Identification of psychiatric patients with high mortality and low medical utilization: a population-based propensity score-matched analysis.

BACKGROUND: The decreased life expectancy and care costs of mental disorders could be enormous. However, research that compares mortality and utilization concurrently across the major category of mental disorders is absent. This study investigated all-cause mortality and medical utilization among patients with and without mental disorders, with an emphasis on identifying the psychiatric category of high mortality and low medical utilization. METHODS: A total of 570,250 individuals identified from the 2002-2013 Taiwan National Health Insurance Reearch Database consistuted 285,125 psychiatric patients and 285,125 non-psychiatric peers through 1:1 dual propensity score matching (PSM). The expenditure survival ratio (ESR) was proposed to indicate potential utilization shortage. The category of mental disorders and 13 covariates were analyzed using the Cox proportional hazard model and general linear model (GLM) through SAS 9.4. RESULTS: PSM analyses indicated that mortality and total medical expenditures per capita were both significantly higher in psychiatric patients than those in non-psychiatric patients (all P <.0.0001). Patients with substance use disorders were reported having the youngest ages at diagnosis and at death, with the highest 25.64 of potential years of life loss (YPLL) and relevant 2904.89 of ESR. Adjusted Cox model and GLM results indicated that, compared with anxiety disorders, affective disorders and substance use disorders were significantly associated with higher mortality (HR = 1.246 and 1.064, respectively; all P < 0.05); schizophrenia was significantly associated with higher total medical expenditures per capita (P < 0.0001). Thirteen additional factors were significantly associated with mortality or utilization (all P < 0.05). CONCLUSION: Substance use disorders are the category of highest YPLL but notably in insufficient utilization. Health care utilization in patients with substance use disorders should be augmented timely after the diagnosis, especially toward home and community care. The factors related to mortality and utilization identified by this study merit clinical attention.

Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Geriatric Ischemic Stroke Patients: Are the Rates Right?

BACKGROUND: Our objective is to estimate the effects associated with higher rates of renin-angiotensin system antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs), in secondary prevention for geriatric (aged >65 years) patients with new ischemic strokes by chronic kidney disease (CKD) status. METHODS AND RESULTS: The effects of ACEI/ARBs on survival and renal risk were estimated by CKD status using an instrumental variable (IV) estimator. Instruments were based on local area variation in ACEI/ARB use. Data abstracted from charts were used to assess the assumptions underlying the instrumental estimator. ACEI/ARBs were used after stroke by 45.9% and 45.2% of CKD and non-CKD patients, respectively. ACEI/ARB rate differences across local areas grouped by practice styles were nearly identical for CKD and non-CKD patients. Higher ACEI/ARB use rates for non-CKD patients were associated with higher 2-year survival rates, whereas higher ACEI/ARB use rates for patients with CKD were associated with lower 2-year survival rates. While the negative survival estimates for patients with CKD were not statistically different from zero, they were statistically lower than the estimates for non-CKD patients. Confounders abstracted from charts were not associated with the instrumental variable used. CONCLUSIONS: Higher ACEI/ARB use rates had different survival implications for older ischemic stroke patients with and without CKD. ACEI/ARBs appear underused in ischemic stroke patients without CKD as higher use rates were associated with higher 2-year survival rates. This conclusion is not generalizable to the ischemic stroke patients with CKD, as higher ACEI/ARBS use rates were associated with lower 2-year survival rates that were statistically lower than the estimates for non-CKD patients.

Colonoscopy screening among US adults aged 40 or older with a family history of colorectal cancer.

INTRODUCTION: Colonoscopy screening reduces colorectal cancer (CRC) incidence and mortality. CRC screening is recommended at age 50 for average-risk people. Screening of first-degree relatives of CRC patients is recommended to begin at age 40 or 10 years before the age at diagnosis of the youngest relative diagnosed with CRC. CRC incidence has increased recently among younger Americans while it has declined among older Americans. The objective of this study was to determine whether first-degree relatives of CRC patients are being screened according to recommended guidelines. METHODS: We studied colonoscopy screening rates among the US population reporting a CRC family history using 2005 and 2010 National Health Interview Survey data. RESULTS: Of 26,064 study-eligible respondents, 2,470 reported a CRC family history; of those with a family history, 45.6% had a colonoscopy (25.2% in 2005 and 65.8% 2010). The colonoscopy rate among first-degree relatives aged 40 to 49 in 2010 (38.3%) was about half that of first-degree relatives aged 50 or older (69.7%). First-degree relatives were nearly twice as likely as nonfirst-degree relatives to have a colonoscopy (adjusted odds ratio [AOR], 1.7; 95% confidence interval, 1.5-1.9), but those aged 40 to 49 were less likely to have a colonoscopy than those in older age groups (AOR, 2.6 for age 50-64; AOR, 3.6 for age ≥65). Interactions with age, insurance, and race/ethnicity were not significant. Having health insurance tripled the likelihood of screening. CONCLUSION: Despite a 5-fold increase in colonoscopy screening rates since 2005, rates among first-degree relatives younger than the conventional screening age have lagged. Screening promotion targeted to this group may halt the recent rising trend of CRC among younger Americans.

Colorectal cancer prevention by an optimized colonoscopy protocol in routine practice.

We conducted a retrospective cohort study to investigate the colorectal cancer (CRC) incidence and mortality prevention achievable in clinical practice with an optimized colonoscopy protocol targeting near-complete polyp clearance. The protocol consisted of: (i) telephonic reinforcement of bowel preparation instructions; (ii) active inspection for polyps throughout insertion and circumferential withdrawal; and (iii) timely updating of the protocol and documentation to incorporate the latest guidelines. Of 17,312 patients provided screening colonoscopies by 59 endoscopists in South Carolina, USA from September 2001 through December 2008, 997 were excluded using accepted exclusion criteria. Data on 16,315 patients were merged with the South Carolina Central Cancer Registry and Vital Records Registry data from January 1996 to December 2009 to identify incident CRC cases and deaths, incident lung cancers and brain cancer deaths (comparison control cancers). The standardized incidence ratios (SIR) and standardized mortality ratios (SMR) relative to South Carolina and US SEER-18 population rates were calculated. Over 78,375 person-years of observation, 18 patients developed CRC versus 104.11 expected for an SIR of 0.17, or 83% CRC protection, the rates being 68% and 91%, respectively among the adenoma- and adenoma-free subgroups (all p < 0.001). Restricting the cohort to ensure minimum 5-year follow-up (mean follow-up 6.64 years) did not change the results. The CRC mortality reduction was 89% (p < 0.001; four CRC deaths vs. 35.95 expected). The lung cancer SIR was 0.96 (p = 0.67), and brain cancer SMR was 0.92 (p = 0.35). Over 80% reduction in CRC incidence and mortality is achievable in routine practice by implementing key colonoscopy principles targeting near-complete polyp clearance.

Reducing Colorectal Cancer Incidence and Disparities: Performance and Outcomes of a Screening Colonoscopy Program in South Carolina.

This study evaluated the efficiency, effectiveness, and racial disparities reduction potential of Screening Colonoscopies for People Everywhere in South Carolina (SCOPE SC), a state-funded program for indigent persons aged 50-64 years (45-64 years for African American (AA)) with a medical home in community health centers. Patients were referred to existing referral network providers, and the centers were compensated for patient navigation. Data on procedures and patient demographics were analyzed. Of 782 individuals recruited (71.2% AA), 85% (665) completed the procedure (71.1% AA). The adenoma detection rate was 27.8% (males 34.6% and females 25.1%), advanced neoplasm rate 7.7% (including 3 cancers), cecum intubation rate 98.9%, inadequate bowel preparation rate 7.9%, and adverse event rate 0.9%. All indicators met the national quality benchmarks. The adenoma rate of 26.0% among AAs aged 45-49 years was similar to that of older Whites and AAs. We found that patient navigation and a medical home setting resulted in a successful and high-quality screening program. The observed high adenoma rate among younger AAs calls for more research with larger cohorts to evaluate the appropriateness of the current screening guidelines for AAs, given that they suffer 47% higher colorectal cancer mortality than Whites.

Vision insurance, eye care visits, and vision impairment among working-age adults in the United States.

OBJECTIVES: To compare rates of eye care visits and vision impairment among working-age adults with vision insurance vs without, among the total sample of Behavioral Risk Factor Surveillance Survey respondents and among a subsample of respondents who had diagnoses of glaucoma, age-related macular degeneration (ARMD), and/or cataract. DESIGN: Using the Behavioral Risk Factor Surveillance Survey 2008 vision module data, we examined the likelihood of an eye care visit within the past year and of self reported visual impairment among 27 152 adults aged 40 to 65 years and among a subset of 3158 persons (11.6%) with glaucoma, ARMD, and/or cataract. Multivariate logistic regression models were used. RESULTS: About 40% of both the study population and the subsample with glaucoma, ARMD, and/or cataract had no vision insurance. Respondents with vision insurance were more likely than those without to have had eye care visits (general population adjusted odds ratio [AOR], 1.90 [95% CI, 1.89-1.90]; glaucoma-ARMD-cataract subsample AOR, 2.15 [95% CI, 2.13-2.17]), to have no difficulty recognizing friends across the street (general population AOR, 1.24 [95% CI, 1.22-1.26]; eye-disease subsample AOR, 1.45 [95% CI, 1.42-1.49]), and to have no difficulty reading printed matter (general population AOR, 1.34 [95% CI, 1.33-1.35]; eye-disease subsample AOR, 1.37 [95% CI, 1.34-1.39]). Respondents from the total sample who had an eye care visit were better able to recognize friends across the street (AOR, 1.07) and had no difficulty reading printed matter (AOR, 1.70), and respondents from the eye-disease subsample who had an eye care visit also were better able to recognize friends across the street (AOR, 1.71) and had no difficulty reading printed matter (AOR, 1.45). CONCLUSIONS: Lack of vision insurance impedes eye care utilization, which, in turn, may irrevocably affect vision. Vision insurance for preventive eye care should cease to be a separate insurance benefit and should be mandatory in all health plans.

Restaurant industry preparedness against intentional food contamination: results of a South Carolina survey.

Food safety and food defense are both responsibilities of public health agencies. Food safety practices within restaurants are regulated by state and local public health laws based on the US Food and Drug Administration Model Food Code. However, little is known about preemptive practices against intentional food-borne outbreaks within restaurants. The researchers administered a survey to a 50 percent random sample of South Carolina's restaurants, a state that relies heavily on tourism and the restaurant industry for its economic well-being. The survey received a response rate of 15 percent. The food defense practice items fall under three functional categories: employee management and training practices; vendor and delivery-related practices; and physical facilities and operational security practices. This study presents the results, classified by geographic region. Findings indicate some key areas of vulnerability that need attention to protect the public from mass food outbreaks due to intentional contamination. Of concern, there is much variation in practices by geographic region. On the basis of the survey, recommendations are made to improve restaurant preparedness against food-borne outbreaks from terrorism and malevolent contamination.