults ≥21 years with type 2 diabetes at moderate cardiovascular risk to compare initiation of glimepiride, glipizide, or glyburide on the incidence of chronic kidney disease (CKD) stage 3 or worse, including initiation of kidney replacement therapy (primary outcome); secondary outcomes examined incident CKD stages 3-4, kidney failure (including kidney replacement therapy), all-cause mortality, and hypoglycemia requiring emergency department or hospital care. Random treatment assignment was emulated using propensity scores, estimated using the super learner ensemble method, and incorporated as inverse probability of treatment weights into proportional hazards models.ResultsThe weighted study cohort included 295 092 individuals starting glimepiride (n=134 926), glipizide (n=145 984), and glyburide (n=14 182). One year after treatment initiation, stage 3 or worse CKD developed in 2.1% of patients in the glimepiride group, 2.2% in the glipizide group, and 1.8% in the glyburide group. Glyburide was associated with a lower risk of kidney complications compared with both glimepiride (HR 0.84, 95% CI 0.76 to 0.92) and glipizide (HR 0.81, 95% CI 0.73 to 0.89), despite a higher risk of severe hypoglycemia (HR 1.47, 95% CI 1.27 to 1.71 vs glipizide and HR 1.22, 95% CI 1.05 to 1.42 vs glimepiride). In contrast, the risk of kidney complications was modestly increased with glipizide compared with glimepiride use (HR 1.04, 95% CI 1.00 to 1.07).ConclusionsGlyburide was associated with a modestly lower risk of kidney complications, despite a higher risk of hypoglycemia, while glipizide was associated with a higher risk of kidney complications. These hypothesis-generating findings suggest important within-class differences that warrant consideration in clinical decision-making and future research. Despite rigorous prespecified causal inference analytic methods, the risk of unmeasured confounding and bias by indication with the use of observational data remains.Trial registration numberNCT05214573.

IntroductionTo examine within-class sulfonylurea safety, we compared risks of major adverse cardiovascular events (MACE) and severe hypoglycemia among adults with type 2 diabetes (T2D) and moderate cardiovascular risk following sulfonylurea initiation.Research design and methodsWe conducted a target trial emulation including adults ≥21 years old with T2D and moderate cardiovascular risk who initiated glimepiride, glipizide or glyburide between 2014 and 2021, using claims data from Optum Labs Data Warehouse and the Medicare fee-for-service 100% sample. Study outcomes were MACE (primary), expanded MACE and its components and emergency department or hospital encounters for hypoglycemia, ascertained during follow-up through 2022. Inverse probability of treatment weighting (IPTW) was applied using propensity scores estimated using the super learner ensemble, and outcomes were examined using IPTW Cox proportional hazards models.ResultsThe weighted study cohort comprised 314 699 patients (mean age 66.9 years, 52.0% men, 76.6% non-Hispanic white). At 1 year, MACE was experienced by 2.5%, 2.7% and 2.8% of patients starting glimepiride, glipizide and glyburide, respectively. Compared with glimepiride, glyburide and glipizide were associated with higher risk of MACE (HR 1.10, 95% CI 1.05 to 1.16 for glyburide; HR 1.05, 95% CI 1.03 to 1.07 for glipizide). At 1 year, severe hypoglycemia was experienced by 0.3%, 0.3% and 0.4% of patients starting glimepiride, glipizide and glyburide, respectively. Glyburide was associated with a greater risk of severe hypoglycemia compared with glipizide (HR 1.43, 95% CI 1.23 to 1.65), while glipizide was associated with a lower risk compared with glimepiride (HR 0.82, 95% CI 0.77 to 0.87).ConclusionsAmong adults with T2D and moderate cardiovascular risk, glimepiride was associated with lowest risk of MACE and glipizide with lowest risk of severe hypoglycemia. These results can help inform treatment selection if sulfonylureas are used for glucose-lowering.

Although scholars have long studied circumstances that shape prejudice, inquiry into factors associated with long-term prejudice reduction has been more limited. Using a 6-year longitudinal study of non-Black physicians in training (N = 3,134), we examined the effect of three medical-school factors—interracial contact, medical-school environment, and diversity training—on explicit and implicit racial bias measured during medical residency. When accounting for all three factors, previous contact, and baseline bias, we found that quality of contact continued to predict lower explicit and implicit bias, although the effects were very small. Racial climate, modeling of bias, and hours of diversity training in medical school were not consistently related to less explicit or implicit bias during residency. These results highlight the benefits of interracial contact during an impactful experience such as medical school. Ultimately, professional institutions can play a role in reducing anti-Black bias by encouraging more frequent, and especially more favorable, interracial contact.

The environment in which a patient lives influences their health outcomes. However, the degree to which community factors are associated with readmissions is uncertain. To estimate the influence of community factors on the Centers for Medicare & Medicaid Services risk-standardized hospital-wide readmission measure (HWR)-a quality performance measure in the U.S. We assessed 71 community variables in 6 domains related to health outcomes: clinical care; health behaviors; social and economic factors; the physical environment; demographics; and social capital. Medicare fee-for-service patients eligible for the HWR measure between July 2014-June 2015 (n = 6,790,723). Patients were linked to community variables using their 5-digit zip code of residence. We used a random forest algorithm to rank variables for their importance in predicting HWR scores. Variables were entered into 6 domain-specific multivariable regression models in order of decreasing importance. Variables with P-values <0.10 were retained for a final model, after eliminating any that were collinear. Among 71 community variables, 19 were retained in the 6 domain models and in the final model. Domains which explained the most to least variance in HWR were: physical environment (R2 = 15%); clinical care (R2 = 12%); demographics (R2 = 11%); social and economic environment (R2 = 7%); health behaviors (R2 = 9%); and social capital (R2 = 8%). In the final model, the 19 variables explained more than a quarter of the variance in readmission rates (R2 = 27%). Readmissions for a wide range of clinical conditions are influenced by factors relating to the communities in which patients reside. These findings can be used to target efforts to keep patients out of the hospital.

Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States. We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSA between 2005 and 2013 who were discharged home. Study inclusion required continuous insurance enrollment for the 12 months preceding and the 31 days following the index ED visit. During the study period we included only the first ED visit for each patient. A total of 49,672 (14.2%) had a return visit to the ED or had a hospitalization within 30 days following discharge. Mean time to the next ED visit or inpatient admission was 11.7 days. An increased age (age 65+ vs. age <18 years; OR 1.65, 95% CI [1.57 to 1.74]), chronic medical comorbidities (Hwang comorbidity 5+ vs 0; OR 1.31, 95% CI [1.27 to 1.35]), prior ED and inpatient utilization (4+ visits vs 0 visits; OR 5.59, 95% CI [5.41 to 5.78]) were associated with return visits within 30 days following discharge. In an analysis of nearly 350,000 ED visits for MHSA, 14.2 % of patients returned to the ED or hospital within 30 days. This study identified a number of factors associated with return visits for acute care.

Patient-reported outcome measure (PROM) surveillance and collaborative care improve cancer symptom control. However, human resource requirements constrain their implementation and reach. Electronic health record (EHR) facilitation reduces resource needs and might allow population-level scaling. We aimed to assess the effect of EHR facilitation of PROM-directed collaborative care on clinical and health services outcomes. E2C2 was a cohort cluster-randomised, unblinded, stepped-wedge, pragmatic trial, in which we randomly assigned 15 clusters of medical oncology and haematology clinics in the USA sharing a common EHR, Epic, to five sequences to compare an intervention of remotely delivered electronic PROM (ePROM) symptom surveillance and EHR-facilitated collaborative care (ECC) management with a usual care (UC) control of ePROM surveillance alone. Sequences transitioned from the UC control to the ECC intervention state at 8-month intervals. All adult (aged ≥18 years) patients who received medical oncology or haematology care in a US multi-state health system were enrolled. All cancer stages, cancer types, and treatment phases were included, except for patients enrolled in hospice or with acute leukaemia. SPPADE symptoms (sleep interference, pain, impaired physical function, anxiety, depression, and energy deficit or fatigue) were assessed with 0–10-point numerical rating scales linked to clinical encounters. The prespecified co-primary outcomes were all post-baseline SPPADE scores, and clinically actionable scores (≥4/10), among participants who completed at least two ePROMs. The outcomes were assessed using multivariate regression of cluster-period mean SPPADE symptom scores against intervention exposure, baseline SPPADE scores, fixed-cluster, and secular time effects. The trial is registered at ClinicalTrials.gov (NCT03892967) and is now closed to recruitment. From March 28, 2019, to Jan 31, 2023, 50 207 patients were enrolled and administered ePROMs in association with oncology or haematology visits. In the analytical cohort of 24 874 participants, 10 390 (42%) were assigned ePROMS in both the ECC and UC periods. Of the 19 084 [77%] in the ECC group, 11 138 (58%) were female, 7946 (42%) were male, and 18189 (95%) were White; and of the 16 180 (65%) in the UC group, 9621 (60%) were female, 6559 (40%) were male, and 15468 (96%) were White. 21 153 (85%) participants reported one or more clinically actionable symptoms (defined as SPPADE score ≥4/10). In multivariate analyses, mean population joint SPPADE symptom burden favoured ECC periods (p=0·0055) with adjusted mean differences of –0·12 (95% CI –0·19 to –0·05) for anxiety, –0·08 (–0·15 to –0·01) for depression, –0·06 (–0·16 to 0·03) for fatigue, –0·04 (–0·14 to 0·07) for pain, 0·03 (–0·07 to 0·14) for physical function, and –0·07 (–0·16 to 0·02) for sleep. ECC benefit was also noted following actionable scores (p<0·0001) with adjusted mean differences of –0·10 (–0·17 to –0·03) for anxiety, –0·09 (–0·16 to –0·02) for depression, –0·09 (–0·18 to –0·01) for fatigue, 0·04 (–0·05 to 0·12) for pain, 0·07 (–0·03 to 0·17) for physical function, and –0·02 (–0·10 to 0·07) for sleep. Centralised EHR-facilitated, symptom surveillance and collaborative care management are more beneficial than symptom surveillance alone in reducing the population burden of SPPADE symptoms in oncology patients. US National Institutes of Health.

Population wellbeing, an aggregate measure of positive mental, physical, and emotional health, has previously been used as a marker of community thriving. We examined whether several community measures of wellbeing, and their change since 2012, could be used to understand electoral changes that led to the outcome of the 2016 United States presidential election. We found that areas of the US which had the largest shifts away from the incumbent party had both lower wellbeing and greater drops in wellbeing when compared with areas that did not shift. In comparison, changes in income were not related to voting shifts. Well-being may be more useful in predicting and understanding electoral outcomes than some more conventional voting determinants.

Background Inequities in healthcare delivery and outcomes remain pervasive. The United States’ Centers for Medicare and Medicare Services (CMS) started confidentially reporting to hospitals data on disparities in readmission rates for Medicare beneficiaries in 2019. Whether hospitals with readmission disparities are more likely to establish equity efforts is an important policy question. We examined relationships between hospitals with readmission disparities for Medicare beneficiaries in 2019, and hospital equity efforts in 2022, measured by (a) the presence of an equity officer and (b) the strength of a hospital’s equity environment. Methods We conducted a retrospective study of US hospitals in the American Hospital Association Annual Survey that were eligible for CMS’ Hospital-Wide Readmission and Disparity measures using 2019 Medicare data. Outcomes: hospital equity efforts in 2022 measured by the presence of a hospital equity officer and a hospital’s equity environment composite score. Exposure: Disparities in 2019 Medicare readmissions by insurance (dual-eligible vs. non-dual-eligible patients) and by race (Black vs. White patients). Covariates: hospital characteristics. We used regression analyses to examine relationships between hospitals with and without disparities in readmissions in 2019 (by insurance and race separately) and our two outcomes. Results 2019 hospital-level disparities by insurance conferred a 1.35 times increased odds (95% CI: 1.17–1.56) of having an equity officer and 0.76 (0.22) point increase in equity environment composite scores in 2022 in unadjusted analyses. These relationships were not significant after adjusting for hospital covariates. There was no relationship between disparities by race and 2022 equity efforts. Conclusions Our findings suggest that hospital-level readmission disparities do not necessarily incentivize hospital-level equity efforts. Hospital organizational type, which likely influences not only its patient population but also hospital culture, may be a stronger predictor of hospital equity efforts. This study contributes to the discussion of how we measure, report on and create accountability to equity at the hospital-level.

Background Physicians who work in the private sector while also holding a salaried job in a public hospital, known as “dual practice,” is one of the main retention strategies adopted by the government of Ethiopia. Dual practice was legally endorsed in Tigray National Regional State, Ethiopia in 2010. Therefore, the aim of this study was to explore the extent of dual practice, reasons why physicians engage in it, and its effects on public hospital services in this state in northern Ethiopia. Methods A cross-sectional study using mixed methods was conducted from February to March 2011 in six geographically representative public hospitals of Tigray National Regional State. A semi-structured, self-administered questionnaire was distributed to all physicians working in the study hospitals, and an interviewer-administered, structured questionnaire was used to collect data from admitted patients. Focus group discussions were conducted with hospital governing boards. Quantitative and qualitative data were used in the analysis. Results Data were collected from 31 physicians and 449 patients in the six study hospitals. Six focus group discussions were conducted. Twenty-eight (90.3%) of the physicians were engaged in dual practice to some extent: 16 (51.6%) owned private clinics outside the public hospital, 5 (16.1%) worked part-time in outside private clinics, and 7 (22.6%) worked in the private wing of public hospitals. Income supplementation was the primary reason for engaging in dual practice, as reported by 100% of the physicians. The positive effects of dual practice from both managers’ and physicians’ perspectives were physician retention in the public sector. Ninety-one patients (20.3%) had been referred from a private clinic immediately prior to their current admission-a circular diversion pattern. Eighteen (19.8%) of the diverted patients reported that health workers in the public hospitals diverted them. Conclusions Circular diversion pattern of referral system is the key negative consequence of dual practice. Physicians and hospital managers agreed that health worker retention was the main positive consequence of dual practice upon the public sector, and banning dual practice would result in a major loss of senior physicians. The motive behind the circular diversion pattern described by patients should be studied further.