Papers by Sudha Xirasagar
Research into management methods
Journal of Public Health Management and Practice, May 1, 2017
Context: Despite implementation of the Affordable Care Act (ACA), as of 2015, about 25.8 million ... more Context: Despite implementation of the Affordable Care Act (ACA), as of 2015, about 25.8 million working-age Americans remained uninsured and vulnerable to premature death because of poor health care access. The ACA-mandated phasing out of disproportionate share hospital payments that supported charity care may aggravate care access for the residual uninsured. Objectives: To estimate excess deaths among the uninsured and the potential ACA impact on the basis of a recent cohort's mortality experience. We hypothesized a higher uninsured mortality risk than the available pre-2000 estimate because of worsening of care disparities owing to technology-driven advances in life-saving care. Design: We conducted a retrospective cohort study of the 1999 to 2002 National Health and Nutrition Examination Survey respondents observed through 2011. We estimated (a) weighted Cox proportional mortality hazard of uninsured working-age adults adjusted for demographics, comorbidity, and lifestyle behaviors, (b) weighted mortality rates among the uninsured and insured within age and comorbidity strata, and (c) excess deaths because of uninsurance using the Institute of Medicine methodology. Setting: Noninstitutionalized US population. Participants: Adults aged 20 to 64 years. Main Outcome Measure: Mortality. Results: Of 7274 study-eligible respondents, 20.6% were uninsured and 478 died during follow-up, for an adjusted uninsured mortality hazard ratio of 1.57 (95% confidence interval, 1.12-2.21) versus privately insured, translating to 48 529 excess deaths among the population aged 25 to 64 years in 2011 (7.8% of total deaths in this age group). The estimated proportion of excess deaths was 52% higher than the pre-2000 cohort study. The mortality disparity increased with age and comorbidity. Conclusions: Findings support our hypotheses, and indicate that post-ACA, a residual 4.7% excess mortality among working-age adults will continue, about 30 428 excess deaths annually. Restoration of disproportionate share hospital supports and continued advocacy for universal health care coverage are needed to reduce avoidable deaths.
Précis: This study aims to investigate the association between primary open-angle glaucoma (POAG)... more Précis: This study aims to investigate the association between primary open-angle glaucoma (POAG) and tinnitus. We found that tinnitus was significantly associated with preexisting POAG [adjusted odds ratio (OR)=1.298]. Purpose: The purpose of this study was to investigate the association between POAG and tinnitus using nationwide population-based data from Taiwan. Methods: Data for this case-control study were retrieved from the Taiwan National Health Insurance Research Database for all 542,682 patients with a first-time diagnosis of tinnitus (cases), and 1,628,046 propensity score–matched controls from Taiwan’s National Health Insurance system. We performed multiple logistic regression analysis to estimate the odds (ORs) of prior POAG among cases versus controls. Results: Of total 2,170,728 study patients, 85,257 (3.93%) had POAG before the index date of tinnitus, 25,496 (4.70%) among cases and 59,761 (3.67%) among controls (P<0.001). Multiple logistic regression analysis showed a significant association between prior POAG and tinnitus (OR=1.298, 95% confidence interval: 1.278-1.318) after adjusting for age, sex, monthly income, geographic location and residential urbanization level, hyperlipidemia, diabetes, obesity, anemia, rheumatoid arthritis, alcohol abuse, nicotine dependence, anxiety disorder, depressive disorder, and hypertension. Conclusions: Patients with POAG have a higher risk of tinnitus compared with those without the disease. Ophthalmologists should be aware of this association and further studies are needed to understand underlying mechanisms.
Clinical Rheumatology, Apr 6, 2019
The revised affiliation is now presented correctly in this article. The remainder of the article ... more The revised affiliation is now presented correctly in this article. The remainder of the article remains unchanged. Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Clinical Rheumatology, Sep 12, 2018
The revised affiliation is now presented correctly in this article. The remainder of the article ... more The revised affiliation is now presented correctly in this article. The remainder of the article remains unchanged. Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
International Journal of Environmental Research and Public Health, Jan 25, 2021
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Journal of racial and ethnic health disparities, Aug 15, 2017
With 23 and 47% higher colorectal cancer (CRC) incidence and mortality, respectively, among Afric... more With 23 and 47% higher colorectal cancer (CRC) incidence and mortality, respectively, among African Americans vs. Whites, CRC screening studies are important. Screening guidelines recommend 5-yearly colonoscopy screening of persons with a family history of CRC (first-degree relatives, FDRs), beginning at 40 years of age. For this elevated-risk group, colonoscopy screening is preferred because of the risk of more aggressive cancer that may elude early detection by other methods. African Americans with a family history of CRC are at the intersection of two elevated risk demographics, race and FDR status. This study explored racial disparities in colonoscopy
Journal of Surgical Research, Sep 1, 2021
BACKGROUND Colonic stent placement can avoid urgent surgery for large bowel obstruction in select... more BACKGROUND Colonic stent placement can avoid urgent surgery for large bowel obstruction in selected patients. Population-wide stent utilization patterns and outcomes are unknown. MATERIALS AND METHODS Using retrospective, population-based, Nationwide Inpatient Sample data, we studied patients with colonic stents discharged during 2010-2015. The primary outcome was ostomy creation during the same hospitalization. Other outcomes were perforation or peritonitis, and in-hospital death. Associations of outcomes with stent indication were investigated, adjusting for patient-, admission-, and hospital characteristics. We estimated annual population-wide stent use volumes. RESULTS Of 4257 patients with stent placement (52% male, mean age 64.6 years), 9.9% had non-metastatic colon cancer, 12.9% metastatic colon cancer, 37.8% extracolonic malignancy (ECM), and 39.3% had benign obstruction. In 8.1% of patients, ostomy creation surgery was performed. Perforation or peritonitis occurred in 16.7%, and in-hospital death in 4.5%. Relative to ECM, ostomy creation was several-fold more likely among nonmetastatic colon cancer (adjusted odds ratio (OR) 3.4; 95%CI, 2.1-5.5), metastatic colon cancer (adjusted OR 2.5; 95%CI, 1.7-3.7), and benign obstruction patients (adjusted OR 3.1; 95%CI, 2.1-4.7). Benign obstruction was associated with high risk of perforation/peritonitis (adjusted OR 3.1 relative to non-metastatic CC (95%CI, 2.1-4.5)). Perforation/peritonitis was highly associated with inpatient death (adjusted OR 6.8 (95%CI, 4.9-9.5)). Annually, about 3,580 patients underwent stent placement, with benign obstruction showing an increasing trend (P=0.0002). CONCLUSIONS Over 75% of stent placements were done for patients with benign disease and ECM obstruction. Subsequent ostomy creation during the hospitalization was least likely among ECM patients. Rates of perforation/peritonitis in benign obstructions were concerningly high. (22.2%).
Journal of Glaucoma, Feb 22, 2022
Précis: This study aims to investigate the association between primary open-angle glaucoma (POAG)... more Précis: This study aims to investigate the association between primary open-angle glaucoma (POAG) and tinnitus. We found that tinnitus was significantly associated with preexisting POAG [adjusted odds ratio (OR)=1.298]. Purpose: The purpose of this study was to investigate the association between POAG and tinnitus using nationwide population-based data from Taiwan. Methods: Data for this case-control study were retrieved from the Taiwan National Health Insurance Research Database for all 542,682 patients with a first-time diagnosis of tinnitus (cases), and 1,628,046 propensity score–matched controls from Taiwan’s National Health Insurance system. We performed multiple logistic regression analysis to estimate the odds (ORs) of prior POAG among cases versus controls. Results: Of total 2,170,728 study patients, 85,257 (3.93%) had POAG before the index date of tinnitus, 25,496 (4.70%) among cases and 59,761 (3.67%) among controls (P<0.001). Multiple logistic regression analysis showed a significant association between prior POAG and tinnitus (OR=1.298, 95% confidence interval: 1.278-1.318) after adjusting for age, sex, monthly income, geographic location and residential urbanization level, hyperlipidemia, diabetes, obesity, anemia, rheumatoid arthritis, alcohol abuse, nicotine dependence, anxiety disorder, depressive disorder, and hypertension. Conclusions: Patients with POAG have a higher risk of tinnitus compared with those without the disease. Ophthalmologists should be aware of this association and further studies are needed to understand underlying mechanisms.
Gastroenterology, May 1, 2021
Oral Oncology, May 1, 2023
Journal of Headache and Pain, May 6, 2020
Background: Tinnitus due to hyperactivity across neuronal ensembles along the auditory pathway is... more Background: Tinnitus due to hyperactivity across neuronal ensembles along the auditory pathway is reported. We hypothesized that trigeminal neuralgia patients may subsequently suffer from tinnitus. Using nationwide, population-based data and a retrospective cohort study design, we investigated the risk of tinnitus within 1 year following trigeminal neuralgia. Methods: We used the Taiwan National Health Insurance Research Dataset, a claims database, to identify all patients diagnosed with trigeminal neuralgia from January 2001 to December 2014, 12,587 patients. From the remaining patients, we identified 12,587 comparison patients without trigeminal neuralgia by propensity score matching, using sex, age, monthly income, geographic region, residential urbanization level, and tinnitus-relevant comorbidities (hyperlipidemia, diabetes, coronary heart disease, hypertension, cervical spondylosis, temporomandibular joint disorders and injury to head and neck and index year). All study patients (n = 25,174) were tracked for a one-year period to identify those with a subsequent diagnosis of tinnitus over 1-year follow-up. Results: Among total 25,174 sample patients, the incidence of tinnitus was 18.21 per 100 person-years (95% CI = 17.66~18.77), the rate being 23.57 (95% CI = 22.68~24.49) among patients with trigeminal neuralgia and 13.17 (95% CI = 12.53~13.84) among comparison patients. Furthermore, the adjusted Cox proportional hazard ratio for tinnitus in the trigeminal neuralgia group was 1.68 (95% CI = 1.58~1.80) relative to the comparison cohort. Conclusions: We found a significantly increased risk of tinnitus within 1 year of trigeminal neuralgia diagnosis compared to those without the diagnosis. Further studies in other countries and ethnicities are needed to explore the relationship between trigeminal neuralgia and subsequent tinnitus.
European Archives of Oto-rhino-laryngology, Jul 26, 2021
Few studies have explored population-based incidence rates of microtia using nationwide data. The... more Few studies have explored population-based incidence rates of microtia using nationwide data. The aim of this study was to analyze the 10-year secular trends in the incidence of microtia and/or anotia in Taiwan from 2008 to 2017 using nationwide population-based data. Patient data were retrieved from Taiwan’s National Health Insurance Dataset, after identifying 1152 children aged ≤ 1 year with a first-time diagnosis of microtia or anotia between January 2008 and December 2017. The annual microtia–anotia incidence rate was the sum of new microtia–anotia cases in a year divided by total infant population in the year. Furthermore, we used the annual percent change (APC) to study the secular trend in microtia–anotia incidence rate. The annual incidence rate of microtia–anotia averaged across the 10-year period was 57.7 per 100,000 infants (standard deviation = 8.6). The annual incidence rates of microtia and anotia were 53.3 and 4.4 per 100,000 infants, respectively, during this period. Furthermore, female infants had a higher incidence than males (63.3 vs. 52.4 per 100,000). The incidence of microtia–anotia gradually decreased between 2008 and 2017 with an APC of − 5.64% (95% CI − 9.31 ~ − 1.18%, p = 0.004). Since 2011, females had a significantly higher annual incidence rate of microtia–anotia than males. The incidence of microtia–anotia was 57.7 per 100,000 infants in Taiwan, which declined during the study period 2008–2017. The female-to-male incidence ratio was 1.21:1.
The Journal of Clinical Pharmacology, Oct 17, 2018
To date, few epidemiologic studies have investigated the relationship between pioglitazone use an... more To date, few epidemiologic studies have investigated the relationship between pioglitazone use and prostate cancer. The available studies show conflicting findings. This case-control study explored the association between prior pioglitazone usage and prostate cancer using a large, populationbased data set. Data were derived from the Longitudinal Health Insurance Database 2005 in Taiwan, a population-based sample of National Health Insurance enrollees with longitudinal claims data since 1995. Cases were 3513 patients with prostate cancer aged over 40 years, and the controls were 3513 patients without prostate cancer, matched with prostate cancer cases on age, and having a medical care utilization episode in the year of the index prostate cancer (1 control per case). We performed conditional logistic regression to examine the odds ratio and 95% confidence intervals for prior pioglitazone use between cases and controls. Analysis showed that 178 of the total sample patients (2.53%) had used pioglitazone prior to the index date. Prior pioglitazone use was found in 72 (2.05%) cases and 106 (3.02%) controls. The crude odds ratio of prior pioglitazone usage for cases was 0.67 (95% confidence interval, 0.50-0.91) compared to controls. After adjusting for demographic characteristics and comorbidities, the negative association of prior pioglitazone with prostate cancer persisted (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.80). We concluded that there was an inverse association between prior pioglitazone usage and prostate cancer in this study.
Journal of Clinical Medicine, Dec 13, 2022
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Journal of Gastrointestinal Surgery, Aug 12, 2022
Journal of Headache and Pain, Sep 18, 2020
Annals of Internal Medicine, Sep 18, 2018
TO THE EDITOR: Kahi and colleagues (1) conclude that colonoscopy reduces colorectal cancer (CRC) ... more TO THE EDITOR: Kahi and colleagues (1) conclude that colonoscopy reduces colorectal cancer (CRC) mortality risk by 61%, the complement of the 0.39 odds ratio for colonoscopy exposure among patients with CRC (case patients) versus control participants matched on age and sex. Their conclusion is problematic because colonoscopy status was unreliable (the identification algorithm is 70% accurate). Furthermore, case patients were substantially more predisposed to CRC because they comprised more black persons and more persons with lower socioeconomic status, a family history of CRC, comorbidities, and a history of cigarette smoking than the control group (Table 1 of the article). Case patients were also predisposed to present with late-stage disease by the study cutoff age of 50 years because of lead-time bias due to the greater likelihood of more aggressive CRC and earlier incidence of CRC (which is more common among black persons and those with a family history of CRC), whereas control participants had yet to present with CRC. Moreover, the mean age at diagnosis was 70.8 years; with control participants matched to case patients on the basis of the latter&amp;amp;#39;s age, just a few years of lead-time bias would substantially inflate the prevention rate, especially considering control participants&amp;amp;#39; low colonoscopy rate. Finally, a precondition for equating exposure odds with relative risk for the outcome is that case patients and control participants have similar risk and protective factors (2). Overall, Kahi and colleagues&amp;amp;#39; conclusion is challenged by inaccurate exposure classification, lead-time bias, and dissimilarities between case patients and control participants. We disagree with the authors that colonoscopy quality is driven by endoscopists&amp;amp;#39; subspecialty training, a claim that is supported by dated studies. Among case patients provided colonoscopy by gastroenterologists, 709 (14%) developed CRC; most of these cases of cancer should have been prevented. Furthermore, we have shown that actual performance quality combined with active follow-upnot subspecialty trainingdrives CRC prevention (3). Our study endoscopists were mostly primary care physicians and were required to follow a strict quality protocol that included meticulous patient coaching for colonic cleansing, a high cecal intubation rate, inspection of every fold during withdrawal, mandatory viewing of the video monitor by all persons present in the room, operational and patient positioning support by endoscopy technicians for complete polypectomy, monitoring of endoscopists&amp;amp;#39; adenoma detection rates and withdrawal times, and patient follow-up (4). Using detailed data on every patient and his or her polyps and with a CRC case-capture during follow-up exceeding 99%, we showed prevention of CRC incidence and mortality of 83% and 89%, respectively, regardless of sex and race. The adenoma detection rate among our study&amp;amp;#39;s endoscopists was 30%, similar to that of the highest quintile of endoscopists in Corley and associates&amp;amp;#39; landmark study (5). In conclusion, Kahi and colleagues probably overestimated the protective effect of colonoscopy as performed by gastroenterologists in the Veterans Affairs health system.
Clinical Otolaryngology, Feb 28, 2019
The purpose of this study was to evaluate the association between osteoporosis and salivary gland... more The purpose of this study was to evaluate the association between osteoporosis and salivary gland stone using a population-based claims database. Design: A case-control design Setting: Taiwan Participants: We retrieved the sample for this case-control study from the Taiwan "Longitudinal Health Insurance Database 2005". All 557 patients aged 40 years or older with a diagnosis of sialolithiasis were cases and 1671 matched controls (without sialolithiasis) were selected. Subjects and Methods: We used the chi-square test to explore differences between cases and controls on socio-demographic characteristics. Furthermore, conditional logistic regressions were used to examine the association of sialolithiasis with previously diagnosed osteoporosis.
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Papers by Sudha Xirasagar