Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients.

Background: High morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient's survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort. Methods: A retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital's trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis. Results: There were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded. Conclusions: A negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.

Using the Uganda National Panel Survey to analyze the effect of staple food consumption on undernourishment in Ugandan children.

BACKGROUND: The United Nations' Millennium Development Goals Report, 2015, documents that, since 1990, the number of stunted children in sub-Saharan Africa has increased by 33% even though it has fallen in all other world regions. Recognizing this, in 2011 the Government of Uganda implemented a 5-year Nutrition Action Plan. One important tenet of the Plan is to lessen malnutrition in young children by discouraging over-consumption of nutritionally deficient, but plentiful, staple foods, which it defines as a type of food insecurity. METHODS: We use a sample of 6101 observations on 3427 children age five or less compiled from three annual waves of the Uganda National Panel Survey to measure undernourishment. We also use the World Health Organization's Child Growth Standards to create a binary variable indicating stunting and another indicating wasting for each child in each year. We then use random effects to estimate binary logistic regressions that show that greater staple food concentrations affect the probability of stunting and wasting. RESULTS: The estimated coefficients are used to compute adjusted odds ratios (OR) that estimate the effect of greater staple food concentration on the likelihood of stunting and the likelihood of wasting. Controlling for other relevant covariates, these odds ratios show that a greater proportion of staple foods in a child's diet increases the likelihood of stunting (OR = 1.007, p = 0.005) as well as wasting (OR = 1.011, p = 0.034). Stunting is confirmed with subsamples of males only (OR = 1.006, p = 0.05) and females only (OR = 1.008, p = 0.027), suggesting that the finding is not gender specific. Another subsample of children aged 12 months or less, most of whom do not yet consume solid food, shows no statistically significant relationship, thus supporting the validity of the other findings. CONCLUSION: Diets containing larger proportions of staple foods are associated with greater likelihoods of both stunting and wasting in Ugandan children. Other causes of stunting and wasting identified in past research are also confirmed with the Uganda data. Finally, the analysis provides clues to other possible causes of undernourishment in young children.

The relationships between housing quality and occupant health in Uganda.

The Government of Uganda created in 2010 a strategic plan to invest in public health as part of its broader national development goals. The health plan recognizes housing and urbanization as a determinant of health, but has not yet formulated policy to address the relationship. This study can help guide health policy development as it relates to housing. It estimates relationships between housing quality and occupant health using "count outcome" regression models. An economic model of optimal household labor allocation in poor countries provides the foundation for the regression modeling. The data used to estimate the regressions are a stratified random sample of 7096 households surveyed in the 2005-06 Uganda National Household Survey. They provide, among other things, detailed information on physical housing attributes as well as the health status of its occupants. Consistent with the economic model and other empirical work, the results show that exposure to burning of biomass for cooking has the largest adverse health effect. Different definitions of illness yield results consistent with expectations, and a separate specification test suggests that the findings are reasonably robust.

Medicare Part D roulette: potential implications of random assignment and plan restrictions.

BACKGROUND: Dual-eligible (Medicare/Medicaid) beneficiaries are randomly assigned to a benchmark plan, which provides prescription drug coverage under the Part D benefit without consideration of their prescription drug profile. To date, the potential for beneficiary assignment to a plan with poor formulary coverage has been minimally studied and the resultant financial impact to beneficiaries unknown. OBJECTIVE: We sought to determine cost variability and drug use restrictions under each available 2010 California benchmark plan. METHODS: Dual-eligible beneficiaries were provided Part D plan assistance during the 2010 annual election period. The Medicare Web site was used to determine benchmark plan costs and prescription utilization restrictions for each of the six California benchmark plans available for random assignment in 2010. A standardized survey was used to record all de-identified beneficiary demographic and plan specific data. For each low-income subsidy-recipient (n = 113), cost, rank, number of non-formulary medications, and prescription utilization restrictions were recorded for each available 2010 California benchmark plan. Formulary matching rates (percent of beneficiary's medications on plan formulary) were calculated for each benchmark plan. RESULTS: Auto-assigned beneficiaries had only a 34% chance of being assigned to the lowest cost plan; the remainder faced potentially significant avoidable out-of-pocket costs. Wide variations between benchmark plans were observed for plan cost, formulary coverage, formulary matching rates, and prescription utilization restrictions. CONCLUSIONS: Beneficiaries had a 66% chance of being assigned to a sub-optimal plan; thereby, they faced significant avoidable out-of-pocket costs. Alternative methods of beneficiary assignment could decrease beneficiary and Medicare costs while also reducing medication non-compliance.

Use of potentially inappropriate medications in an ambulatory Medicare population.

OBJECTIVE: To determine the prevalence of potentially inappropriate medication (PIM) use by applying the Beers criteria in an ambulatory population of Medicare beneficiaries, and to identify the most common PIMs/PIM classes taken by this population. DESIGN: Cross-sectional, observational study. SETTING: Nine community outreach events throughout central and northern California. PATIENTS: 295 ambulatory Medicare beneficiaries (65 to 98 years of age). INTERVENTIONS: Pharmacy students, under the supervision of licensed pharmacists, assisted beneficiaries with Medicare Part D plan enrollment and medication review, including identification of PIMs. MAIN OUTCOME MEASURES: Number of PIMs taken by beneficiaries and the most frequent PIMs/PIM classes. RESULTS: 54 (18.3%) beneficiaries were taking at least one PIM. The most common PIMs taken by the study group were alprazolam, clonidine, and estrogen. The two most common classes of such medications were benzodiazepines and antiarrhythmics. CONCLUSION: Many older adults continue to receive medications that should be avoided because of limited effectiveness and/or potential for harm. Prescribers and pharmacists must be diligent in ensuring that medications given to older adults are necessary and appropriate. Outreach events targeting seniors provide an ideal forum to identify and address such issues.

Does substituting home care for institutional care lead to a reduction in Medicaid expenditures?

In 1981 Congress introduced Home and Community Based Services (HCBS) waivers in an attempt to contain Medicaid long-term care expenditures. This paper analyzes the efficacy of the waiver program. To date, little is known about its impact on cost containment. Using state-level Medicaid data on expenditures and the number of individuals participating in HCBS waivers between 1992 and 2000, this study estimates the impact of HCBS waivers on total Medicaid expenditures as well as on Medicaid institutional, home health and pharmaceutical expenditures. A fixed effects model is used to analyze Medicaid expenditures using variation in the size of HCBS waiver programs across states and over time. The results, robust across multiple specifications, show increases rather than decreases in total Medicaid spending as well as increases in the other Medicaid spending categories analyzed. This implies that there is no evidence of substitution from institutional care to the HCBS waiver program or that cost-shifting is occurring. In fact, the large magnitude of the estimated spending increases suggests the waivers may induce more people to enter the Medicaid program.

Analysis of national annual variation in total patient out-of-pocket Medicare Part D stand-alone prescription drug plan costs from 2007 to 2008.

OBJECTIVE: This is the first study to compare total Medicare Part D (MPD) stand-alone prescription drug plan (PDP) estimated annual costs (EAC) between 2007 and 2008 in all MPD regions of the US using a patient cohort of Medicare-eligible patients. METHODS: A total of 50 patients were selected at random from a database of Medicare-eligible patients. Each patient profile, based on pharmacy claims data, was entered into the Medicare website and the EAC of each PDP in each of the 34 MPD regions was obtained. The lowest, 25th percentile, median and highest EAC plans were obtained for each patient in each region for 2007 and 2008. Pair-wise, within-region, between-year comparisons were made using the Wilcoxon Signed-Ranks test. RESULTS: Annual trends were variable between MPD regions. Only the highest EAC showed significant decreases in some regions, while all other comparisons showed no change or an increase in regional costs. CONCLUSIONS: Out-of-pocket Medicare prescription drug costs increased from 2007 to 2008. Increases in plan costs highlight the need for annual re-evaluation of PDP costs so that the patient is able to obtain the lowest cost plan each year. The decrease in the highest cost plan may suggest improvements in formulary coverage.