Derek DeLia - Academia.edu (original) (raw)

Papers by Derek DeLia

Research paper thumbnail of Food Environments Within and Outside of Schools Play a Critical Role in Curtailing the Rise in Obesity among School-Aged Children over Time

Research paper thumbnail of 1277 Clinician-To-Clinician Connectedness and Access to Gastric Cancer Surgery at Nci-Designated Cancer Centers

Gastroenterology, May 1, 2023

Research paper thumbnail of A Focus on Amputation Level: Factors Preventing Length Preservation in the National Inpatient Sample

Journal of the American Podiatric Medical Association, 2022

Background: Diabetic lower-extremity disease is the primary driver of mortality in patients with ... more Background: Diabetic lower-extremity disease is the primary driver of mortality in patients with diabetes. Amputations at the forefoot or ankle preserve limb length, increase function, and, ultimately, reduce deconditioning and mortality compared with higher-level amputations, such as below-the-knee amputations (BKAs). We sought to identify risk factors associated with amputation level to understand barriers to length-preserving amputations (LPAs). Methods: Diabetic lower-extremity admissions were extracted from the 2012-2014 National Inpatient Survey using ICD-9-CM diagnosis codes. The main outcome was a two-level variable consisting of LPAs (transmetatarsal, Syme, and Chopart) versus BKAs. Logistic regression analysis was used to determine contributions of patient- and hospital-level factors to likelihood of undergoing LPA versus BKA. Results: The study cohort represented 110,355 admissions nationally: 42,375 LPAs and 67,980 BKAs. The population was predominantly white (56.85%), older than 50 years (82.55%), and male (70.38%). On multivariate analysis, living in an urban area (relative risk ratio [RRR] = 1.48; P < .0001) and having vascular intervention in the same hospital stay (RRR = 2.96; P < .0001) were predictive of LPA. Patients from rural locations but treated in urban centers were more likely to receive BKA. Minorities were more likely to present with severe disease, limiting delivery of LPAs. A high Elixhauser comorbidity score was related to BKA receipt. Conclusions: This study identifies delivery biases in amputation level for patients without access to large, urban hospitals. Rural patients seeking care in these centers are more likely to receive higher-level amputations. Further examination is required to determine whether earlier referral to multidisciplinary centers is more effective at reducing BKA rates versus satellite centers in rural localities.

Research paper thumbnail of Parent-Measured and Parent-Estimated Child’s Heights and Weights—Reply

JAMA Pediatrics, Feb 1, 2020

Research paper thumbnail of Differential Associations Between Changes in Food Environment and Changes in BMI Among Adults Living in Urban, Low-Income Communities

Journal of Nutrition, Nov 1, 2022

ABSTRACT Background Food environments can contribute to excess weight gain among adults, but the ... more ABSTRACT Background Food environments can contribute to excess weight gain among adults, but the evidence is mixed. Objectives This longitudinal study investigated the associations between changes in the food environment and changes in BMI in adults and whether changes in the food environment differentially impact various subgroups. Methods At 2 time points, BMI was calculated using self-reported height and weight data from 517 adults (mean age, 41 years) living in 4 New Jersey cities. The counts of different types of food outlets within 0.4, 0.8, and 1.6 km of respondents’ residences were collected at baseline and tracked until follow-up. A binary measure of social standing (social-advantage group, n = 219; social-disadvantage group, n = 298) was created through a latent class analysis using social, economic, and demographic variables. Multivariable linear regression modeled the associations between changes in BMI with measures of the food environment; additionally, interaction terms between the measures of food environment and social standing were examined. Results Overall, over 18 months, an increase in the number of small grocery stores within 0.4 km of a respondent's residence was associated with a decrease in BMI (β = −1.0; 95% CI: −1.9, −0.1; P = 0.024), while an increase in the number of fast-food restaurants within 1.6 km was associated with an increase in BMI (β = 0.1; 95% CI: 0.01, 0.2; P = 0.027). These overall findings, however, masked some group-specific associations. Interaction analyses suggested that associations between changes in the food environment and changes in BMI varied by social standing. For instance, the association between changes in fast-food restaurants and changes in BMI was only observed in the social-disadvantage group (β = 0.1; 95% CI: 0.02, 0.2; P = 0.021). Conclusions In a sample of adults living in New Jersey, changes in the food environment had differential effects on individuals’ BMIs, based on their social standing.

Research paper thumbnail of Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness

Medical Care, Mar 11, 2021

BACKGROUND Permanent supportive housing (PSH) programs have the potential to improve health and r... more BACKGROUND Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). CONCLUSIONS Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

Research paper thumbnail of Determinants of Sugar-Sweetened Beverage Consumption among Low-Income Children: Are There Differences by Race/Ethnicity, Age, and Sex?

Journal of the Academy of Nutrition and Dietetics, Dec 1, 2017

Background-Understanding determinants of high consumption of sugar-sweetened beverages (SSB), a h... more Background-Understanding determinants of high consumption of sugar-sweetened beverages (SSB), a highly prevalent obesogenic behavior, will help build effective customized public health interventions. Objective-To identify child and parent lifestyle and household demographic factors predictive of high SSB consumption frequency in children from low-income, ethnically diverse communities that may help inform public health interventions. Design-Cross-sectional telephone household survey.

Research paper thumbnail of Emergency Department Utilization and Surge Capacity in New Jersey, 1998-2003

Emergency department (ED) overcrowding is a nationwide problem with numerous consequences. Overcr... more Emergency department (ED) overcrowding is a nationwide problem with numerous consequences. Overcrowding can reduce healthcare quality by increasing the potential for medical errors, prolonging pain and suffering, and reducing patient satisfaction with services. In some cases, emergency patients are "boarded" in the ED until inpatient beds become available and ambulances are diverted to other hospitals causing significant delays in treatment when there may be little time to spare. Concern about ED capacity is heightened by the threat of Emergency Department Utilization and Surge Capacity in NJ

Research paper thumbnail of Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multi-State Evaluation

Diseases of The Colon & Rectum, Mar 30, 2023

Semi-structured interviews were held with patients scheduled for elective general surgical proced... more Semi-structured interviews were held with patients scheduled for elective general surgical procedures (25 patients undergoing 13 unique operations by 11 different surgeons) at a single institution after informed consent was obtained. Recordings were transcribed verbatim, coded independently by 2 coders, and an inductive thematic analysis was performed. RESULTS: Overall, patients anticipated the perioperative elements of their surgical experience, but did not understand what would actually happen during their operations. Several major themes emerged: Most patients described the operative experience as preoperative preparation and care until the time of sedation, followed by some aspects of recovery, patients were limited in their ability to describe their scheduled procedures and often articulated that they did not fully understand the physical aspects, patients trusted their surgeons to "fix" their conditions, concerns about adequacy of anesthesia often superseded anxiety about the procedure itself, and patients had limited understanding of all operating room personnel and their roles during operation. CONCLUSIONS: Patients trust their surgeons to perform their operations even though they have a limited understanding of what will physically happen in the operating room. This brings into question what information patients need, want, and understand in regard to informed consent, and how they develop trust in their surgeons.

Research paper thumbnail of 116EMF Association of Varying Care Coordination Strategies in the Emergency Department With Return Visits

Annals of Emergency Medicine, Oct 1, 2021

Research paper thumbnail of Health, social, and economic characteristics of patients enrolled in a COVID-19 recovery program

PLOS ONE, Nov 30, 2022

At least one in five people who recovered from acute COVID-19 have persistent clinical symptoms, ... more At least one in five people who recovered from acute COVID-19 have persistent clinical symptoms, however little is known about the impact on quality-of-life (QOL), socioeconomic characteristics, fatigue, work and productivity. We present a cross-sectional descriptive characterization of the clinical symptoms, QOL, socioeconomic characteristics, fatigue, work and productivity of a cohort of patients enrolled in the MedStar COVID Recovery Program (MSCRP). Our participants include people with mental and physical symptoms following recovery from acute COVID-19 and enrolled in MSCRP, which is designed to provide comprehensive multidisciplinary care and aid in recovery. Participants completed medical questionnaires and the PROMIS-29, Fatigue Severity Scale, Work and Productivity Impairment Questionnaire, and Social Determinants of Health surveys. Participants (n = 267, mean age 47.6 years, 23.2% hospitalized for COVID-19) showed impaired QOL across all domains assessed with greatest impairment in physical functioning (mean 39.1 ± 7.4) and fatigue (mean 60.6 ±. 9.7). Housing or "the basics" were not afforded by 19% and food insecurity was reported in 14% of the cohort. Participants reported elevated fatigue (mean 4.7 ± 1.1) and impairment with activity, work productivity, and on the job effectiveness was reported in 63%, 61%, and 56% of participants, respectively. Patients with persistent mental and physical symptoms following initial illness report impairment in QOL, socioeconomic hardships, increased fatigue and decreased work and productivity. Our cohort highlights that even those who are not hospitalized and recover from less severe COVID-19 can have long-term impairment, therefore designing, implementing, and scaling programs to focus on mitigating impairment and restoring function are greatly needed.

Research paper thumbnail of 219EMF Emergency Department Care Coordination Strategies and Perceived Impact Across Maryland

Annals of Emergency Medicine, 2019

Study Objectives: In 2014, there were 2.5 million Americans with opioid use disorder (OUD). The U... more Study Objectives: In 2014, there were 2.5 million Americans with opioid use disorder (OUD). The U.S. opioid epidemic has since worsened, disproportionately in the New England (NE) states. Opioid-related ED visits continue to rise, putting EDs in an important position to act. Yet, it is unknown if opioid-related ED policies have changed in response to the escalating crisis. We investigated the prevalence of OUD prevention and treatment policies in NE EDs in 2018 compared with 2014. Methods: Two regional surveys were administered in 2015 and 2019 about opioid-related ED policies during 2014 and 2018, respectively. The National Emergency Department Inventory-USA was used to identify all NE EDs open 24/7/365. Each ED director was mailed a survey up to three times; EDs not responding to mailed surveys were contacted by phone for survey completion by interview. In both years, to assess prevention policies, EDs were asked if they had a policy to: use a screening tool, access prescription drug monitoring program (PDMP) before prescribing, notify primary care physician (PCP)/primary opioid prescriber, and prescribe/dispense naloxone to patients at risk of overdose. To assess treatment policies, EDs were asked if they had a policy to refer to recovery resources (both years) and prescribe/dispense buprenorphine to patients with OUD (2018 only). We also asked about the percent of patients at risk of opioid overdose who were offered naloxone, and the percent of patients with OUD who were offered buprenorphine. For the change analysis, we excluded EDs that did not participate in both years. The analysis also assumed that no EDs regularly prescribed/dispensed buprenorphine in 2014. Statistical analyses included descriptive statistics and two-sample test of proportions to assess change in policy responses between years. Results: Of 195 EDs open in 2014, 169 (87%) completed the survey. Of 194 EDs open in 2018, 141 (73%) have completed the survey to date; data collection is ongoing. Of 193 EDs open both years, 121 participated in both surveys. In 2018, the most commonly reported policy was accessing PDMP (97%); the least common policy was prescribing/dispensing buprenorphine to at risk patients (40%, Figure). EDs differed widely in prescribing/dispensing naloxone to patients at risk of opioid overdose, with 47 EDs (36%) offering naloxone to 80% of patients at risk vs 44 EDs (33%) that reported this in <10% of patients at risk. Most EDs (n¼92, 71%) reported prescribing/dispensing buprenorphine to <10% of patients with OUD. Among the 121 EDs that responded both years, the greatest change in a policy was in prescribing/ dispensing naloxone (absolute change of +56%, P<0.001). There was no significant change in notification of PCP/prescriber (P¼0.20). Overall, there were increases in EDs with any prevention policy (+14%, P<0.001) and any treatment policy (+12%, P¼ 0.03). Conclusion: Most opioid-related ED policies increased between 2014 and 2018. More effort is needed to advance this work and to better translate some major policies (eg, offering naloxone and buprenorphine) into clinical practice.

Research paper thumbnail of Effects of food and physical activity environments on children's weight status in low-income urban neighborhoods

Research paper thumbnail of Impact of Clinician Linkage on Unequal Access to High-Volume Hospitals for Colorectal Cancer Surgery

Journal of The American College of Surgeons, Apr 5, 2022

BACKGROUND: Understanding drivers of persistent surgical disparities remains an important area of... more BACKGROUND: Understanding drivers of persistent surgical disparities remains an important area of cancer care delivery and policy. The degree to which clinician linkages contribute to disparities in access to quality colorectal cancer surgery is unknown. Using hospital surgical volume as a proxy for quality, the study team evaluated how clinician linkages impact access to colorectal cancer surgery at high-volume hospitals (HVHs). STUDY DESIGN: Maryland’s Health Services Cost Review Commission was used to evaluate 6,909 patients who underwent colon or rectal cancer operations from 2013 to 2018. Two linkages based on patient sharing were examined separately for colon and rectal cancer surgery: (1) from primary care clinicians to specialists (gastroenterologist or medical oncologist) and (2) from specialists to surgeons (general or colorectal). A referral link was defined as 9 or more shared patients between 2 clinicians. Adjusted regression models examined associations between referral links and odds of receiving colon or rectal cancer operations at HVHs. RESULTS: The cohort included 5,645 colon and 1,264 rectal cancer patients across 52 hospitals. Every additional referral link between a primary care clinician and a specialist connected to a HVH was associated with a 12% and 14% increased likelihood of receiving colon (odds ratio [OR] 1.12, CI 1.07 to 1.17) and rectal (OR 1.14, CI 1.08 to 1.20]) cancer operations at a HVH, respectively. Every additional referral link between a specialist and a surgeon at a HVH was associated with at least a 25% increased likelihood of receiving colon (OR 1.28, CI 1.20 to 1.36) and rectal (OR 1.25, CI 1.15 to 1.36) cancer operation at a HVH. CONCLUSIONS: Patients of clinicians with linkages to HVHs are more likely to have their colorectal cancer operations at these hospitals. These findings suggest that policy interventions targeting clinician relationships are an important step in providing equitable surgical care.

Research paper thumbnail of The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project

Journal of Ambulatory Care Management, 2020

The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a uniq... more The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a unique combination of features regarding ACO geography, involvement of managed care organizations (MCOs), and shared savings parameters. Ultimately, the Demonstration did not lead to a sustainable accountable care financing model and shared savings were deemphasized. Instead, the ACOs evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and MCOs. Currently, the state is developing policy parameters to reposition the ACOs as regional partners to implement state-directed population health initiatives.

Research paper thumbnail of ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery

Surgery, 2021

BACKGROUND Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated pers... more BACKGROUND Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. METHODS State inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states. RESULTS The Affordable Care Act's expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P < .0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P < .0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged. CONCLUSION Medicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.

Research paper thumbnail of Demonstration Program: Seeking Opportunities for Better Care and Lower Costs among Complex Low-Income Patients

A small but growing number of states are turning to accountable care concepts to improve their Me... more A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Med- icaid Accountable Care Organization (ACO) Demonstration program to offer local provider coalitions the opportunity to share any savings they generate. Impetus came frominitiativesinCamdenthataimtoreducecoststhroughimprovedcarecoordination among hospital high users and which have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercialACOs,theNewJerseydemonstrationaddressestheunique concernsfaced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey dem- onstration. We also examine their characteristics to inform Medicaid accountable care strategies.Wefindsubstantialv...

Research paper thumbnail of Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

Plastic and Reconstructive Surgery - Global Open, 2021

Background: Wounds in the comorbid population require limb salvage to prevent amputation. Extensi... more Background: Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined. Methods: Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010–2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl–Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors. Results: The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive. Conclusion: Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Research paper thumbnail of Evidence That Changes in Community Food Environments Lead to Changes in Children’s Weight: Results from a Longitudinal Prospective Cohort Study

Journal of the Academy of Nutrition and Dietetics, 2020

Background Strategies to improve the community food environment have been recommended for address... more Background Strategies to improve the community food environment have been recommended for addressing childhood obesity, but evidence substantiating their effectiveness is limited. Objective Our aim was to examine the impact of changes in availability of key features of the community food environment, such as supermarkets, small grocery stores, convenience stores, upgraded convenience stores, pharmacies, and limited service restaurants, on changes in children's body mass index z scores (zBMIs). Design We conducted a longitudinal cohort study. Participants/setting Two cohorts of 3-to 15-year-old children living in 4 low-income New Jersey cities were followed during 2-to 5-year periods from 2009 through 2017. Data on weight status were collected at 2 time points (T1 and T2) from each cohort; data on food outlets in the 4 cities and within a 1-mile buffer around each city were collected multiple times between T1 and T2. Main outcome measures We measured change in children's zBMIs between T1 and T2. Statistical analysis Changes in the food environment were conceptualized as exposure to changes in counts of food outlets across varying proximities (0.25 mile, 0.5 mile, and 1.0 mile) around a child's home, over different lengths of time a child was exposed to these changes before T2 (12 months, 18 months, and 24 months). Multivariate models examined patterns in relationships between changes in zBMI and changes in the food environment.

Research paper thumbnail of Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample

Plastic & Reconstructive Surgery, 2020

Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amput... more Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amputation per 100,000 population, ages 18 years and older. Excludes any-listed diagnosis of traumatic lower-extremity amputation admissions, toe amputation admission (likely to be traumatic), obstetric admissions, and transfers from other institutions.

Research paper thumbnail of Food Environments Within and Outside of Schools Play a Critical Role in Curtailing the Rise in Obesity among School-Aged Children over Time

Research paper thumbnail of 1277 Clinician-To-Clinician Connectedness and Access to Gastric Cancer Surgery at Nci-Designated Cancer Centers

Gastroenterology, May 1, 2023

Research paper thumbnail of A Focus on Amputation Level: Factors Preventing Length Preservation in the National Inpatient Sample

Journal of the American Podiatric Medical Association, 2022

Background: Diabetic lower-extremity disease is the primary driver of mortality in patients with ... more Background: Diabetic lower-extremity disease is the primary driver of mortality in patients with diabetes. Amputations at the forefoot or ankle preserve limb length, increase function, and, ultimately, reduce deconditioning and mortality compared with higher-level amputations, such as below-the-knee amputations (BKAs). We sought to identify risk factors associated with amputation level to understand barriers to length-preserving amputations (LPAs). Methods: Diabetic lower-extremity admissions were extracted from the 2012-2014 National Inpatient Survey using ICD-9-CM diagnosis codes. The main outcome was a two-level variable consisting of LPAs (transmetatarsal, Syme, and Chopart) versus BKAs. Logistic regression analysis was used to determine contributions of patient- and hospital-level factors to likelihood of undergoing LPA versus BKA. Results: The study cohort represented 110,355 admissions nationally: 42,375 LPAs and 67,980 BKAs. The population was predominantly white (56.85%), older than 50 years (82.55%), and male (70.38%). On multivariate analysis, living in an urban area (relative risk ratio [RRR] = 1.48; P &lt; .0001) and having vascular intervention in the same hospital stay (RRR = 2.96; P &lt; .0001) were predictive of LPA. Patients from rural locations but treated in urban centers were more likely to receive BKA. Minorities were more likely to present with severe disease, limiting delivery of LPAs. A high Elixhauser comorbidity score was related to BKA receipt. Conclusions: This study identifies delivery biases in amputation level for patients without access to large, urban hospitals. Rural patients seeking care in these centers are more likely to receive higher-level amputations. Further examination is required to determine whether earlier referral to multidisciplinary centers is more effective at reducing BKA rates versus satellite centers in rural localities.

Research paper thumbnail of Parent-Measured and Parent-Estimated Child’s Heights and Weights—Reply

JAMA Pediatrics, Feb 1, 2020

Research paper thumbnail of Differential Associations Between Changes in Food Environment and Changes in BMI Among Adults Living in Urban, Low-Income Communities

Journal of Nutrition, Nov 1, 2022

ABSTRACT Background Food environments can contribute to excess weight gain among adults, but the ... more ABSTRACT Background Food environments can contribute to excess weight gain among adults, but the evidence is mixed. Objectives This longitudinal study investigated the associations between changes in the food environment and changes in BMI in adults and whether changes in the food environment differentially impact various subgroups. Methods At 2 time points, BMI was calculated using self-reported height and weight data from 517 adults (mean age, 41 years) living in 4 New Jersey cities. The counts of different types of food outlets within 0.4, 0.8, and 1.6 km of respondents’ residences were collected at baseline and tracked until follow-up. A binary measure of social standing (social-advantage group, n = 219; social-disadvantage group, n = 298) was created through a latent class analysis using social, economic, and demographic variables. Multivariable linear regression modeled the associations between changes in BMI with measures of the food environment; additionally, interaction terms between the measures of food environment and social standing were examined. Results Overall, over 18 months, an increase in the number of small grocery stores within 0.4 km of a respondent&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s residence was associated with a decrease in BMI (β = −1.0; 95% CI: −1.9, −0.1; P = 0.024), while an increase in the number of fast-food restaurants within 1.6 km was associated with an increase in BMI (β = 0.1; 95% CI: 0.01, 0.2; P = 0.027). These overall findings, however, masked some group-specific associations. Interaction analyses suggested that associations between changes in the food environment and changes in BMI varied by social standing. For instance, the association between changes in fast-food restaurants and changes in BMI was only observed in the social-disadvantage group (β = 0.1; 95% CI: 0.02, 0.2; P = 0.021). Conclusions In a sample of adults living in New Jersey, changes in the food environment had differential effects on individuals’ BMIs, based on their social standing.

Research paper thumbnail of Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness

Medical Care, Mar 11, 2021

BACKGROUND Permanent supportive housing (PSH) programs have the potential to improve health and r... more BACKGROUND Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). CONCLUSIONS Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

Research paper thumbnail of Determinants of Sugar-Sweetened Beverage Consumption among Low-Income Children: Are There Differences by Race/Ethnicity, Age, and Sex?

Journal of the Academy of Nutrition and Dietetics, Dec 1, 2017

Background-Understanding determinants of high consumption of sugar-sweetened beverages (SSB), a h... more Background-Understanding determinants of high consumption of sugar-sweetened beverages (SSB), a highly prevalent obesogenic behavior, will help build effective customized public health interventions. Objective-To identify child and parent lifestyle and household demographic factors predictive of high SSB consumption frequency in children from low-income, ethnically diverse communities that may help inform public health interventions. Design-Cross-sectional telephone household survey.

Research paper thumbnail of Emergency Department Utilization and Surge Capacity in New Jersey, 1998-2003

Emergency department (ED) overcrowding is a nationwide problem with numerous consequences. Overcr... more Emergency department (ED) overcrowding is a nationwide problem with numerous consequences. Overcrowding can reduce healthcare quality by increasing the potential for medical errors, prolonging pain and suffering, and reducing patient satisfaction with services. In some cases, emergency patients are "boarded" in the ED until inpatient beds become available and ambulances are diverted to other hospitals causing significant delays in treatment when there may be little time to spare. Concern about ED capacity is heightened by the threat of Emergency Department Utilization and Surge Capacity in NJ

Research paper thumbnail of Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multi-State Evaluation

Diseases of The Colon & Rectum, Mar 30, 2023

Semi-structured interviews were held with patients scheduled for elective general surgical proced... more Semi-structured interviews were held with patients scheduled for elective general surgical procedures (25 patients undergoing 13 unique operations by 11 different surgeons) at a single institution after informed consent was obtained. Recordings were transcribed verbatim, coded independently by 2 coders, and an inductive thematic analysis was performed. RESULTS: Overall, patients anticipated the perioperative elements of their surgical experience, but did not understand what would actually happen during their operations. Several major themes emerged: Most patients described the operative experience as preoperative preparation and care until the time of sedation, followed by some aspects of recovery, patients were limited in their ability to describe their scheduled procedures and often articulated that they did not fully understand the physical aspects, patients trusted their surgeons to "fix" their conditions, concerns about adequacy of anesthesia often superseded anxiety about the procedure itself, and patients had limited understanding of all operating room personnel and their roles during operation. CONCLUSIONS: Patients trust their surgeons to perform their operations even though they have a limited understanding of what will physically happen in the operating room. This brings into question what information patients need, want, and understand in regard to informed consent, and how they develop trust in their surgeons.

Research paper thumbnail of 116EMF Association of Varying Care Coordination Strategies in the Emergency Department With Return Visits

Annals of Emergency Medicine, Oct 1, 2021

Research paper thumbnail of Health, social, and economic characteristics of patients enrolled in a COVID-19 recovery program

PLOS ONE, Nov 30, 2022

At least one in five people who recovered from acute COVID-19 have persistent clinical symptoms, ... more At least one in five people who recovered from acute COVID-19 have persistent clinical symptoms, however little is known about the impact on quality-of-life (QOL), socioeconomic characteristics, fatigue, work and productivity. We present a cross-sectional descriptive characterization of the clinical symptoms, QOL, socioeconomic characteristics, fatigue, work and productivity of a cohort of patients enrolled in the MedStar COVID Recovery Program (MSCRP). Our participants include people with mental and physical symptoms following recovery from acute COVID-19 and enrolled in MSCRP, which is designed to provide comprehensive multidisciplinary care and aid in recovery. Participants completed medical questionnaires and the PROMIS-29, Fatigue Severity Scale, Work and Productivity Impairment Questionnaire, and Social Determinants of Health surveys. Participants (n = 267, mean age 47.6 years, 23.2% hospitalized for COVID-19) showed impaired QOL across all domains assessed with greatest impairment in physical functioning (mean 39.1 ± 7.4) and fatigue (mean 60.6 ±. 9.7). Housing or "the basics" were not afforded by 19% and food insecurity was reported in 14% of the cohort. Participants reported elevated fatigue (mean 4.7 ± 1.1) and impairment with activity, work productivity, and on the job effectiveness was reported in 63%, 61%, and 56% of participants, respectively. Patients with persistent mental and physical symptoms following initial illness report impairment in QOL, socioeconomic hardships, increased fatigue and decreased work and productivity. Our cohort highlights that even those who are not hospitalized and recover from less severe COVID-19 can have long-term impairment, therefore designing, implementing, and scaling programs to focus on mitigating impairment and restoring function are greatly needed.

Research paper thumbnail of 219EMF Emergency Department Care Coordination Strategies and Perceived Impact Across Maryland

Annals of Emergency Medicine, 2019

Study Objectives: In 2014, there were 2.5 million Americans with opioid use disorder (OUD). The U... more Study Objectives: In 2014, there were 2.5 million Americans with opioid use disorder (OUD). The U.S. opioid epidemic has since worsened, disproportionately in the New England (NE) states. Opioid-related ED visits continue to rise, putting EDs in an important position to act. Yet, it is unknown if opioid-related ED policies have changed in response to the escalating crisis. We investigated the prevalence of OUD prevention and treatment policies in NE EDs in 2018 compared with 2014. Methods: Two regional surveys were administered in 2015 and 2019 about opioid-related ED policies during 2014 and 2018, respectively. The National Emergency Department Inventory-USA was used to identify all NE EDs open 24/7/365. Each ED director was mailed a survey up to three times; EDs not responding to mailed surveys were contacted by phone for survey completion by interview. In both years, to assess prevention policies, EDs were asked if they had a policy to: use a screening tool, access prescription drug monitoring program (PDMP) before prescribing, notify primary care physician (PCP)/primary opioid prescriber, and prescribe/dispense naloxone to patients at risk of overdose. To assess treatment policies, EDs were asked if they had a policy to refer to recovery resources (both years) and prescribe/dispense buprenorphine to patients with OUD (2018 only). We also asked about the percent of patients at risk of opioid overdose who were offered naloxone, and the percent of patients with OUD who were offered buprenorphine. For the change analysis, we excluded EDs that did not participate in both years. The analysis also assumed that no EDs regularly prescribed/dispensed buprenorphine in 2014. Statistical analyses included descriptive statistics and two-sample test of proportions to assess change in policy responses between years. Results: Of 195 EDs open in 2014, 169 (87%) completed the survey. Of 194 EDs open in 2018, 141 (73%) have completed the survey to date; data collection is ongoing. Of 193 EDs open both years, 121 participated in both surveys. In 2018, the most commonly reported policy was accessing PDMP (97%); the least common policy was prescribing/dispensing buprenorphine to at risk patients (40%, Figure). EDs differed widely in prescribing/dispensing naloxone to patients at risk of opioid overdose, with 47 EDs (36%) offering naloxone to 80% of patients at risk vs 44 EDs (33%) that reported this in <10% of patients at risk. Most EDs (n¼92, 71%) reported prescribing/dispensing buprenorphine to <10% of patients with OUD. Among the 121 EDs that responded both years, the greatest change in a policy was in prescribing/ dispensing naloxone (absolute change of +56%, P<0.001). There was no significant change in notification of PCP/prescriber (P¼0.20). Overall, there were increases in EDs with any prevention policy (+14%, P<0.001) and any treatment policy (+12%, P¼ 0.03). Conclusion: Most opioid-related ED policies increased between 2014 and 2018. More effort is needed to advance this work and to better translate some major policies (eg, offering naloxone and buprenorphine) into clinical practice.

Research paper thumbnail of Effects of food and physical activity environments on children's weight status in low-income urban neighborhoods

Research paper thumbnail of Impact of Clinician Linkage on Unequal Access to High-Volume Hospitals for Colorectal Cancer Surgery

Journal of The American College of Surgeons, Apr 5, 2022

BACKGROUND: Understanding drivers of persistent surgical disparities remains an important area of... more BACKGROUND: Understanding drivers of persistent surgical disparities remains an important area of cancer care delivery and policy. The degree to which clinician linkages contribute to disparities in access to quality colorectal cancer surgery is unknown. Using hospital surgical volume as a proxy for quality, the study team evaluated how clinician linkages impact access to colorectal cancer surgery at high-volume hospitals (HVHs). STUDY DESIGN: Maryland’s Health Services Cost Review Commission was used to evaluate 6,909 patients who underwent colon or rectal cancer operations from 2013 to 2018. Two linkages based on patient sharing were examined separately for colon and rectal cancer surgery: (1) from primary care clinicians to specialists (gastroenterologist or medical oncologist) and (2) from specialists to surgeons (general or colorectal). A referral link was defined as 9 or more shared patients between 2 clinicians. Adjusted regression models examined associations between referral links and odds of receiving colon or rectal cancer operations at HVHs. RESULTS: The cohort included 5,645 colon and 1,264 rectal cancer patients across 52 hospitals. Every additional referral link between a primary care clinician and a specialist connected to a HVH was associated with a 12% and 14% increased likelihood of receiving colon (odds ratio [OR] 1.12, CI 1.07 to 1.17) and rectal (OR 1.14, CI 1.08 to 1.20]) cancer operations at a HVH, respectively. Every additional referral link between a specialist and a surgeon at a HVH was associated with at least a 25% increased likelihood of receiving colon (OR 1.28, CI 1.20 to 1.36) and rectal (OR 1.25, CI 1.15 to 1.36) cancer operation at a HVH. CONCLUSIONS: Patients of clinicians with linkages to HVHs are more likely to have their colorectal cancer operations at these hospitals. These findings suggest that policy interventions targeting clinician relationships are an important step in providing equitable surgical care.

Research paper thumbnail of The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project

Journal of Ambulatory Care Management, 2020

The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a uniq... more The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a unique combination of features regarding ACO geography, involvement of managed care organizations (MCOs), and shared savings parameters. Ultimately, the Demonstration did not lead to a sustainable accountable care financing model and shared savings were deemphasized. Instead, the ACOs evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and MCOs. Currently, the state is developing policy parameters to reposition the ACOs as regional partners to implement state-directed population health initiatives.

Research paper thumbnail of ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery

Surgery, 2021

BACKGROUND Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated pers... more BACKGROUND Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. METHODS State inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states. RESULTS The Affordable Care Act's expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P < .0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P < .0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged. CONCLUSION Medicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.

Research paper thumbnail of Demonstration Program: Seeking Opportunities for Better Care and Lower Costs among Complex Low-Income Patients

A small but growing number of states are turning to accountable care concepts to improve their Me... more A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Med- icaid Accountable Care Organization (ACO) Demonstration program to offer local provider coalitions the opportunity to share any savings they generate. Impetus came frominitiativesinCamdenthataimtoreducecoststhroughimprovedcarecoordination among hospital high users and which have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercialACOs,theNewJerseydemonstrationaddressestheunique concernsfaced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey dem- onstration. We also examine their characteristics to inform Medicaid accountable care strategies.Wefindsubstantialv...

Research paper thumbnail of Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

Plastic and Reconstructive Surgery - Global Open, 2021

Background: Wounds in the comorbid population require limb salvage to prevent amputation. Extensi... more Background: Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined. Methods: Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010–2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl–Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors. Results: The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive. Conclusion: Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Research paper thumbnail of Evidence That Changes in Community Food Environments Lead to Changes in Children’s Weight: Results from a Longitudinal Prospective Cohort Study

Journal of the Academy of Nutrition and Dietetics, 2020

Background Strategies to improve the community food environment have been recommended for address... more Background Strategies to improve the community food environment have been recommended for addressing childhood obesity, but evidence substantiating their effectiveness is limited. Objective Our aim was to examine the impact of changes in availability of key features of the community food environment, such as supermarkets, small grocery stores, convenience stores, upgraded convenience stores, pharmacies, and limited service restaurants, on changes in children's body mass index z scores (zBMIs). Design We conducted a longitudinal cohort study. Participants/setting Two cohorts of 3-to 15-year-old children living in 4 low-income New Jersey cities were followed during 2-to 5-year periods from 2009 through 2017. Data on weight status were collected at 2 time points (T1 and T2) from each cohort; data on food outlets in the 4 cities and within a 1-mile buffer around each city were collected multiple times between T1 and T2. Main outcome measures We measured change in children's zBMIs between T1 and T2. Statistical analysis Changes in the food environment were conceptualized as exposure to changes in counts of food outlets across varying proximities (0.25 mile, 0.5 mile, and 1.0 mile) around a child's home, over different lengths of time a child was exposed to these changes before T2 (12 months, 18 months, and 24 months). Multivariate models examined patterns in relationships between changes in zBMI and changes in the food environment.

Research paper thumbnail of Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample

Plastic & Reconstructive Surgery, 2020

Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amput... more Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amputation per 100,000 population, ages 18 years and older. Excludes any-listed diagnosis of traumatic lower-extremity amputation admissions, toe amputation admission (likely to be traumatic), obstetric admissions, and transfers from other institutions.