Program areas at Medical Technology and Practice Patterns
Researching barriers to arteriovenous fistula use in black hemodialysis patients in collaboration with the university of Alabama at birmingham mtppi continued its collaboration with the university of Alabama at birmingham (uab) in year four of investigating the factors contributing to racial disparities in arteriovenous fistula (avf) use among hemodialysis patients. The primary data source for the research was the usrds, a national registry of patients with eskd. The following components of usrds were used: (i) centers for medicare & medicaid services eskd Medical evidence form 2728, completed by dialysis facilities on all incident dialysis patients, was used to obtain type of vascular access in use at the start of eskd, including demographics, such as sex and race, and comorbid condition information. (ii) crownweb data, submitted by dialysis facilities monthly, were used to extract and track the type of vascular access in use (during the last hd session of the month) for each outpatient dialysis month after onset of eskd. Crownweb allowed us to include all outpatient dialysis patients in the united states, regardless of their use of medicare as their primary payer. (iii) medicare claims data, including inpatient, outpatient, and physician/supplier claims, were used to identify surgeons who performed vascular access procedures by their national provider identifier numbers. Our main independent variable of interest was the supply of surgeons, defined as the number of surgeons performing avf or avg placement per 1000 prevalent patients with eskd, across 306 hrrs in 2016 and 2017. Physicians who performed avf or avg placement procedures were determined based on the national provider identifiers from all 2016 to 2017 medicare claims for vascular access procedures and then aggregated for each hrr region. These claims included current procedural terminology codes 36800, 36810, 36818, 36819, 36820, 36821, and 36825 for avf placements and cpt code 36830 for avg placements. Number of eskd patients, as the denominator of surgeon supply measure, was calculated by adding all prevalent dialysis patients in 2016 to 2017 crownweb data in each hrr region based on the zip code for patients' residence. In year 4, the research team published the following article: trends in vascular access among patients initiating hemodialysis in the us. (allon m, zhang y, thamer m, crews dc, lee t. jama network open. 2023 aug 1;6(8):e2326458. Doi: 10.1001/jamanetworkopen.2023.26458. Pmid: 37526939). The research demonstrated a concerning trend of lower avf use and higher catheter use from 2015 - 2020; a finding that contradicts long standing clinical Practice guideline recommendations. The research team will also be presenting this research at the annual asn conference held in philadelphia, pa. a second finding was accepted for presentation at this conference from the research team based on qualitative research conducted on dialysis patients at uab based on various stages of vascular access care. The research compared attitudes and concerns regarding fistula access in black vs. white patients to understand racial disparities. The presentation is entitled "patient perspectives on av fistula use: implications for racial disparities."
Nimhd r01 md017063-01 racial and ethnic disparities in hcc surveillancemtppi researchers collaborated with the stanford university school of medicine and the veterans affairs palo alto healthcare system to collect data from the time period of 1/1/2010 to 12/31/2020 with a target of 19,250 cirrhosis patients that receive usual care from ~550 providers. The providers are affiliated with five geographically disperse safety-net health systems representing broad geographic and ethnic diversity including san francisco community health network (ca), ochsner health system (la), parkland health and hospital system (tx), jackson memorial health system (fl), and metrohealth system (oh). The researchers selected safety-net health systems as study sites since they predominately serve indigent and ethnic minority populations who represent the greatest disparities in chronic liver disease care and would achieve the greatest benefit from studies focused on improving hcc outcomes. The year's research aimed to examine the impact of covid-19 pandemic related disruptions in healthcare delivery in exacerbating racial and ethnic disparities in hcc screening by evaluating adherence to and predictors of guideline concordant hcc screening among cirrhosis patients in the pre-covid-19, covid-19, and post-covid-19 recovery periods. Researchers hypothesized that there would be significantly lower rates of patients receiving guideline-concordant hcc screenings among ethnic minorities and cirrhosis patients of lower socioeconomic status (ses). The research also aimed to identify which patient, provider, and system level factors mediate the relationship between racial and ethnic disparities in hcc screening, stage of tumor at diagnosis, and receipt of curative treatments. Mtppi achieved these goals by utilizing time dependent kaplan meier methods and associated log-rank testing to evaluate race and ethnicity-specific probability of receiving hcc screening. Among cirrhosis patients that successfully underwent first-time hcc screening, mtppi calculated overall crude race and ethnicity-specific rates of receiving two additional hcc screening tests within 12 months following index hcc screening as well as conducted time-dependent analyses using kaplan meier methods and associated log-rank testing. The primary objective is to evaluate race and ethnicity-specific disparities in hcc screening. The comprehensive nature of the study will allow for sub-analyses to evaluate hcc screening rates among other populations, specifically those with limited existing data. In addition, while 6-month is the guideline recommended interval, mtppi will perform a sensitivity analysis using a 12-month interval for initial hcc screening and an additional 24-month follow-up for assessing 2 additional hcc screening exams. The research activities will include tests of the mediating role of patient, provider, and system factors in the relationship between ethnic minority status and hcc screening. Three logistic regression equations, comprising 'mediational analyses', were estimated. First, the dependent variable, hcc screening (done separately for first time and repeat hcc screening and separately for race, hispanic ethnicity, and english as primary language), was regressed on the independent variable of race; second, the mediator (patient, provider and system factors) was regressed on hcc screening; and third, hcc screening was regressed on both the independent variable (race) and mediator. The american association for the study of liver diseases (aasld) selected an abstract from the research team titled "evaluating provider-level factors contributing to sub-optimal surveillance for hepatocellular carcinoma among patients with cirrhosis across four safety-net health systems in the united states" for poster presentation at the liver meeting in boston, ma.
Gilead commit program:subprogram 1: examination of clinical course & outcome of covid-19 among the uninsured working poor in dallas txsubprogram 2: evaluating the epidemiology, clinical course, & outcomes chronic liver disease patients infected with sars-cov-2subprogram 1: this research program continues a collaboration with the ut southwestern Medical center and the uthealth mcgovern Medical school. Mtppi's researchers continued to examine hiv patients for risks that contribute to new hepatitis b infections. Vaccines and hepatitis b specific antiretroviral therapies may offer protection for people with hiv (pwh). Hepatitis b places pwh at increased risk for mortality compared to those pwh without hepatitis b or those with hepatitis b alone. Researchers examined the incidence of new hepatitis b infections and factors which predict risk for acquiring infection among pwh. To validate a potential population of pwh, four validation steps were executed: 1) ided phw with 1 to 9 years of follow-up from 1/11/11-12/31/2018 . Of the patients remaining 2) exclude those with no hiv viral load, no cd4 count. Of the patients remaining 3) exclude hepatitis b surface antigen (hbsag)-positive within 6 months of study entry or 1 year after. Of the patients remaining 4) exclude those with hbv dna and hbeag+ at first 6 months prior to study entry. Once the study population was isolated, a baseline description of demographics was created which was categorized by insurance status, hep b surface ab, age, cd4, race and hiv viral load. Researchers then calculated the likelihood of new hepatitis b and the adjusted odds ratio and determined 1) the incidence of new hepatitis b infection based on +hbsag stratified by hcv 2) incidence of new hepatitis b infection based on hbsag+ stratified by baseline hbsab+ and 3) the proportion of patients on hbv specific medications who had new hbv infection is similar to overall cohort. Research findings show that pwh who are unvaccinated for hepatitis b are at higher risk for new infections. The year's research has been disseminated through clinical conference poster presentations. Three posters were accepted for the infectious diseases society of america (idsa) annual conference held in boston, ma. The posters where titled covid-19 hospitalization - impact of age, race and ethnicity among medicaid and uninsured, covid-19 hospitalizations in north Texas impact of insurance: medicaid vs. uninsured, and impact of insurance status on covid-19 pneumonia outcomes in north texas.subprogram 2: this research program continues a collaboration between mtppi, the stanford university school of medicine, and the veterans affairs palo alto healthcare system. The research team hypothesized that chronic liver disease (cld) patients have a greater risk of developing liver decompensation following covid-19 infection. However, it was unclear whether the increased risks of liver decompensation result in higher overall mortality in cld patients with covid-19 vs. cld patients without covid-19. Researchers aimed to evaluate whether acute sars-cov-2 infection is associated with increased risks of inpatient hospitalization, intensive care unit (icu) admission, and overall mortality among patients with cld. Researchers used the common data schema from the "covid-19 research database", a large u.s. Database containing over 72 million linked patients' electronic health records and claims data, we identified patients with cld (hepatitis c, hepatitis b, alcoholic liver disease, and nonalcoholic fatty liver disease/steatohepatitis) with covid-19 (cld+covid-19) vs. Without covid-19. Patients were followed for at least 6 months until a censoring event occurred or it was the end of the study period (august 31, 2021). Outcomes assessed included the need for inpatient hospitalization, icu admission, and/or overall mortality, and outcomes were compared between groups with chi-square testing. Multivariate regression models evaluated whether covid-19 was independently associated with greater risk of hospitalization, icu admission, and overall mortality in cld patients. Researchers found that among 973,634 adult patients with cld (55.2% men, 44.8% women, 28.9% age >65y, 40.4% age 45-64y, 30.7% age 18-44, 12.0% with cirrhosis), 3.5% had cld+covid-19 and 96.5% had cld without covid-19. Compared to cld without covid-19, cld+covid patients had significantly higher rates of hospitalization (25.7% vs. 9.2%, p<0.01), icu admission (15.5% vs. 4.9%, p<0.01), and overall mortality (5.6% vs. 3.8%, p<0.01). On adjusted multivariate regression, when compared to cld patients without covid-19, cld+covid-19 was associated with significantly greater risk of hospitalization (or 3.27, 95% ci 3.19-3.35, p<0.01), icu admission (or 3.50, 95% ci 3.40-3.61), and overall mortality (or 1.36, 95% ci 1.29-1.42). These findings were likely mediated by increased risks of liver decompensation (hr 1.23, 95% ci 1.15-1.32, p<0.01) and acute on chronic liver failure (aclf) (hr 7.32, 95% ci 6.40-8.38, p<0.01) observed in cld+covid-19 compared to cld without covid-19 patients. Results of this research were disseminated through a peer-reviewed publication: chronic liver disease and cirrhosis are associated with worse outcomes following sars-cov-2 infection.wong rj, zhang y, thamer m. j clin exp hepatol. 2023 jul-aug;13(4):592-600. Doi: 10.1016/j.jceh.2023.01.014. Epub 2023 feb 3. Pmid: 36777086
Janseen scientific affairs
Pcori gwu renal care
Kent state university
Horizon
Other projects