Statements of Interest: Addendum to the Testimony of 9 To 5, the National Association of Working Women, et al. Before the Commission on the Future of Worker-Management Relations

Addendum_Lichtman_et_al_040694.pdf: 179 downloads, before Oct. 1, 2020

Accuracy of ICD-9-CM Codes by Hospital Characteristics and Stroke Severity: Paul Coverdell National Acute Stroke Program

Background—Epidemiological and health services research often use International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes to identify patients with clinical conditions in administrative databases. We determined whether there are systematic variations between stroke patient clinical diagnoses and ICD‐9‐CM codes, stratified by hospital characteristics and stroke severity. Methods and Results—We used the records of patients discharged from hospitals participating in the Paul Coverdell National Acute Stroke Program in 2013. Within this stroke‐enriched cohort, we compared agreement between the attending physician\u27s clinical diagnosis and principal ICD‐9‐CM code and determined whether disagreements varied by hospital characteristics (presence of a stroke unit, stroke team, number of hospital beds, and hospital location). For patients with a documented National Institutes of Health Stroke Scale score at admission, we assessed whether diagnostic agreement varied by stroke severity. Agreement was generally high (\u3e 89%); differences between the physician diagnosis and ICD‐9‐CM codes were primarily attributed to discordance between ischemic stroke and transient ischemic attack (TIA), and subarachnoid and intracerebral hemorrhage. Agreement was higher for patients in metropolitan hospitals with stroke units, stroke teams, and \u3e 200 beds (all P \u3c 0.001). Agreement was lowest (60.3%) for rural hospitals with ≤ 200 beds and without stroke units or teams. Agreement was also lower for milder (94.9%) versus more‐severe (96.4%) ischemic strokes (P \u3c 0.001). Conclusions—We identified disagreements in stroke/TIA coding by hospital characteristics and stroke severity, particularly for milder ischemic strokes. Such systematic variations in ICD‐9‐CM coding practices can affect stroke case identification in epidemiological studies and may have implications for hospital‐level quality metric

Age Differences in the Association of Obstructive Sleep Apnea Risk with Cognition and Quality of Life

Using a sample of 2925 stroke-free participants drawn from a national population-based study, we examined cross-sectional associations of obstructive sleep apnea risk (OSA) with cognition and quality of life and whether these vary with age, while controlling for demographics and co-morbidities. Included participants from the REasons for Geographic And Racial Differences in Stroke Study were aged 47-93. OSA risk was categorized as high or low based on responses to the Berlin Sleep Questionnaire. Cognitive function was assessed with standardized fluency and recall measures. Depressive symptoms were assessed with the four-item Center for Epidemiologic Studies Depression Scale. Health-related Quality of Life (HRQoL) was assessed with the Medical Outcomes Study Short Form-12 (SF-12). MANCOVA statistics were applied separately to the cognitive and quality of life dependent variables while accounting for potential confounders (demographics, co-morbidities). In fully adjusted models, those at high risk for OSA had significantly lower cognitive scores (Wilks’ Lambda = 0.996, F(3, 2786) = 3.31, p < .05) and lower quality of life (depressive symptoms and HRQoL) (Wilks’ Lambda = 0.989, F(3, 2786) = 10.02, p < .0001). However, some of the associations were age-dependent. Differences in cognition and quality of life between those at high and low obstructive sleep apnea risk were most pronounced during middle age, with attenuated effects after age 70

Providing Culturally Competent Care in the Face of Health Disparities: Assessment and Training Recommendations

Background: Community health centers are a critical source of care for populations who disproportionally experience health disparities, including the uninsured and underinsured, racial and ethnic minorities, and patients with a preferred language other than English. Optimus Health Care (Optimus) is the second largest health center in Connecticut, with clinics located in Bridgeport and Stamford. Cultural competency, or a set of behaviors, attitudes, and policies that enable professionals to work effectively in cross-cultural situations holds immense potential for improving patient-physician communication and for providing effective service delivery. Objectives: This study sought to (1) better understand the barriers to care faced among patients at Optimus (2) assess staff knowledge, attitudes, and skills regarding cultural competency to make recommendations regarding future cultural competency staff trainings. Methods: Electronic medical records (EMR) of patients seen at Optimus between January 2012 and March 2013 who had a diagnosis of hyperlipidemia, hypertension, and/or diabetes were analyzed to describe characteristics related to insurance status, race/ethnicity, primary language, age, gender, and clinic location. A web-based survey was developed based on the Cultural Competence Self-Assessment Questionnaire (CCSAQ) and distributed electronically to Optimus staff. Survey results were analyzed to compare responses according to staff position type and themes were examined among respondent assessments of the current cultural competency trainings provided by Optimus. Results: The majority of patients included in the EMR analysis receive Medicare or Medicaid (75.8%) and the majority of chronic conditions among the sample were among racial and ethnic minorities. Interestingly, the majority of Optimus patients with a diagnosis of diabetes, hypertension and/or hyperlipidemia were between the ages of 30-54. Cultural Competency survey respondents noted difficulties in providing care due to language barriers, limited knowledge of intra-cultural group differences, and limited knowledge of how the causes of mental health are viewed by different cultural groups (Survey response rate: 22.4%). When asked to critique Optimus’ current cultural competency training, staff members reported efficiency as a strength and lack of applicability to a practical setting as a weakness, emphasizing the need for an interactive training. Conclusions and Recommendations: In concordance with the national trend, the results of our study indicate that Optimus patients of racial and ethnic minorities are disproportionally affected by chronic illness. Several areas were identified that can be targeted for improving the cultural competency knowledge, practice and delivery, and training needs of Optimus staff. Future studies should assess patient perceptions of cultural competency to allow for further insight into this emerging area of research.https://elischolar.library.yale.edu/ysph_pbchrr/1041/thumbnail.jp

Depressive symptoms in younger women and men with acute myocardial infarction:Insights from the VIRGO Study

BACKGROUND: Depression was recently recognized as a risk factor for adverse medical outcomes in patients with acute myocardial infarction (AMI). The degree to which depression is present among younger patients with an AMI, the patient profile associated with being a young AMI patient with depressive symptoms, and whether relevant sex differences exist are currently unknown. METHODS AND RESULTS: The Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study enrolled 3572 patients with AMI (67.1% women; 2:1 ratio for women to men) between 2008 and 2012 (at 103 hospitals in the United States, 24 in Spain, and 3 in Australia). Information about lifetime history of depression and depressive symptoms experienced over the past 2 weeks (Patient Health Questionnaire; a cutoff score ≥10 was used for depression screening) was collected during index AMI admission. Information on demographics, socioeconomic status, cardiovascular risk, AMI severity, perceived stress (14‐item Perceived Stress Scale), and health status (Seattle Angina Questionnaire, EuroQoL 5D) was obtained through interviews and chart abstraction. Nearly half (48%) of the women reported a lifetime history of depression versus 1 in 4 in men (24%; P<0.0001). At the time of admission for AMI, more women than men experienced depressive symptoms (39% versus 22%, P<0.0001; adjusted odds ratio 1.64; 95% CI 1.36 to 1.98). Patients with more depressive symptoms had higher levels of stress and worse quality of life (P<0.001). Depressive symptoms were more prevalent among patients with lower socioeconomic profiles (eg, lower education, uninsured) and with more cardiovascular risk factors (eg, diabetes, smoking). CONCLUSIONS: A high rate of lifetime history of depression and depressive symptoms at the time of an AMI was observed among younger women compared with men. Depressive symptoms affected those with more vulnerable socioeconomic and clinical profiles

Perceived Stress After Acute Myocardial Infarction: A Comparison Between Young and Middle-Aged Women Versus Men

Objective: The aim of the study was to examine how psychological stress changes over time in young and middle-aged patients after experiencing an acute myocardial infarction (AMI) and whether these changes differ between men and women. Methods: We analyzed data obtained from 2358 women and 1151 men aged 18 to 55 years hospitalized for AMI. Psychological stress was measured using the 14-item Perceived Stress Scale (PSS-14) at initial hospitalization and at 1 month and 12 months after AMI. We used linear mixed-effects models to examine changes in PSS-14 scores over time and sex differences in these changes, while adjusting for patient characteristics and accounting for correlation among repeated observations within patients. Results: Overall, patients' perceived stress decreased over time, especially during the first month after AMI. Women had higher levels of perceived stress than men throughout the 12-month period (difference in PSS-14 score = 3.63, 95% confidence interval = 3.08 to 4.18, p < .001), but they did not differ in how stress changed over time. Adjustment for patient characteristics did not alter the overall pattern of sex difference in changes of perceived stress over time other than attenuating the magnitude of sex difference in PSS-14 score (difference between women and men = 1.74, 95% confidence interval = 1.32 to 2.16, p < .001). The magnitude of sex differences in perceived stress was similar in patients with versus without post-AMI angina, even though patients with angina experienced less improvement in PSS-14 score than those without angina. Conclusions: In young and middle-aged patients with AMI, women reported higher levels of perceived stress than men throughout the first 12 months of recovery. However, women and men had a similar pattern in how perceived stress changed over time

Direct measurement of local oxygen concentration in the bone marrow of live animals

Characterizing how the microenvironment, or niche, regulates stem cell activity is central to understanding stem cell biology and to developing strategies for therapeutic manipulation of stem cells1. Low oxygen tension (hypoxia) is commonly thought to be a shared niche characteristic in maintaining quiescence in multiple stem cell types2–4. However, support for the existence of a hypoxic niche has largely come from indirect evidence such as proteomic analysis5, expression of HIF-1 and related genes6, and staining with surrogate hypoxic markers (e.g. pimonidazole)6–8. Here we perform direct in vivo measurements of local oxygen tension (pO2) in the bone marrow (BM) of live mice. Using two-photon phosphorescence lifetime microscopy (2PLM), we determined the absolute pO2 of the BM to be quite low (<32 mmHg) despite very high vascular density. We further uncovered heterogeneities in local pO2, with the lowest pO2 (~9.9 mmHg, or 1.3%) found in deeper peri-sinusoidal regions. The endosteal region, by contrast, is less hypoxic as it is perfused with small arteries that are often positive for the marker nestin. These pO2 values change dramatically after radiation and chemotherapy, pointing to the role of stress in altering the stem cell metabolic microenvironment