OBJECTIVE To examine the association between hearing aids (HAs) and time to diagnosis of Alzheimer disease (AD) or dementia, anxiety or depression, and injurious falls among adults, aged 66 years and older, within 3 years of hearing loss (HL) diagnosis. DESIGN Retrospective cohort study. SETTING We used 2008 to 2016 national longitudinal claims data (based on office visit, inpatient, or outpatient healthcare encounters) from a large private payer. We used Kaplan‐Meier curves to examine unadjusted disease‐free survival and crude and adjusted Cox regression models to examine associations between HAs and time to diagnosis of three age‐related/HL‐associated conditions within 3 years of HL diagnosis. All models were adjusted for age, sex, race/ethnicity, census divisions, and prior diagnosis of cardiovascular conditions, hypertension, hypercholesterolemia, obesity, and diabetes. PARTICIPANTS The participants included 114 862 adults, aged 66 years and older, diagnosed with HL. MEASUREMENT Diagnosis of (1) AD or dementia; (2) depression or anxiety; and (3) injurious falls. INTERVENTION Use of HAs. RESULTS Large sex and racial/ethnic differences exist in HA use. Approximately 11.3% of women vs 13.3% of men used HAs (95% confidence interval [CI] difference = −0.024 to −0.016). Approximately 13.6% of whites (95% CI = 0.13‐0.14) vs 9.8% of blacks (95% CI = 0.09‐0.11) and 6.5% of Hispanics (95% CI = 0.06‐0.07) used HAs. The risk‐adjusted hazard ratios of being diagnosed with AD/dementia, anxiety/depression, and injurious falls within 3 years after HL diagnosis, for those who used HAs vs those who did not, were 0.82 (95% CI = 0.76‐0.89), 0.89 (95% CI = 0.86‐0.93), and 0.87 (95% CI = 0.80‐0.95), respectively. CONCLUSIONS Use of HAs is associated with delayed diagnosis of AD, dementia, depression, anxiety, and injurious falls among older adults with HL. Although we have shown an association between use of HAs and reduced risk of physical and mental decline, randomized trials are needed to determine whether, and to what extent, the relationship is causal. J Am Geriatr Soc 67:2362–2369, 2019

IMPORTANCE Appendicitis may be missed during initial emergency department (ED) presentation.OBJECTIVE To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. DESIGN, SETTING, AND PARTICIPANTSIn this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged Ն18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis. MAIN OUTCOMES AND MEASURESPotentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis. RESULTSOf 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, ...

Aim To validate the Whitney Comorbidity Index (WCI), which was recently developed to monitor disease status for adults with cerebral palsy (CP), and to identify WCI scores associated with an increased mortality risk using a representative sample of adults with CP. Method Data from 2016 to 2018 were used from a random 20% sample from the fee‐for‐service Medicare database for this retrospective cohort study. The WCI was examined as unweighted (WCIunw) and weighted (WCIw) among adults at least 18 years old with CP. Cox regression models were developed with mortality as the outcome after adjusting for demographics. A concordance statistic (C‐statistic) of at least 0.70 was considered as showing sufficient validity. The hazard ratio of mortality for each WCI score was estimated. Secondary analyses were performed for subgroups with co‐occurring epilepsy and/or intellectual disabilities. Results For the entire group (n=16 728) and subgroups, the WCI showed sufficient validity (C‐statistic 0.73–0.81). For the entire group, the mortality rate was elevated for a score of 1 compared with 0 from the WCIunw (hazard ratio 3.06; 95% confidence interval [CI] 1.52–6.17) and WCIw (hazard ratio 4.08; 95% CI 1.69–9.85), and became larger with each WCI score. Results were similar for the subgroups. Interpretation The WCI is a valid marker for health/disease status for adults with CP. Several WCI score thresholds were identified to assist in clinical decision making for preventive medicine and intervention implementation. The Whitney Comorbidity Index (WCI) is valid among 16 728 adults with CP. The WCI is valid for those with co‐occurring epilepsy and/or intellectual disabilities. Thresholds of the WCI score were identified to assist clinical decision making.

We evaluated whether rotavirus vaccination is associated with the incidence of type 1 diabetes among children. We designed a cohort study of 1,474,535 infants in the United States from 2001–2017, using data from a nationwide health insurer. There was a 33% reduction in the risk of type 1 diabetes with completion of the rotavirus vaccine series compared to the unvaccinated (95% CI: 17%, 46%). Completion of the pentavalent vaccine series was associated with 37% lower risk of type 1 diabetes (95% CI: 22%, 50%). Partial vaccination (incompletion of the series) was not associated with the incidence of type 1 diabetes. There was a 31% reduction in hospitalizations in the 60-day period after vaccination (95% CI: 27%, 35%) compared to unvaccinated children. Overall, there was a 3.4% decrease in incidence annually in children ages 0–4 in the United States from 2006–2017 which coincides with the vaccine introduction in 2006. We conclude that rotavirus vaccination is associated with a reduced incidence of type 1 diabetes. Rotavirus vaccination may be the first practical measure that could play a role in the prevention of this disease.

Objective:To determine the influence of delivery hospital on the rate of vaginal birth after cesarean (VBAC).Study Design:This retrospective cohort study used claims data from Blue Cross and Blue Shield of Michigan. Women with a prior cesarean and a singleton livebirth between 2012 and 2016 were included. We calculated the hospital-specific risk-standardized VBAC rates and median odds ratio as a measure of variation.Result:Hospital-level adjusted rates varied nearly 10-fold (3.7%-35.5%). Compared to the lowest volume hospitals (1st quartile), the likelihood of VBAC increased for those in the 2nd (adjusted OR 2.75 [95% CI 1.23-6.17]), 3rd (adjusted OR 3.73 [95% CI 1.59-8.75]), and 4th quartiles (adjusted OR 2.9 [95% CI 1.11-7.72]). The median OR suggested significant variation by hospital after adjustment.Conclusion:The delivery hospital itself explains a large amount of the variation in rates of VBAC after adjustment for patient and hospital characteristics.

It is not clear if patients are less adherent to low molecular weight heparin (LMWH) compared to direct oral anticoagulants (DOACs) for cancer‐associated thrombosis (CAT). We evaluated medication adherence among two propensity‐matched groups of patients with CAT by comparing the proportion of days covered (PDC). Median treatment persistence on DOACs was more than 80 days longer than LMWH. Medication adherence was high (~95%) and was similar with LMWH compared to DOACs. Abstract BackgroundLow molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are used to treat cancer‐associated thrombosis (CAT). It is not clear if patients are less adherent to LMWH compared to DOACs. ObjectivesTo compare medication persistence and adherence between LMWH and DOACs. Patients/MethodsWe analyzed Optum's de‐identified Clinformatics® Data Mart Database of privately insured adults with cancer diagnosed between January 2009 and October 2015 who were undergoing chemotherapy, immunotherapy, targeted or hormonal therapies; developed CAT; and were treated with an outpatient anticoagulant. The proportion of days covered (PDC) was calculated from the date of anticoagulant prescription until the anticoagulant was switched, stopped, or the study end. Medication adherence was defined as PDC ≥ 80%, ≥95%, and by comparing the mean PDC. ResultsTwo propensity‐matched groups of 1128 patients were identified. Patient persistence was higher with DOACs compared to LMWH (median 116 days versus 34 days). With adherence defined as PDC ≥ 80%, we found no significant difference (95.6% versus 94.6% adherence with DOACs versus LMWH, P = .33). The mean difference of PDC between the two groups was also similar. With medication adherence defined as PDC ≥ 95%, adherence was evident in 73% of DOAC users and 81% of patients on LMWH (P < .001). Prescription copayments were higher on average for LMWH compared to DOACs (mean $153.61 versus 40.67; standard deviation $306.74 versus $33.11). ConclusionPatients remain on DOACs longer than LMWH, but medication adherence is similar with LMWH.

ImportanceHospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events.ObjectiveTo determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB.Design, Setting, and ParticipantsThis 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022.ExposureParticipation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion.Main Outcomes and MeasuresOverall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration.ResultsOf the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00).Conclusions and RelevanceThis quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

Urinary tract infection (UTI) and community-acquired pneumonia (CAP) are the most common infections treated in hospitals. UTI and CAP are also commonly overdiagnosed, resulting in unnecessary antibiotic use and diagnostic delays. While much is known individually about overdiagnosis of UTI and CAP, it is not known whether hospitals with higher overdiagnosis of one also have higher overdiagnosis of the other. Correlation of overdiagnosis of these two conditions may indicate underlying hospital-level contributors, which in turn may represent targets for intervention. To evaluate the association of overdiagnosis of UTI and CAP, we first determined the proportion of hospitalised patients treated for CAP or UTI at 46 hospitals in Michigan who were overdiagnosed according to national guideline definitions. Then, we used Pearson’s correlation coefficient to compare hospital proportions of overdiagnosis of CAP and UTI. Finally, we assessed for ‘diagnostic momentum’ (ie, accepting a previous diagnosis without sufficient scepticism) by determining how often overdiagnosed patients remained on antibiotics on day 3 of hospitalisation. We included 14 085 patients treated for CAP (11.4% were overdiagnosed) and 10 398 patients treated for UTI (27.8% were overdiagnosed) across 46 hospitals. Within hospitals, the proportion of patients overdiagnosed with UTI was moderately correlated with the proportion of patients overdiagnosed with CAP (r=0.53, p<0.001). Over 80% (81.8% (n=952/1164) of UTI; 89.9% (n=796/885) of CAP) of overdiagnosed patients started on antibiotics by an emergency medicine clinician remained on antibiotics on day 3 of hospitalisation. In conclusion, we found overdiagnosis of UTI and CAP to be correlated at the hospital level. Reducing overdiagnosis of these two common infections may benefit from systematic interventions.