A common practice of metanalysis is combining the results of numerous studies on the effects of a... more A common practice of metanalysis is combining the results of numerous studies on the effects of a risk factor on a disease outcome. If several of these composite relative risks are estimated from the medical literature for a specific disease, they cannot be combined in a multivariate risk model, as is often done in individual studies, because methods are not available to overcome the issues of risk factor colinearity and heterogeneity of the different cohorts. We propose a solution to these problems for general linear regression of continuous outcomes using a simple example of combining two independent variables from two sources in estimating a joint outcome. We demonstrate that when explicitly modifying the underlying data characteristics (correlation coefficients, standard deviations, and univariate betas) over a wide range, the predicted outcomes remain reasonable estimates of empirically derived outcomes (gold standard). This method shows the most promise in situations where the primary interest is in generating predicted values as when identifying a high-risk group of individuals. The resulting partial regression coefficients are less robust than the predicted values.
Psychiatric research and clinical practice, Oct 7, 2020
Studies show decreased depression diagnosis, psychotherapy, and medications and increased suicide... more Studies show decreased depression diagnosis, psychotherapy, and medications and increased suicide attempts following US Food and Drug Administration antidepressant warnings regarding suicidality risk among youth. Effects on care spilled over to older adults. This study investigated whether suicide deaths increased following the warnings and declines in depression care. Methods: We conducted an interrupted time series study of validated death data (1990-2017) to estimate changes in trends of US suicide deaths per 100,000 adolescents (ages 10-19) and young adults (ages 20-24) after the warnings, controlling for baseline trends. Results: Before the warnings (1990-2002), suicide deaths decreased markedly. After the warnings (2005-2017) and abrupt declines in treatment, this downward trend reversed. There was an immediate increase of 0.49 suicides per 100,000 adolescents, 95% confidence interval [CI]: 0.12, 0.86) and a trend increase of 0.03 suicides per 100,000 adolescents per year (95% CI: 0.026, 0.031). Similarly, there was an immediate increase of 2.07 suicides per 100,000 young adults (95% CI: 1.04, 3.10) and a trend increase of 0.05 suicides per 100,000 young adults per year (95% CI: 0.04, 0.06). Assuming baseline trends continued, there may have been 5958 excess suicides nationally by 2010 among yearly cohorts of 43 million adolescents and 21 million young adults. Conclusions: We observed increases in suicide deaths among youth following the warnings and declines in depression care. Alternative explanations were explored, including substance use, economic recessions, smart phone use, and unintentional injury deaths. Additional factors may have contributed to continued increases in youth suicide during the last decade. Combined with previous research on declining treatment, these results call for re-evaluation of the antidepressant warnings.
This study examined attitudes of African American women toward medical care and health insurance.... more This study examined attitudes of African American women toward medical care and health insurance. Data were analyzed from the National Medical Expenditure Survey, a large household survey conducted by the Agency for Health Care Policy and Research and focusing on insurance and health care utilization. The responses of African American women tended neither to downplay the importance of receiving health care as essential to health maintenance and recovery from illness, nor to minimize health insurance as a worthwhile investment. When African American women did give responses discounting the importance of health care, the attitude difference failed to account for race-related differences in utilization. There was no evidence in the data to indicate that attitudes lead African American women to neglect seeking medical care or acquiring health insurance, and solutions to the problem of medical care underutilization must be sought elsewhere.
Little is known about the impact of treatment-resistant hypertension (TRH) on health-related qual... more Little is known about the impact of treatment-resistant hypertension (TRH) on health-related quality of life (HrQoL). We aimed to compare HrQoL measures in adults with apparent TRH (aTRH) and non-resistant hypertension among nationally representative US Medical Expenditure Panel Survey data pooled from 2000 to 2011. Cohorts compared were adults with aTRH (⩾2 unique fills from ⩾ 4 antihypertensive classes during a year) versus non-resistant hypertension (those with hypertension not meeting the aTRH definition). Key outcomes were cohort differences in SF-12v2 physical component summary (PCS) and mental component summary (MCS) scores and disease-state utility using the SF-6D. Of 57 150 adults with hypertension, 2501 (4.4%) met criteria for aTRH. Persons with aTRH, compared with non-resistant hypertension, were older (mean, 68 vs 61 years), had a higher BMI (30.9 vs 29.7 kg m −2) and were more likely to be Black (20% vs 14%), but less likely to be female (46% vs 54%). Persons with aTRH, compared with non-resistant hypertension, had lower mean PCS scores (35.8 vs 43.2; P o0.0001), and utility (0.68 vs 0.74; P o0.0001), but similar MCS scores (49.1 vs 50.4). In multivariable-adjusted analyses, aTRH was associated with a 2.37 (95% CI 1.71 to 3.02) lower PCS score and 0.02 (95% CI 0.01 to 0.03) lower utility, compared with non-resistant hypertension. In conclusion, aTRH was associated with substantially lower HrQoL in physical functioning and health utility, but not in mental functioning, compared with non-resistant hypertension. The multivariable-adjusted reduction in physical functioning was similar in magnitude to previous observations comparing hypertension with no hypertension.
Introduction: Early treatment for hypertension (HTN) portends better outcomes. However, few real-... more Introduction: Early treatment for hypertension (HTN) portends better outcomes. However, few real-world studies have assessed initial antiHTN regimens and how they differ by baseline blood pressure (BP). We sought to compare initial treatment patterns, stratified by BP, between Medicaid and Medicare recipients. Methods: We performed a cross-sectional study of adults with newly-treated HTN in the One Florida+ Consortium(2012-2020) who had linked claims-EHR data from the treatment initiation visit. Eligible patients were Floridians with Medicaid or Medicare aged ≥18 years, with diagnosed HTN, who filled ≥1 first-line antiHTN class with no evidence of anti HTN fills during the year prior (in which continuous insurance enrollment was required). Baseline BP was categorized per current HTN guidelines, and logistic regression was used to estimate age-adjusted odds of combination vs. monotherapy, per 10 mmHg increase in systolic BP (SBP) or diastolic BP (DBP). Results: We included 2,902 patients (47% Medicaid, 53% Medicare); mean age was 44 (Medicaid) and 67 yrs(Medicare); 60% (64% and 56%, respectively) were women and 42% (57% and 29%, respectively) were Black. Initial antiHTN classes were similar comparing cohorts: ACEI, ARB and thiazide initiation varied little by BP category, in contrast to CCBs and β-blockers (Figure, panels A-B). In age-adjusted analyses, use of initial combination therapy was 40% more likely (OR, 1.40; 95% CI, 1.11, 1.76) among Medicare recipients and inversely related to BP category (panels C-D) among Medicare patients, in which each 10mmHg greater SBP (OR, 0.93; 95% CI, 0.88, 0.97) and DBP (OR 0.82; 95% CI, 0.75, 0.90) had lower odds of combination therapy. Among Medicaid recipients, only SBP associated with combination therapy (OR1.11; 95% CI, 1.03, 1.20). Conclusions: We observed similar initial class patterns among Medicaid & Medicare recipients across baseline BP, but differential use of combination therapy was less likely at higher baseline BP in Medicare recipients, which contrasts current guidance.
The American Pediatric Society (APS) and Society for Pediatric Research (SPR) Virtual Chat series... more The American Pediatric Society (APS) and Society for Pediatric Research (SPR) Virtual Chat series on "Challenges in Pediatric Academic Medicine" provides a forum for bringing together diverse members of the pediatric academic community at many different stages of their careers, ranging from students and residents, to fellows and junior faculty and senior leadership. The goal of this series is to openly and directly address key challenges facing academic medicine through organized discussions that includes a panel consisting of outstanding leaders in the field. Past topics have included navigating career transitions, disparities in health care and outcomes, the Dean's view of academic medicine, and valuing and achieving diversity in academic medicine. Today's session focuses on mentorship, which has been identified as one of the most vital determinants of launching, developing and sustaining successful careers in academics, especially for the clinician-scientist. Although much has been written and discussed regarding mentorship, many complexities regarding the mentor-mentee relationship and related issues, remain major challenges.
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association... more OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association between higher institutional volumes and improved outcomes for aSAH patients has been studied extensively. However, the literature exploring patterns of transfer in this context is sparse. Expansion of the endovascular workforce has raised concerns about the decentralization of care, reduced institutional volumes, and worsened patient outcomes. In this paper, the authors explored various patient and hospital factors associated with the transfer of aSAH patients by using a nationally representative database. METHODS The 2013 and 2014 years of the National Inpatient Sample (NIS) were used to define an observational cohort of patients with ruptured brain aneurysms. The initial search identified patients with SAH (ICD-9-CM 430). Those with concomitant codes suggesting trauma or other intracranial vascular abnormalities were excluded. Finally, the patients who had not undergone a subsequent procedure to repair an intracranial aneurysm were excluded. These criteria yielded a cohort of 4373 patients, 1379 of whom had undergone microsurgical clip ligation and 2994 of whom had undergone endovascular repair. The outcome of interest was transfer status, and the NIS data element TRAN_IN was used to define this state. Multiple explanatory variables were identified, including age, sex, primary payer, median household income by zip code, race, hospital size, hospital control, hospital teaching status, and hospital location. These variables were evaluated using descriptive statistics, bivariate correlation analysis, and multivariable logistic regression modeling to determine their relationship with transfer status. RESULTS Patients with aSAH who were treated in an urban teaching hospital had higher odds of being a transfer (OR 2.15, 95% CI 1.71-2.72) than the patients in urban nonteaching hospitals. White patients were more likely to be transfer patients than were any of the other racial groups (p < 0.0001). Moreover, patients who lived in the highest-income zip codes were less likely to be transferred than the patients in the lowest income quartile (OR 0.78, 95% CI 0.64-0.95). Repair type (clip vs coil) and primary payer were not associated with transfer status. CONCLUSIONS A relatively high percentage of patients with aSAH are transferred between acute care hospitals. Race and income were associated with transfer status. White patients are more likely to be transferred than other races. Patients from zip codes with the highest income transferred at lower rates than those from the lowest income quartile. Transfer patients were preferentially sent to urban teaching hospitals. The modality of aneurysm treatment was not associated with transfer status.
The most valuable resource is time: Insights from a novel national program to improve retention o... more The most valuable resource is time: Insights from a novel national program to improve retention of physician-scientists with caregiving responsibilities. Acad Med.
Journal of the American Heart Association, Jan 3, 2023
Background Knowledge of real‐world antihypertensive use is limited to prevalent hypertension, lim... more Background Knowledge of real‐world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first‐line antihypertensives (angiotensin‐converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or β‐blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin‐converting enzyme inhibitors (39%) followed by β‐blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of β‐blockers, a single drug accounted for ≥75% of use of each class. β‐blocker use decreased (35%–26%), and calcium channel blocker use increased (24%–28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real‐world implementation in early hypertension care.
Journal of Heart and Lung Transplantation, Apr 1, 2014
s S313 Conclusion: The risk of thrombosis after anticoagulation reversal in our cohort of CF-LVAD... more s S313 Conclusion: The risk of thrombosis after anticoagulation reversal in our cohort of CF-LVAD patients was acceptably low.
Journal of The American Society of Hypertension, Apr 1, 2014
Little is known about the impact of treatment-resistant hypertension (TRH) on health-related qual... more Little is known about the impact of treatment-resistant hypertension (TRH) on health-related quality of life (HrQoL). We aimed to compare HrQoL measures in adults with apparent TRH (aTRH) and non-resistant hypertension among nationally representative US Medical Expenditure Panel Survey data pooled from 2000 to 2011. Cohorts compared were adults with aTRH (⩾2 unique fills from ⩾ 4 antihypertensive classes during a year) versus non-resistant hypertension (those with hypertension not meeting the aTRH definition). Key outcomes were cohort differences in SF-12v2 physical component summary (PCS) and mental component summary (MCS) scores and disease-state utility using the SF-6D. Of 57 150 adults with hypertension, 2501 (4.4%) met criteria for aTRH. Persons with aTRH, compared with non-resistant hypertension, were older (mean, 68 vs 61 years), had a higher BMI (30.9 vs 29.7 kg m −2) and were more likely to be Black (20% vs 14%), but less likely to be female (46% vs 54%). Persons with aTRH, compared with non-resistant hypertension, had lower mean PCS scores (35.8 vs 43.2; P o0.0001), and utility (0.68 vs 0.74; P o0.0001), but similar MCS scores (49.1 vs 50.4). In multivariable-adjusted analyses, aTRH was associated with a 2.37 (95% CI 1.71 to 3.02) lower PCS score and 0.02 (95% CI 0.01 to 0.03) lower utility, compared with non-resistant hypertension. In conclusion, aTRH was associated with substantially lower HrQoL in physical functioning and health utility, but not in mental functioning, compared with non-resistant hypertension. The multivariable-adjusted reduction in physical functioning was similar in magnitude to previous observations comparing hypertension with no hypertension.
come countries. METHODS: We systematically reviewed the literature on the application of CVD risk... more come countries. METHODS: We systematically reviewed the literature on the application of CVD risk models in pharmacoeconomic studies. We assessed the quality of incorporation of risk models in these studies by evaluating the agreement of the population characteristics and the time horizon applied between the risk model and the pharmacoeconomic study, the appropriateness of the risk model for the population studied, and the incorporation of the uncertainty of the risk model in the sensitivity analysis. RESULTS: We identified 12 studies using published CVD risk models. The studies demonstrated the usefulness of projecting intermediate effectiveness endpoints to long term, health and cost related, benefits. However, our quality assessment highlighted the distance between the populations of the risk model and the studies reviewed, the disagreement between risk model and study time horizons, and the lack of consideration of all uncertainty surrounding risk predictions. CONCLUSIONS: Given that utilizing a risk model to project the effect of a pharmacological intervention to CVD events provides an estimate of the intervention's clinical and economic impact, consideration should be paid on the agreement between the study and risk model populations as well as the level of uncertainty that these predictions add to the decision-analytic model. In the absence of hard endpoint trials, the value of risk models to model pharmacological efficacy in primary CVD prevention remains high, although their limitation should be acknowledged.
Background: This study was a national scan of education resources on integrating sex and gender c... more Background: This study was a national scan of education resources on integrating sex and gender considerations into research. The purpose was to assess capacity for educating researchers and to identify gaps, with implications for implementation of guidelines or mandates to consider sex and gender differences in research. Information sources were U.S. training programs in women's health and sex/gender difference research, Building Interdisciplinary Research Careers in Women's Health (BIRCWH), and published peer-reviewed biomedical literature. Materials and Methods: This descriptive study used multiple methods: a national survey and a comprehensive literature review. BIRCWH leaders responded to a survey regarding education on sex/gender difference research for BIRCWH scholars (response rate 100%, 20 of 20). A comprehensive literature review was conducted for 1993-2018. Results: Nearly half (45%) of BIRCWH institutions offered education on integrating sex or gender differences in clinical translational research; of those, roughly half (54%) offered in-person training and one-third (31%) offered content within existing for-credit courses. Respondents preferred online training (84%) to in-person offerings or reference materials (47% and 42% respectively). Published indexed literature on sex or gender differences has quadrupled since 1993, although growth in these publications remained flat in the most recent six years. Conclusions: Published resources to educate researchers on integrating sex and gender differences into medical research have increased, and BIRCWH programs connect scholars to national resources. Educational gaps remain due to limited access to curricula on applied research approaches, design, and methods for sex/gender difference research. BIRCWH programs desire curricula that are easily accessible online and asynchronously; sanctioned and supported by national thought leaders; linked to required training such as rigor and reproducibility; foster collaboration; and offer practical applications. Evidence-based, high-quality educational curricula and a dissemination plan are needed to enhance the adoption and integration of sex and gender into scientific endeavors.
A common practice of metanalysis is combining the results of numerous studies on the effects of a... more A common practice of metanalysis is combining the results of numerous studies on the effects of a risk factor on a disease outcome. If several of these composite relative risks are estimated from the medical literature for a specific disease, they cannot be combined in a multivariate risk model, as is often done in individual studies, because methods are not available to overcome the issues of risk factor colinearity and heterogeneity of the different cohorts. We propose a solution to these problems for general linear regression of continuous outcomes using a simple example of combining two independent variables from two sources in estimating a joint outcome. We demonstrate that when explicitly modifying the underlying data characteristics (correlation coefficients, standard deviations, and univariate betas) over a wide range, the predicted outcomes remain reasonable estimates of empirically derived outcomes (gold standard). This method shows the most promise in situations where the primary interest is in generating predicted values as when identifying a high-risk group of individuals. The resulting partial regression coefficients are less robust than the predicted values.
Psychiatric research and clinical practice, Oct 7, 2020
Studies show decreased depression diagnosis, psychotherapy, and medications and increased suicide... more Studies show decreased depression diagnosis, psychotherapy, and medications and increased suicide attempts following US Food and Drug Administration antidepressant warnings regarding suicidality risk among youth. Effects on care spilled over to older adults. This study investigated whether suicide deaths increased following the warnings and declines in depression care. Methods: We conducted an interrupted time series study of validated death data (1990-2017) to estimate changes in trends of US suicide deaths per 100,000 adolescents (ages 10-19) and young adults (ages 20-24) after the warnings, controlling for baseline trends. Results: Before the warnings (1990-2002), suicide deaths decreased markedly. After the warnings (2005-2017) and abrupt declines in treatment, this downward trend reversed. There was an immediate increase of 0.49 suicides per 100,000 adolescents, 95% confidence interval [CI]: 0.12, 0.86) and a trend increase of 0.03 suicides per 100,000 adolescents per year (95% CI: 0.026, 0.031). Similarly, there was an immediate increase of 2.07 suicides per 100,000 young adults (95% CI: 1.04, 3.10) and a trend increase of 0.05 suicides per 100,000 young adults per year (95% CI: 0.04, 0.06). Assuming baseline trends continued, there may have been 5958 excess suicides nationally by 2010 among yearly cohorts of 43 million adolescents and 21 million young adults. Conclusions: We observed increases in suicide deaths among youth following the warnings and declines in depression care. Alternative explanations were explored, including substance use, economic recessions, smart phone use, and unintentional injury deaths. Additional factors may have contributed to continued increases in youth suicide during the last decade. Combined with previous research on declining treatment, these results call for re-evaluation of the antidepressant warnings.
This study examined attitudes of African American women toward medical care and health insurance.... more This study examined attitudes of African American women toward medical care and health insurance. Data were analyzed from the National Medical Expenditure Survey, a large household survey conducted by the Agency for Health Care Policy and Research and focusing on insurance and health care utilization. The responses of African American women tended neither to downplay the importance of receiving health care as essential to health maintenance and recovery from illness, nor to minimize health insurance as a worthwhile investment. When African American women did give responses discounting the importance of health care, the attitude difference failed to account for race-related differences in utilization. There was no evidence in the data to indicate that attitudes lead African American women to neglect seeking medical care or acquiring health insurance, and solutions to the problem of medical care underutilization must be sought elsewhere.
Little is known about the impact of treatment-resistant hypertension (TRH) on health-related qual... more Little is known about the impact of treatment-resistant hypertension (TRH) on health-related quality of life (HrQoL). We aimed to compare HrQoL measures in adults with apparent TRH (aTRH) and non-resistant hypertension among nationally representative US Medical Expenditure Panel Survey data pooled from 2000 to 2011. Cohorts compared were adults with aTRH (⩾2 unique fills from ⩾ 4 antihypertensive classes during a year) versus non-resistant hypertension (those with hypertension not meeting the aTRH definition). Key outcomes were cohort differences in SF-12v2 physical component summary (PCS) and mental component summary (MCS) scores and disease-state utility using the SF-6D. Of 57 150 adults with hypertension, 2501 (4.4%) met criteria for aTRH. Persons with aTRH, compared with non-resistant hypertension, were older (mean, 68 vs 61 years), had a higher BMI (30.9 vs 29.7 kg m −2) and were more likely to be Black (20% vs 14%), but less likely to be female (46% vs 54%). Persons with aTRH, compared with non-resistant hypertension, had lower mean PCS scores (35.8 vs 43.2; P o0.0001), and utility (0.68 vs 0.74; P o0.0001), but similar MCS scores (49.1 vs 50.4). In multivariable-adjusted analyses, aTRH was associated with a 2.37 (95% CI 1.71 to 3.02) lower PCS score and 0.02 (95% CI 0.01 to 0.03) lower utility, compared with non-resistant hypertension. In conclusion, aTRH was associated with substantially lower HrQoL in physical functioning and health utility, but not in mental functioning, compared with non-resistant hypertension. The multivariable-adjusted reduction in physical functioning was similar in magnitude to previous observations comparing hypertension with no hypertension.
Introduction: Early treatment for hypertension (HTN) portends better outcomes. However, few real-... more Introduction: Early treatment for hypertension (HTN) portends better outcomes. However, few real-world studies have assessed initial antiHTN regimens and how they differ by baseline blood pressure (BP). We sought to compare initial treatment patterns, stratified by BP, between Medicaid and Medicare recipients. Methods: We performed a cross-sectional study of adults with newly-treated HTN in the One Florida+ Consortium(2012-2020) who had linked claims-EHR data from the treatment initiation visit. Eligible patients were Floridians with Medicaid or Medicare aged ≥18 years, with diagnosed HTN, who filled ≥1 first-line antiHTN class with no evidence of anti HTN fills during the year prior (in which continuous insurance enrollment was required). Baseline BP was categorized per current HTN guidelines, and logistic regression was used to estimate age-adjusted odds of combination vs. monotherapy, per 10 mmHg increase in systolic BP (SBP) or diastolic BP (DBP). Results: We included 2,902 patients (47% Medicaid, 53% Medicare); mean age was 44 (Medicaid) and 67 yrs(Medicare); 60% (64% and 56%, respectively) were women and 42% (57% and 29%, respectively) were Black. Initial antiHTN classes were similar comparing cohorts: ACEI, ARB and thiazide initiation varied little by BP category, in contrast to CCBs and β-blockers (Figure, panels A-B). In age-adjusted analyses, use of initial combination therapy was 40% more likely (OR, 1.40; 95% CI, 1.11, 1.76) among Medicare recipients and inversely related to BP category (panels C-D) among Medicare patients, in which each 10mmHg greater SBP (OR, 0.93; 95% CI, 0.88, 0.97) and DBP (OR 0.82; 95% CI, 0.75, 0.90) had lower odds of combination therapy. Among Medicaid recipients, only SBP associated with combination therapy (OR1.11; 95% CI, 1.03, 1.20). Conclusions: We observed similar initial class patterns among Medicaid &amp; Medicare recipients across baseline BP, but differential use of combination therapy was less likely at higher baseline BP in Medicare recipients, which contrasts current guidance.
The American Pediatric Society (APS) and Society for Pediatric Research (SPR) Virtual Chat series... more The American Pediatric Society (APS) and Society for Pediatric Research (SPR) Virtual Chat series on "Challenges in Pediatric Academic Medicine" provides a forum for bringing together diverse members of the pediatric academic community at many different stages of their careers, ranging from students and residents, to fellows and junior faculty and senior leadership. The goal of this series is to openly and directly address key challenges facing academic medicine through organized discussions that includes a panel consisting of outstanding leaders in the field. Past topics have included navigating career transitions, disparities in health care and outcomes, the Dean's view of academic medicine, and valuing and achieving diversity in academic medicine. Today's session focuses on mentorship, which has been identified as one of the most vital determinants of launching, developing and sustaining successful careers in academics, especially for the clinician-scientist. Although much has been written and discussed regarding mentorship, many complexities regarding the mentor-mentee relationship and related issues, remain major challenges.
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association... more OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association between higher institutional volumes and improved outcomes for aSAH patients has been studied extensively. However, the literature exploring patterns of transfer in this context is sparse. Expansion of the endovascular workforce has raised concerns about the decentralization of care, reduced institutional volumes, and worsened patient outcomes. In this paper, the authors explored various patient and hospital factors associated with the transfer of aSAH patients by using a nationally representative database. METHODS The 2013 and 2014 years of the National Inpatient Sample (NIS) were used to define an observational cohort of patients with ruptured brain aneurysms. The initial search identified patients with SAH (ICD-9-CM 430). Those with concomitant codes suggesting trauma or other intracranial vascular abnormalities were excluded. Finally, the patients who had not undergone a subsequent procedure to repair an intracranial aneurysm were excluded. These criteria yielded a cohort of 4373 patients, 1379 of whom had undergone microsurgical clip ligation and 2994 of whom had undergone endovascular repair. The outcome of interest was transfer status, and the NIS data element TRAN_IN was used to define this state. Multiple explanatory variables were identified, including age, sex, primary payer, median household income by zip code, race, hospital size, hospital control, hospital teaching status, and hospital location. These variables were evaluated using descriptive statistics, bivariate correlation analysis, and multivariable logistic regression modeling to determine their relationship with transfer status. RESULTS Patients with aSAH who were treated in an urban teaching hospital had higher odds of being a transfer (OR 2.15, 95% CI 1.71-2.72) than the patients in urban nonteaching hospitals. White patients were more likely to be transfer patients than were any of the other racial groups (p < 0.0001). Moreover, patients who lived in the highest-income zip codes were less likely to be transferred than the patients in the lowest income quartile (OR 0.78, 95% CI 0.64-0.95). Repair type (clip vs coil) and primary payer were not associated with transfer status. CONCLUSIONS A relatively high percentage of patients with aSAH are transferred between acute care hospitals. Race and income were associated with transfer status. White patients are more likely to be transferred than other races. Patients from zip codes with the highest income transferred at lower rates than those from the lowest income quartile. Transfer patients were preferentially sent to urban teaching hospitals. The modality of aneurysm treatment was not associated with transfer status.
The most valuable resource is time: Insights from a novel national program to improve retention o... more The most valuable resource is time: Insights from a novel national program to improve retention of physician-scientists with caregiving responsibilities. Acad Med.
Journal of the American Heart Association, Jan 3, 2023
Background Knowledge of real‐world antihypertensive use is limited to prevalent hypertension, lim... more Background Knowledge of real‐world antihypertensive use is limited to prevalent hypertension, limiting our understanding of how treatment evolves and its contribution to persistently poor blood pressure control. We sought to characterize antihypertensive initiation among new users. Methods and Results Using Medicaid and Medicare data from the OneFlorida+ Clinical Research Consortium, we identified new users of ≥1 first‐line antihypertensives (angiotensin‐converting enzyme inhibitor, calcium channel blocker, angiotensin receptor blocker, thiazide diuretic, or β‐blocker) between 2013 and 2021 among adults with diagnosed hypertension, and no antihypertensive fill during the prior 12 months. We evaluated initial antihypertensive regimens by class and drug overall and across study years and examined variation in antihypertensive initiation across demographics (sex, race, and ethnicity) and comorbidity (chronic kidney disease, diabetes, and atherosclerotic cardiovascular disease). We identified 143 054 patients initiating 188 995 antihypertensives (75% monotherapy; 25% combination therapy), with mean age 59 years and 57% of whom were women. The most commonly initiated antihypertensive class overall was angiotensin‐converting enzyme inhibitors (39%) followed by β‐blockers (31%), calcium channel blockers (24%), thiazides (19%), and angiotensin receptor blockers (11%). With the exception of β‐blockers, a single drug accounted for ≥75% of use of each class. β‐blocker use decreased (35%–26%), and calcium channel blocker use increased (24%–28%) over the study period, while initiation of most other classes remained relatively stable. We also observed significant differences in antihypertensive selection across demographic and comorbidity strata. Conclusions These findings indicate that substantial variation exists in initial antihypertensive prescribing, and there remain significant gaps between current guideline recommendations and real‐world implementation in early hypertension care.
Journal of Heart and Lung Transplantation, Apr 1, 2014
s S313 Conclusion: The risk of thrombosis after anticoagulation reversal in our cohort of CF-LVAD... more s S313 Conclusion: The risk of thrombosis after anticoagulation reversal in our cohort of CF-LVAD patients was acceptably low.
Journal of The American Society of Hypertension, Apr 1, 2014
Little is known about the impact of treatment-resistant hypertension (TRH) on health-related qual... more Little is known about the impact of treatment-resistant hypertension (TRH) on health-related quality of life (HrQoL). We aimed to compare HrQoL measures in adults with apparent TRH (aTRH) and non-resistant hypertension among nationally representative US Medical Expenditure Panel Survey data pooled from 2000 to 2011. Cohorts compared were adults with aTRH (⩾2 unique fills from ⩾ 4 antihypertensive classes during a year) versus non-resistant hypertension (those with hypertension not meeting the aTRH definition). Key outcomes were cohort differences in SF-12v2 physical component summary (PCS) and mental component summary (MCS) scores and disease-state utility using the SF-6D. Of 57 150 adults with hypertension, 2501 (4.4%) met criteria for aTRH. Persons with aTRH, compared with non-resistant hypertension, were older (mean, 68 vs 61 years), had a higher BMI (30.9 vs 29.7 kg m −2) and were more likely to be Black (20% vs 14%), but less likely to be female (46% vs 54%). Persons with aTRH, compared with non-resistant hypertension, had lower mean PCS scores (35.8 vs 43.2; P o0.0001), and utility (0.68 vs 0.74; P o0.0001), but similar MCS scores (49.1 vs 50.4). In multivariable-adjusted analyses, aTRH was associated with a 2.37 (95% CI 1.71 to 3.02) lower PCS score and 0.02 (95% CI 0.01 to 0.03) lower utility, compared with non-resistant hypertension. In conclusion, aTRH was associated with substantially lower HrQoL in physical functioning and health utility, but not in mental functioning, compared with non-resistant hypertension. The multivariable-adjusted reduction in physical functioning was similar in magnitude to previous observations comparing hypertension with no hypertension.
come countries. METHODS: We systematically reviewed the literature on the application of CVD risk... more come countries. METHODS: We systematically reviewed the literature on the application of CVD risk models in pharmacoeconomic studies. We assessed the quality of incorporation of risk models in these studies by evaluating the agreement of the population characteristics and the time horizon applied between the risk model and the pharmacoeconomic study, the appropriateness of the risk model for the population studied, and the incorporation of the uncertainty of the risk model in the sensitivity analysis. RESULTS: We identified 12 studies using published CVD risk models. The studies demonstrated the usefulness of projecting intermediate effectiveness endpoints to long term, health and cost related, benefits. However, our quality assessment highlighted the distance between the populations of the risk model and the studies reviewed, the disagreement between risk model and study time horizons, and the lack of consideration of all uncertainty surrounding risk predictions. CONCLUSIONS: Given that utilizing a risk model to project the effect of a pharmacological intervention to CVD events provides an estimate of the intervention's clinical and economic impact, consideration should be paid on the agreement between the study and risk model populations as well as the level of uncertainty that these predictions add to the decision-analytic model. In the absence of hard endpoint trials, the value of risk models to model pharmacological efficacy in primary CVD prevention remains high, although their limitation should be acknowledged.
Background: This study was a national scan of education resources on integrating sex and gender c... more Background: This study was a national scan of education resources on integrating sex and gender considerations into research. The purpose was to assess capacity for educating researchers and to identify gaps, with implications for implementation of guidelines or mandates to consider sex and gender differences in research. Information sources were U.S. training programs in women's health and sex/gender difference research, Building Interdisciplinary Research Careers in Women's Health (BIRCWH), and published peer-reviewed biomedical literature. Materials and Methods: This descriptive study used multiple methods: a national survey and a comprehensive literature review. BIRCWH leaders responded to a survey regarding education on sex/gender difference research for BIRCWH scholars (response rate 100%, 20 of 20). A comprehensive literature review was conducted for 1993-2018. Results: Nearly half (45%) of BIRCWH institutions offered education on integrating sex or gender differences in clinical translational research; of those, roughly half (54%) offered in-person training and one-third (31%) offered content within existing for-credit courses. Respondents preferred online training (84%) to in-person offerings or reference materials (47% and 42% respectively). Published indexed literature on sex or gender differences has quadrupled since 1993, although growth in these publications remained flat in the most recent six years. Conclusions: Published resources to educate researchers on integrating sex and gender differences into medical research have increased, and BIRCWH programs connect scholars to national resources. Educational gaps remain due to limited access to curricula on applied research approaches, design, and methods for sex/gender difference research. BIRCWH programs desire curricula that are easily accessible online and asynchronously; sanctioned and supported by national thought leaders; linked to required training such as rigor and reproducibility; foster collaboration; and offer practical applications. Evidence-based, high-quality educational curricula and a dissemination plan are needed to enhance the adoption and integration of sex and gender into scientific endeavors.
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Papers by Anne Libby