Category: Nevin Manimala

JAMA Health Forum. 2025 Jul 3;6(7):e251923. doi: 10.1001/jamahealthforum.2025.1923.

ABSTRACT

IMPORTANCE: Health care organizations are increasingly measuring social risk using Z codes. Types of social risk captured in Z codes include issues related to employment, housing, education, or other psychosocial circumstances. Prior work has found low use of Z codes overall, but measurement may be biased in other ways that have implications for risk adjustment and resource allocation.

OBJECTIVE: To characterize Z code measurement among hospitalized Medicare beneficiaries across levels of clinical complexity and historical health care utilization and examine implications of these patterns for mortality prediction.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included Medicare beneficiaries with an inpatient hospital admission in 2022. Data were analyzed from May 2024 to June 2025.

MAIN OUTCOMES AND MEASUREMENTS: Presence of Z codes (codes Z55 to Z65) in any diagnosis field for a hospital admission, variation in Z code documentation across beneficiaries categorized by clinical risk (Elixhauser Comorbidity Index risk scores and predicted 30-day mortality risk) and historical utilization levels (number of hospitalizations in the prior year), and the association between Z code documentation and observed 30-day mortality, controlling for hospital fixed effects.

RESULTS: Among 7 069 611 hospitalized Medicare beneficiaries in 2022, 3 816 420 (54.0%) were female, and 6 093 932 (86.1%) were 65 years or older. A total of 148 592 (2.1%) had at least 1 Z code on the index hospital claim. Within-hospital Z code prevalence was higher for beneficiaries with lower Elixhauser Comorbidity Index clinical risk scores (2.8% vs 1.5%) and higher among patients with at least 2 hospitalizations in the prior year (2.6%) than patients with zero (1.8%) or 1 (2.1%) prior hospitalizations. Despite known population-level associations between social risk and increased mortality, Z code prevalence was highest among beneficiaries with the lowest predicted 30-day mortality risk (4.4%) and lowest among beneficiaries with the highest mortality risk (1.6%). Correspondingly, in within-hospital analyses that did not adjust for patient-level covariates such as demographic characteristics and clinical risk, the presence of a Z code was associated with a lower probability of observed 30-day mortality (5.1% vs 4.2%; difference, -0.9 percentage points; 95% CI, -1.0 to -0.8).

CONCLUSIONS AND RELEVANCE: This cohort study found that Z code use patterns likely underrepresent social risk among clinically complex patients, resulting in a spurious negative association between documented social risk and mortality. Alternative socioeconomic indicators, including data collected for population and public health surveillance, may offer more reliable measures of social risk than Z codes.

PMID:40679817 | DOI:10.1001/jamahealthforum.2025.1923

JAMA Health Forum. 2025 Jul 3;6(7):e251952. doi: 10.1001/jamahealthforum.2025.1952.

ABSTRACT

IMPORTANCE: Radiation treatments are an essential but expensive component of cancer care.

OBJECTIVE: To elucidate trends in radiation spending and identify factors associated with practice-level variations across the US health care system to inform alternative payment model design.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cross-sectional study analyzed fee-for-service Medicare beneficiaries from 2009 to 2020. Patients were continuously enrolled in fee-for-service Medicare Parts A and B during the 1 year prior through 28 days after a radiation treatment episode. Data were analyzed from January 2023 to September 2024.

EXPOSURES: Medicare beneficiaries with cancer who received radiation therapy.

MAIN OUTCOMES AND MEASURES: Radiation treatment-specific standardized spending and utilization during 90-day treatment episodes were examined and characterized by radiation type (conformal, intensity modulated, stereotactic, proton, or brachytherapy) and number of fractions. Linear regression models with practice random effects to understand practice-level variation in standardized radiation spending were estimated. Variables were added to adjust for year, patient demographics, cancer type, geography, radiation technology, and number of fractions per episode.

RESULTS: From 2009 to 2020, 1 898 864 beneficiaries with cancer (mean [SD] age, 74 [8.4] years; 48.5% female) initiated 2 149 385 radiation treatment episodes at 2150 practices. Mean (SD) 90-day standardized radiation treatment-specific spending was $13 683 ($8628). Practice-level per-episode radiation-specific spending variation was high (SD after adjusting for year, $4121). It remained high even after adjusting for patient demographic characteristics, cancer type, geography, radiation technology, and number of fractions (SD, $1487). From 2009 to 2020, unadjusted per-episode standardized radiation-specific spending increased slightly from $12 978 to $13 689 (P = .04). During this time, the median (IQR) number of fractions per episode decreased from 25 (10-33) to 16 (5-29) (P < .001), while the proportion of radiation episodes using intensity-modulated or proton radiation treatment increased (from 5% to 18% and 0.4% to 2%, respectively [both P < .001]) and use of conformal radiation treatment decreased from 61% to 38% (P < .001).

CONCLUSIONS AND RELEVANCE: In this cross-sectional study, there was substantial variation in practice-level radiation spending and number of fractions for older patients with cancer undergoing radiation treatment both within and across health care markets. This practice-level variation suggests that there may be opportunities for savings under population-based payment models.

PMID:40679816 | DOI:10.1001/jamahealthforum.2025.1952

J Psychiatr Pract. 2025 Jul 1;31(4):209-213. doi: 10.1097/PRA.0000000000000871.

ABSTRACT

Suicide among older adults is a critical yet often overlooked public health concern, with this population exhibiting the highest suicide rates globally. This article explores the multifaceted factors contributing to suicide in older adults, including depression, loneliness, chronic illness, financial stress, and a loss of purpose. It also addresses challenges in identifying and preventing suicide, such as stigma, limited access to mental health services, and misclassification of cases. Current prevention strategies, including screening tools like the Geriatric Depression Scale, integrated care models, and community-based interventions, are discussed alongside ethical debates surrounding autonomy in end-of-life decisions. The article highlights critical research gaps in understanding how various social, cultural, and economic factors intersect to influence suicide risk in older adults. It underscores the need for longitudinal studies and culturally tailored interventions, particularly leveraging telehealth solutions to improve access to care. Recommendations for primary care physicians include enhancing suicide risk screening, fostering collaboration with mental health specialists, and leveraging community resources to reduce isolation. By adopting a comprehensive and collaborative approach, health care providers, researchers, and policymakers can address the unique needs of this vulnerable population and work toward reducing suicide rates among older adults.

PMID:40679801 | DOI:10.1097/PRA.0000000000000871

J Psychiatr Pract. 2025 Jul 1;31(4):192-200. doi: 10.1097/PRA.0000000000000868.

ABSTRACT

OBJECTIVE: Women with bipolar disorder are at higher risk of complications during pregnancy, which may be associated with risky behaviors by the mother during acute episodes, as well as pharmacotherapy’s inherent risks to mother and/or infant. The goal of this narrative review is to discuss the treatment of bipolar disorder during pregnancy and breastfeeding.

METHODS: A literature search was conducted between October 2023 and July 2024 using the PubMed database, with MeSH terms “bipolar disorder” and “pregnancy” combined with the Boolean operator “AND.” Publications from 2014 to 2024 were considered, resulting in the identification of 573 articles. After titles were reviewed, 84 papers were selected for full-text review, 33 of which were included in the study.

RESULTS: Cardiopathies associated with lithium use during pregnancy in infants were reported in the 1970s, but more recent case-control and cohort studies have shown that this risk is much lower than was previously reported. However, maintaining lithium levels during pregnancy can be challenging due to physiological adaptations in renal function. Valproate exposure has been found to be associated with increased risk of neural tube defects, craniofacial, cardiac, genital, and musculoskeletal abnormalities in infants. There does not appear to be an increased risk of malformations associated with lamotrigine, and results of studies diverge concerning carbamazepine and oxcarbazepine. No statistically significant association has been reported concerning the risk of congenital malformations and prenatal exposure to antipsychotics as a group, as well as for the subgroup of atypical antipsychotics. However, it is possible that risperidone slightly increases the risk of cardiac malformations. Electroconvulsive therapy during pregnancy appears to be a relatively safe treatment; however, the small sample size reported in the literature limits more robust conclusions.

CONCLUSIONS: Pharmacotherapy during pregnancy and lactation requires careful discussion and documentation so that the prescriber and the patient can be aware of its risks and benefits.

PMID:40679799 | DOI:10.1097/PRA.0000000000000868

Pharm Res. 2025 Jul 18. doi: 10.1007/s11095-025-03892-6. Online ahead of print.

ABSTRACT

PURPOSE: In vitro dissolution testing is a critical quality attribute for solid dosage forms. Apart from similarity factor (f2), other alternatives namely model independent and dependent methods are suggested by regulatory agencies. Current manuscript attempts to compare various model independent approaches on dissolution similarity.

METHODS: Dissolution data with various degrees of variability (10-20%, 40-50%, 70-80%) are compared using similarity factor f2 (estimated, expected, bias corrected with percentile & BCa intervals) and novel approaches such as EDNE, SE, T2EQ, and MSD. Further, a flow chart is proposed to assist selection of suitable methodology.

RESULTS: The expected f2 was stringent as compared to other f2 types and the Bca confidence intervals approach increased chance of acceptance as compared to conventional f2 bootstrap. Further, EDNE results synchronized with f2 analysis. Outcome from SE, T2EQ approaches depends on value of equivalence margin. MSD approach was most stringent as compared to others. Finally, a decision tree has been proposed to facilitate the selection of appropriate methodology for similarity analysis with consideration of regulatory perspectives.

CONCLUSIONS: Overall, various model independent approaches are compared for dissolution similarity analysis. This comprehensive guidance will assist formulation and biopharmaceutics scientists to enhance the success rate of similarity while ensuring regulatory compliance and thus helps to achieve drug product with consistent performance.

PMID:40679781 | DOI:10.1007/s11095-025-03892-6

Int J Clin Pharm. 2025 Jul 18. doi: 10.1007/s11096-025-01964-6. Online ahead of print.

ABSTRACT

INTRODUCTION: The American Geriatrics Society (AGS) Beers Criteria and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria are extensively utilized in identifying potentially inappropriate medications (PIMs) among older adults. Older adults with heart failure (HF) confront the dual challenge of polypharmacy and inadequate adherence to evidence-based medications, which further complicates their medication management and clinical outcomes.

AIM: To assess the effectiveness of the AGS Beers (2023) Criteria and the STOPP (v3) criteria in identifying PIMs among older adults with HF and to analyze patterns of polypharmacy and evidence-based medications.

METHOD: This retrospective study was conducted at a tertiary academic medical center in China and involved 1578 outpatients aged ≥ 65 years with HF who received at least one outpatient prescription between January 1 and December 31, 2023. Data on demographics, comorbidities, and prescribed medications were extracted from the hospital’s electronic medical record (EMR) system. PIMs were identified with the AGS Beers (2023) Criteria and the STOPP (v3) criteria. The data were analyzed using descriptive statistics in Microsoft Excel.

RESULTS: Polypharmacy and hyperpolypharmacy were prevalent among the patients, affecting 65.3% and 15.7% of the cohort, respectively. PIMs were identified in 75.5% of patients (1192/1578), with a total of 2128 PIM cases observed according to the Beers Criteria, with the most common PIM being rivaroxaban (32.3%). The STOPP (v3) criteria identified PIMs in 28.9% of patients (n = 471), with the most frequent PIMs being statin use in frail patients aged ≥ 85 years (26.8%) and prolonged use of proton-pump inhibitors (16.6%). Among all patients in our study, 61.6% received either an angiotensin-converting enzyme inhibitor, angiotensin-II receptor blocker, or angiotensin receptor-neprilysin inhibitor (ACEI/ARB/ARNI); 57.0% were prescribed β-blockers; and 32.6% used a sodium-glucose cotransporter 2 inhibitor.

CONCLUSION: While the Beers Criteria identified a greater number of PIMs in this study, both tools have differing strengths in detecting medication-related risks. Their combined use may provide a more holistic assessment of prescribing appropriateness. The widespread use of PIMs in older adults with HF, coupled with the frequent underuse of beneficial therapies, calls for systematic interventions. Pharmacist-led interventions and electronic decision-support systems that integrate evidence-based prescribing, deprescribing, and regular medication reviews are crucial for optimizing therapeutic outcomes in older adults with HF.

PMID:40679772 | DOI:10.1007/s11096-025-01964-6

Sleep Breath. 2025 Jul 18;29(4):249. doi: 10.1007/s11325-025-03415-y.

ABSTRACT

PURPOSE: Evaluate patient phenotypes and longitudinal patterns of hypoglossal nerve stimulator (HGNS) use and identify predictors of long-term HGNS adherence.

METHODS: Patients who underwent HGNS implantation for obstructive sleep apnea (OSA) from 2017 to 2023 and had available data through 9 months post-device activation were included. Adherence rate was defined as percentage of patients using the device for at least 4 h for 70% of nights. Repeated measures ANOVA and Cochran’s Q tests were used to analyze changes in HGNS use over time. A k-means clustering analysis was used to identify HGNS user subgroups with shared characteristics and associations with HGNS use.

RESULTS: A total of 59 patients were included, with a mean (SD) age of 62.7 (11.2) years, mean (SD) body mass index of 28.5 kg/m2 (3.2), and an average pre-operative apnea-hypopnea index (AHI) of 38.7 events/hour; the majority were male (78%) and White (98.3%). Patients used their HGNS devices on average for 81.1% of nights (SD 23.5%) and 362 min/night (SD 115), with 0.96 (SD 1.4) pauses/night at 9 months post-activation. The mean percentage of nights and the time/night used decreased significantly over the first 9 months (p < 0.001 for both), while pauses/night increased (p = 0.008). The estimated adherence rate was 52.5% at 9 months. The cluster analysis revealed subgroups with shared characteristics; however, clusters were not associated with HGNS use.

CONCLUSIONS: HGNS use appears to decrease over the first nine months after activation. Additional research is warranted to investigate drivers of HGNS use decrement. Given lack of a standardized definition for adherence, future studies should report more granular HGNS use metrics to facilitate comparison across studies.

PMID:40679756 | DOI:10.1007/s11325-025-03415-y

Emerg Radiol. 2025 Jul 18. doi: 10.1007/s10140-025-02366-x. Online ahead of print.

ABSTRACT

PURPOSE: This study aimed to evaluate and compare the diagnostic performance and image quality of deep learning reconstruction (DLR) with hybrid iterative reconstruction (Hybrid IR) and filtered back projection (FBP) in contrast-enhanced CT venography for deep vein thrombosis (DVT).

METHODS: A retrospective analysis was conducted on 51 patients who underwent lower limb CT venography, including 20 with DVT lesions and 31 without DVT lesions. CT images were reconstructed using DLR, Hybrid IR, and FBP. Quantitative image quality metrics, such as contrast-to-noise ratio (CNR) and image noise, were measured. Three radiologists independently assessed DVT lesion detection, depiction of DVT lesions and normal structures, subjective image noise, artifacts, and overall image quality using scoring systems. Diagnostic performance was evaluated using sensitivity and area under the receiver operating characteristic curve (AUC). The paired t-test and Wilcoxon signed-rank test compared the results for continuous variables and ordinal scales, respectively, between DLR and Hybrid IR as well as between DLR and FBP.

RESULTS: DLR significantly improved CNR and reduced image noise compared to Hybrid IR and FBP (p < 0.001). AUC and sensitivity for DVT detection were not statistically different across reconstruction methods. Two readers reported improved lesion visualization with DLR. DLR was also rated superior in image quality, normal structure depiction, and noise suppression by all readers (p < 0.001).

CONCLUSIONS: DLR enhances image quality and anatomical clarity in CT venography. These findings support the utility of DLR in improving diagnostic confidence and image interpretability in DVT assessment.

PMID:40679754 | DOI:10.1007/s10140-025-02366-x

Infection. 2025 Jul 18. doi: 10.1007/s15010-025-02606-9. Online ahead of print.

ABSTRACT

PURPOSE: Sepsis survivors suffer from frequent rehospitalizations, of which a certain proportion is considered preventable by timely and adequate management in the outpatient setting (= ambulatory care sensitive conditions, ACSC). We aimed to assess the frequency of and risk factors for ACSC and infection-associated ACSC rehospitalization among sepsis survivors.

METHODS: Population-based, retrospective cohort study among using nationwide health claims data of the “AOK- die Gesundheitskasse”. Sepsis patients with inpatient treatment in 2016-2019 were identified using ICD-codes. Among sepsis hospital survivors, ACSC and infection-related ACSC were identified. Patient-related risk factors for ACSC were assessed by a multiple logistic regression analysis.

RESULTS: We included 347,826 sepsis patients and 234,874 sepsis hospital survivors. A total of 53.2% and 21.3% of sepsis survivors had at least one ACSC and infection-related ACSC rehospitalizations in the 12-months post-discharge, respectively. ACSC rehospitalizations often occurred closely after discharge and more frequently affected older, male, care dependent patients as well as those living in rural areas.

CONCLUSION: ACSC are common among sepsis survivors. This underlines to need for structured aftercare programs and interventions in these patients, particularly for ACSC risk groups which comprise older, male, care dependent patients in rural areas.

PMID:40679743 | DOI:10.1007/s15010-025-02606-9

Obes Surg. 2025 Jul 18. doi: 10.1007/s11695-025-08077-z. Online ahead of print.

ABSTRACT

Bariatric surgery is effective for treating obesity and its comorbidities, but the optimal technique remains debated. This meta-analysis compared one-anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB) in comorbidity remission and postoperative outcomes. We analyzed 12 trials, assessing T2DM, hypertension, and sleep apnea remission, as well as postoperative complications. Statistical analyses included risk differences (RD) and risk ratios (RR). OAGB was non-inferior to RYGB for T2DM remission (RD -1%; 95% CI -10% to 8%) but had higher risks of bile reflux (RR 7.62; 95% CI 1.97-29.46) and de novo GERD (RR 5.10; 95% CI 1.44-18.00). While OAGB is effective for T2DM remission, RYGB is superior in reducing bile reflux and GERD, highlighting the need for individualized surgical approaches.

PMID:40679731 | DOI:10.1007/s11695-025-08077-z