A Pragmatic Approach to Streamlining Single-Use Plastics in Health Care

In older inpatients with polypharmacy, medication optimization did not improve outcomes at 48 wk

Source Citation Ie K, Hirose M, Sakai T, et al. Medication optimization protocol efficacy for geriatric inpatients: a randomized clinical trial. JAMA Netw Open. 2024;7:e2423544. 39078632

In older adults receiving high-risk medications, a deprescribing intervention did not reduce falls at 18 mo

Source Citation Phelan EA, Williamson BD, Balderson BH, et al. Reducing central nervous system–active medications to prevent falls and injuries among older adults: a cluster randomized clinical trial. JAMA Netw Open. 2024;7:e2424234. 39052289

Changes in Dialysis Center Quality Associated With the End-Stage Renal Disease Quality Incentive Program: An Observational Study With a Regression Discontinuity Design: Annals of Internal Medicine: Vol 174, No 8

Background: In 2012, the Centers for Medicare & Medicaid Services started levying performance-based financial penalties against outpatient dialysis centers under the mandatory End-Stage Renal Disease Quality Incentive Program. Objective: To determine whether penalization was associated with improvement in dialysis center quality. Design: Leveraging the threshold for penalization (total performance score < 60), a regression discontinuity design was used to examine the effect of penalization on quality over 2 years. Publicly available Medicare data from 2015–2018 were used. The effect of penalization at dialysis centers with different characteristics (for example, size or chain affiliation) was also examined. Setting: United States. Participants: Outpatient dialysis centers (n = 5830). Measurements: Dialysis center total performance scores (a composite metric ranging from 0 to 100 based on clinical quality and adherence to reporting requirements) and individual measures that contribute to the total performance score. Results: There were 1109 (19.0%) outpatient dialysis centers that received penalties in 2017 on the basis of performance in 2015. Penalized centers were located in ZIP codes with a higher average proportion of non-White residents (36.4% vs. 31.2%; P < 0.001) and residents with lower median income ($49 290 vs. $51 686; P < 0.001). Penalization was not associated with improvement in total performance scores in 2017 (0.4 point [95% CI, −2.5 to 3.2 points]) or 2018 (0.3 point [CI, −2.8 to 3.4 points]). This was consistent across dialysis centers with different characteristics. There was also no association between penalization and improvement in specific measures. Limitation: The study could not account for how centers respond to penalization. Conclusion: Penalization under the End-Stage Renal Disease Quality Incentive Program was not associated with improvement in the quality of outpatient dialysis centers. Primary Funding Source: None.

The Effect of Influenza Vaccination for the Elderly on Hospitalization and Mortality: An Observational Study With a Regression Discontinuity Design: Annals of Internal Medicine: Vol 172, No 7

Background: Observational studies using traditional research designs suggest that influenza vaccination reduces hospitalizations and mortality among elderly persons. Accordingly, health authorities in some countries prioritize vaccination of this population. Nevertheless, questions remain about this policy's effectiveness given the potential for bias and confounding in observational data. Objective: To determine the effectiveness of the influenza vaccine in reducing hospitalizations and mortality among elderly persons by using an observational research design that reduces the possibility of bias and confounding. Design: A regression discontinuity design was applied to the sharp change in vaccination rate at age 65 years that resulted from an age-based vaccination policy in the United Kingdom. In this design, comparisons were limited to individuals who were near the age-65 threshold and were thus plausibly similar along most dimensions except vaccination rate. Setting: England and Wales. Participants: Adults aged 55 to 75 years residing in the study area during 2000 to 2014. Intervention: Seasonal influenza vaccine. Measurements: Hospitalization and mortality rates by month of age. Results: The data included 170 million episodes of care and 7.6 million deaths. Turning 65 was associated with a statistically and clinically significant increase in rate of seasonal influenza vaccination. However, no evidence indicated that vaccination reduced hospitalizations or mortality among elderly persons. The estimates were precise enough to rule out results from many previous studies. Limitation: The study relied on observational data, and its focus was limited to individuals near age 65 years. Conclusion: Current vaccination strategies prioritizing elderly persons may be less effective than believed at reducing serious morbidity and mortality in this population, which suggests that supplementary strategies may be necessary. Primary Funding Source: National Institute on Aging.

Regression of Xanthelasmas With Statin Treatment in a Normolipidemic Patient

The Effect of Heat Exposure on Myocardial Blood Flow and Cardiovascular Function

Background: Heat extremes are associated with greater risk for cardiovascular death. The pathophysiologic mechanisms mediating this association are unknown. Objective: To quantify the myocardial blood flow (MBF) requirements of heat exposure. Design: Experimental study. (ClinicalTrials.gov: NCT04549974) Setting: Laboratory-based. Participants: 61 participants, comprising 20 healthy young adults (mean age, 28 years), 21 healthy older adults (mean age, 67 years), and 20 older adults with coronary artery disease (CAD) (mean age, 70 years). Intervention: Participants were heated until their core temperature increased 1.5 °C; MBF was measured before heat exposure and at every increase of 0.5 °C in core temperature. Measurements: The primary outcome was MBF measured by positron emission tomography–computed tomography. Secondary outcomes included heart rate, blood pressure, and body weight change. Results: At a core temperature increase of 1.5 °C, MBF increased in healthy young adults (change, 0.8 mL/min/g [95% CI, 0.5 to 1.0 mL/min/g]), healthy older adults (change, 0.7 mL/min/g [CI, 0.5 to 0.9 mL/min/g]), and older adults with CAD (change, 0.6 mL/min/g [CI, 0.3 to 0.8 mL/min/g]). This represented a 2.08-fold (CI, 1.75- to 2.41-fold), 1.79-fold (CI, 1.59- to 1.98-fold), and 1.64-fold (CI, 1.41- to 1.87-fold) change, respectively, from preexposure values. Imaging evidence of asymptomatic heat-induced myocardial ischemia was seen in 7 adults with CAD (35%) in post hoc analyses. Limitations: In this laboratory-based study, heating was limited to about 100 minutes and participants were restricted in movement and fluid intake. Participants refrained from strenuous exercise and smoking; stopped alcohol and caffeine intake; and withheld β-blockers, calcium-channel blockers, and nitroglycerin before heating. Conclusion: Heat exposure that increases core temperature by 1.5 °C nearly doubles MBF. Changes in MBF did not differ by age or presence of CAD, but some older adults with CAD may experience asymptomatic myocardial ischemia. Primary Funding Source: Canadian Institutes of Health Research.

Medicare Advantage: High Costs and Poor Protection

Long COVID: The Enduring Pandemic

Association Between Hospital Type and Resilience During COVID-19 Caseload Stress: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 177, No 10

Background: Imbalances between hospital caseload and care resources that strained U.S. hospitals during the pandemic have persisted after the pandemic amid ongoing staff shortages. Understanding which hospital types were more resilient to pandemic overcrowding-related excess deaths may prioritize patient safety during future crises. Objective: To determine whether hospital type classified by capabilities and resources (that is, extracorporeal membrane oxygenation [ECMO] capability, multiplicity of intensive care unit [ICU] types, and large or small hospital) influenced COVID-19 volume–outcome relationships during Delta wave surges. Design: Retrospective cohort study. Setting: 620 U.S. hospitals in the PINC AI Healthcare Database. Participants: Adult inpatients with COVID-19 admitted July to November 2021. Measurements: Hospital-months were ranked by previously validated surge index (severity-weighted COVID-19 inpatient caseload relative to hospital bed capacity) percentiles. Hierarchical models were used to evaluate the effect of log-transformed surge index on the marginally adjusted probability of in-hospital mortality or discharge to hospice. Effect modification was assessed for by 4 mutually exclusive hospital types. Results: Among 620 hospitals recording 223 380 inpatients with COVID-19 during the Delta wave, there were 208 ECMO-capable, 216 multi-ICU, 36 large (≥200 beds) single-ICU, and 160 small (<200 beds) single-ICU hospitals. Overall, 50 752 (23%) patients required admission to the ICU, and 34 274 (15.3%) died. The marginally adjusted probability for mortality was 5.51% (95% CI, 4.53% to 6.50%) per unit increase in the log surge index (strain attributable mortality = 7375 [CI, 5936 to 8813] or 1 in 5 COVID-19 deaths). The test for interaction showed no difference (P = 0.32) in log surge index–mortality relationship across 4 hospital types. Results were consistent after excluding transferred patients, restricting to patients with acute respiratory failure and mechanical ventilation, and using alternative strain metrics. Limitation: Residual confounding. Conclusion: Comparably detrimental relationships between COVID-19 caseload and survival were seen across all hospital types, including highly advanced centers, and well beyond the pandemic’s learning curve. These lessons from the pandemic heighten the need to minimize caseload surges and their effects across all hospital types during public health and staffing crises. Primary Funding Source: Intramural Research Program of the National Institutes of Health Clinical Center.