Empirical and Normative Implications of Social Networks for Disparities: The Case of Renal Transplantation

This dissertation examines the extent to which individual-level and social network-level factors explain disparities in living donor kidney transplantation (LDKT) and considers the moral implications. Paper One examines whether patient characteristics explain racial disparities in the rate of donor presentation and LDKT in a sample of 752 potential kidney recipients and 654 potential kidney donors. Propensity score matching and subclassification were used to balance the patient characteristics. Survival models revealed that only 24% of blacks compared to 39% of whites would have at least one potential donor evaluated within the first year, even after accounting for differences in the distribution of patient characteristics. Thus, lower rates of donor presentation among black recipients cannot be explained by differences in individual-level characteristics. Paper Two examines whether differences in social networks contribute to disparities in LDKT. Using interview and medical record data from a representative sample of 389 dialysis patients in Greater Boston and a subsample of 302 alters, we found that social network characteristics, especially network size, were strongly predictive of pursuing LDKT. Significant racial disparities in health and medical distrust among social networks of black patients present compelling evidence for network effects. Fewer network members of black patients may be eligible for donation owing to compositional health differences, and those eligible may be less willing to donate due to greater distrust or poor socioeconomic position. Paper Three argues that society ought to be concerned with previously neglected disparities in LDKT, specifically the fraction stemming from disparities in social networks because networks provide one pathway by which inequalities can be perpetuated throughout society and over time. Insofar as social networks are influenced by an unjust distribution of social forces, and social networks influence life chances by restricting (or enhancing) one’s ability to obtain a LDKT, then life chances of dialysis patients are unjustly determined by social networks. Potential policies aimed at providing compensatory damages to patients whose networks have been adversely affected by the unjust influence of social determinants are examined

Caregiver Satisfaction with a Video Telehealth Home Safety Evaluation for Dementia

Family caregivers are vital to telehealth-delivered dementia care. The objective of this mixed methods descriptive study conducted in the VA Bedford Healthcare System was to examine caregiver satisfaction with a video telehealth dementia home safety occupational therapy evaluation. Ten caregivers of Veterans with dementia participated. Ratings of caregiver satisfaction, measured by nine Likert scale items including ability to see and hear, were examined in relation to person and visit-related contextual factors extracted from RA field notes, to develop an in-depth understanding of caregiver experience. Person factors included caregiver age and gender and Veteran cognitive status. Visit-related contextual factors included occurrence  of technical glitches. Caregiver visit satisfaction was overall positive, with exceptions related to technological glitches and the presence of the person with dementia during the visit. Veteran cognitive status appeared to influence caregiver satisfaction. Implications of the study are that proactively addressing technical glitches and incorporating dementia stage-specific approaches may optimize caregivers’ telehealth experience.

Utilization of ACP CPT codes among high-need Medicare beneficiaries in 2017: A brief report

IMPORTANCE: Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service. OBJECTIVE: To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population. DESIGN: Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries. SETTING: Nationally representative FFS Medicare 20% sample. PARTICIPANTS: Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill and frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled ( \u3c 65). All participants had data available for years 2016-2017. EXPOSURE: Receipt of a billed ACP discussion, CPT codes 99497 or 99498. MAIN OUTCOME AND MEASURE: Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region. RESULTS: Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill and frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p \u3c .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the \u3c 65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p \u3c .05 compared with non-high needs). CONCLUSIONS AND RELEVANCE: While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant

Potential Unintended Consequences Of Recent Shared Decision Making Policy Initiatives

Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed

Advance care planning among Medicare beneficiaries with dementia undergoing surgery

IMPORTANCE: Advance care planning (ACP), in which patients or their surrogates discuss goals and preferences for care with physicians, attorneys, friends, and family, is an important approach to help align goals with actual treatment. ACP may be particularly valuable in patients with advanced serious illnesses such as Alzheimer\u27s disease and related dementias (ADRDs) for whom surgery carries significant risks. OBJECTIVE: To determine the frequency, timing, and factors associated with ACP billing in Medicare beneficiaries with ADRD undergoing nontrauma inpatient surgery. DESIGN: This national cohort study analyzes Medicare fee-for-service claims data from 2016 to 2017. All patients had a 6-month lookback and follow-up period. SETTING: National Medicare fee-for-service data. PARTICIPANTS: All patients with ADRD, defined according to the Chronic Conditions Warehouse, undergoing inpatient surgery from July 1, 2016 to June 30, 2017. EXPOSURES: Patient demographics, medical history, and procedural outcomes. MAIN OUTCOME: ACP billing codes from 6 months before to 6 months after admission for inpatient surgery. RESULTS: This study included 289,428 patients with ADRD undergoing surgery, of whom 21,754 (7.5%) had billed ACP within the 6 months before and after surgical admission. In a multivariable analysis, patients of white race, male sex, and residence in the Southern and Midwestern United States were at the highest risk of not receiving ACP. Of all patients who received ACP, 5960 (27.4%) did so before surgery while 12,658 (52.8%) received ACP after surgery. Timing of ACP after surgery was associated with an Elixhauser comorbidity index of 3 or higher (1.23, p = 0.045) and major postoperative complication or death (odds ratio 1.52, p \u3c 0.0001). CONCLUSIONS AND RELEVANCE: Overall ACP billing code use is low among Medicare patients with ADRD undergoing surgery. Billed ACP appears to have a reactive pattern, occurring most commonly after surgery and in association with postoperative mortality and complications. Additional study is warranted to understand barriers to use

Poorly differentiated hepatocellular carcinoma: resection is equivalent to transplantation in patients with low liver fibrosis

Organ allocation criteria for liver transplantation focus on tumor size and multifocality while tumor differentiation and existing liver damage are omitted. This study analyzes the impact of hepatocellular carcinoma (HCC) grade and liver fibrosis comparing resection (SX) to transplantation (LT). The National Cancer Database was queried between 2004 and 2016 for solitary HCC meeting Milan criteria undergoing SX vs LT. Two groups were created: low fibrosis (LF) vs high fibrosis (HF) and stratified by grade. Cox multivariable regression models, Kaplan–Meier survival analyses and log-rank tests were performed. 1515 patients were identified; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months; LT mOS was 47.9 months vs SX mOS of 34.9 months (P < .001). Multivariate analysis revealed SX, no chemotherapy, longer hospital stays, and age to be associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, SX vs LT did not impact survival for poorly differentiated HCC in LF patients, independent of tumor size. HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vs LT. Therefore, current HCC transplantation criteria should incorporate tumor grade or liver fibrosis for optimal organ allocation