Showing papers by "Michael J. Fine published in 2021"

Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System.

Abstract: Importance Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. Objective To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. Design, Setting, and Participants This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. Exposures Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. Main Outcomes and Measures Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. Results Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. Conclusions and Relevance This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.

Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare.

Abstract: Background and objectives Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown. Design, setting, participants, & measurements We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation. Results Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non–Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1). Conclusions Most dually enrolled veterans underwent transplantation at a non–Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration–only post-transplant care had the lowest 5-year mortality.

Association of Race and Ethnicity and Anticoagulation in Patients with Atrial Fibrillation Dually Enrolled in VA and Medicare: Effects of Medicare Part D on Prescribing Disparities

Abstract: Background: Racial and ethnic disparities in anticoagulation exist in atrial fibrillation (AF) management in Medicare and the Veterans Health Administration (VA), but the influence of dual VA and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare Part D enrollment on anticoagulation disparities. Methods: We identified patients with incident AF (2014-2018) dually enrolled in VA and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants, DOACs) within 90 days of AF diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare Part D enrollment and an interaction term for these variables. Results: In 43,789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare Part D. Overall, 29,680 (67.8%) patients initiated any anticoagulant, of which 17,568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (p= 0.001), and lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (p=0.001) initiated DOACs. Compared to White patients, Black patients had significantly lower initiation of any anticoagulant, adjusted odds ratio (aOR) 0.89; 95% CI 0.82-0.97. The aORs for DOAC initiation were significantly lower for Black (0.72; 95% CI, 0.65-0.81) and Hispanic (0.84; 95% CI, 0.70-1.00) than White patients.The interaction between race and ethnicity and Medicare Part D enrollment was non-significant for any anticoagulant (p=0.99) and DOAC (p=0.27) therapies. Conclusions: In dually enrolled VA and Medicare patients with AF, Black patients were less likely to initiate any anticoagulant and Black and Hispanic patients were less likely to initiate DOACs. Medicare Part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.

Association Between Neighborhood-Level Poverty and Incident Atrial Fibrillation: a Retrospective Cohort Study.

Abstract: Background Atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality. While neighborhood-level factors, such as poverty, have been related to prevalence of AF risk factors, the association between neighborhood poverty and incident AF has been limited. Objective Using a large cohort from a health system serving the greater Chicago area, we sought to determine the association between neighborhood-level poverty and incident AF. Design Retrospective cohort study. Participants Adults, aged 30 to 80 years, without baseline cardiovascular disease from January 1, 2005, to December 31, 2018. Main measures We geocoded and matched residential addresses of all eligible patients to census-level poverty estimates from the American Community Survey. Neighborhood-level poverty (low, intermediate, and high) was defined as the proportion of residents in the census tract living below the federal poverty threshold. We used generalized linear mixed effects models with a logit link function to examine the association between neighborhood poverty and incident AF, adjusting for patient demographic and clinical AF risk factors. Key results Among 28,858 in the cohort, patients in the high poverty group were more often non-Hispanic Black or Hispanic and had higher rates of AF risk factors. Over 5 years of follow-up, 971 (3.4%) patients developed incident AF. Of these, 502 (51.7%) were in the low poverty, 327 (33.7%) in the intermediate poverty, and 142 (14.6%) in the high poverty group. The adjusted odds ratio (aOR) of AF was higher for the intermediate poverty compared with that for the low poverty group (aOR 1.23 [95% CI 1.01-1.48]). The point estimate for the aOR of AF incidence was similar, but not statistically significant, for the high poverty compared with the low poverty group (aOR 1.25 [95% CI 0.98-1.59]). Conclusion In adults without baseline cardiovascular disease managed in a large, integrated health system, intermediate neighborhood poverty was significantly associated with incident AF. Understanding neighborhood-level drivers of AF disparities will help achieve equitable care.

Prescriber perspectives on low-value prescribing: A qualitative study.

Abstract: BACKGROUND Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood. OBJECTIVE To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians. DESIGN Qualitative study using semi-structured interviews. SETTING Academic and community primary care practices within University of Pittsburgh Medical Center health system. PARTICIPANTS Sixteen primary care physicians. MEASUREMENTS We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing. RESULTS We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable. CONCLUSIONS Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

National Media Coverage of the Veterans Affairs Waitlist Scandal: Effects on Veterans' Distrust of the VA Health Care System.

Abstract: BACKGROUND On April 23, 2014, US media outlets broadcast reports of excessive wait times and "secret" waitlists at some Veterans Affairs (VA) hospitals, precipitating legislation to increase Veterans' access to private sector health care. OBJECTIVE The aims were to assess changes in Veterans' distrust in the VA health care system before and after the media coverage and explore sex and racial/ethnic differences in the temporal patterns. METHODS Veterans completed semistructured interviews on health care satisfaction from June 2013 to January 2015, including a validated scale of health system distrust (range: 1-5). We used linear splines with knots at 90-day intervals to assess changes in distrust before and after April 23, 2014 ("day 0") in linear mixed models. To explore sex and racial/ethnic differences in temporal patterns, we stratified models by sex and tested for interactions of race/ethnicity with time. RESULTS For women (n=600), distrust scores (mean=2.09) increased by 0.45 in days 0-90 (P<0.01), then decreased by 0.45 in days 90-180 (P<0.01). Among men (n=575), distrust scores (mean=2.05) increased by 0.18 in days 0-90 (P=0.059). Distrust levels were significantly higher for Black versus White women (time adjusted mean difference=0.21) and for Black and Hispanic versus White men (differences=0.26 and 0.18). However, the temporal patterns did not vary by race/ethnicity for women or men (interaction P=0.85 and 0.21, respectively). CONCLUSIONS Health system distrust increased in women following media coverage of VA access problems and was higher in Black/Hispanic versus White Veterans at all time periods. Such perceptions could influence Veteran decisions to seek health care in the community rather than VA.

Racial/Ethnic Differences in 30-Day Mortality for Heart Failure and Pneumonia in the Veterans Health Administration Using Claims-based, Clinical, and Social Risk-adjustment Variables.

Abstract: Background Prior studies have identified lower mortality in Black Veterans compared with White Veterans after hospitalization for common medical conditions, but these studies adjusted for comorbid conditions identified in administrative claims. Objectives The objectives of this study were to compare mortality for non-Hispanic White (hereafter, "White"), non-Hispanic Black (hereafter, "Black"), and Hispanic Veterans hospitalized for heart failure (HF) and pneumonia and determine whether observed mortality differences varied according to whether claims-based comorbid conditions and/or clinical variables were included in risk-adjustment models. Research design This was an observational study. Subjects The study cohort included 143,520 admissions for HF and 127,782 admissions for pneumonia for Veterans hospitalized in 132 Veterans Health Administration (VA) Medical Centers between January 2009 and September 2015. Measures The primary independent variable was racial/ethnic group (ie, Black, Hispanic, and non-Hispanic White), and the outcome was all-cause mortality 30 days following admission. To compare mortality by race/ethnicity, we used logistic regression models that included different combinations of claims-based, clinical, and sociodemographic variables. For each model, we estimated the average marginal effect (AME) for Black and Hispanic Veterans relative to White Veterans. Results Among the 143,520 (127,782) hospitalizations for HF (pneumonia), the average patient age was 71.6 (70.9) years and 98.4% (97.1%) were male. The unadjusted 30-day mortality rates for HF (pneumonia) were 7.2% (11.0%) for White, 4.1% (10.4%) for Black and 8.4% (16.9%) for Hispanic Veterans. Relative to White Veterans, when only claims-based variables were used for risk adjustment, the AME (95% confidence interval) for the HF [pneumonia] cohort was -2.17 (-2.45, -1.89) [0.08 (-0.41, 0.58)] for Black Veterans and 1.32 (0.49, 2.15) [4.51 (3.65, 5.38)] for Hispanic Veterans. When clinical variables were incorporated in addition to claims-based ones, the AME, relative to White Veterans, for the HF [pneumonia] cohort was -1.57 (-1.88, -1.27) [-0.83 (-1.31, -0.36)] for Black Veterans and 1.50 (0.71, 2.30) [3.30 (2.49, 4.11)] for Hispanic Veterans. Conclusions Compared with White Veterans, Black Veterans had lower mortality, and Hispanic Veterans had higher mortality for HF and pneumonia. The inclusion of clinical variables into risk-adjustment models impacted the magnitude of racial/ethnic differences in mortality following hospitalization. Future studies examining racial/ethnic disparities should consider including clinical variables for risk adjustment.

An Interrupted Time-series Evaluation of the Association Between State Laws Mandating Prescriber Use of Prescription Drug Monitoring Programs and Discontinuation of Chronic Opioid Therapy in US Veterans.

Abstract: Background Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. Methods We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). Results We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. Conclusion We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

Authorship stories panel discussion: Fostering ethical authorship by cultivating a growth mindset.

Abstract: Because peer review publication is essential for academic advancement across scientific fields, when authorship is wrongly attributed the consequences can be profound, particularly for junior researchers who are still establishing their professional norms and scientific reputations. Professional societies have published guidelines for authorship, yet authorship dilemmas frequently arise and have harmful consequences for scientific careers. Researchers have noted the complexities of authorship and called for new mechanisms to foster more ethical research cultures within institutions. To address this call, we organized a panel discussion at the Institute for Clinical Research Education at the University of Pittsburgh in which senior faculty members from diverse backgrounds and professional disciplines discussed their own authorship challenges (e.g., renegotiating author order, reconciling inter-professional authorship norms, managing coauthor power differentials) and offered strategies to avoid and/or resolve them. Informed by growth mind-set theory, our storytelling format facilitated an open exchange between senior and junior researchers, situated authorship dilemmas in specific contexts and career stages, and taught researchers how to address authorship challenges not adequately informed by guideline recommendations. Though not empirically assessed, we believe this approach represents a simple, low-cost, and replicable way to cultivate ethical and transparent authorship practices among researchers across scientific fields.