Association of Positive Airway Pressure Use With Acute Care Utilization and Costs.

STUDY OBJECTIVES: The current value-based medical climate has led to scrutiny of all medical costs. Given the relationship between obstructive sleep apnea (OSA) and many significant comorbid medical conditions, treating patients with OSA via positive airway pressure (PAP) therapy might reduce health care expenditures. Our goal was to determine the relationship between PAP use and acute care utilization and costs. METHODS: This was a retrospective cohort study of adult patients who initiated PAP therapy after a diagnosis of moderate-severe OSA at a large integrated health system during 2014-2016. RESULTS: The study consisted of 1,098 patients, of which 60% were on PAP > 4 h/night for ≥ 70% of the nights. The average h/night were 5.3 (standard deviation 2.4). Increasing PAP usage was associated with reduced inpatient (rate ratio [RR] 0.92, 95% confidence interval [CI] 0.86-0.98) and overall acute care visits (RR 0.96, 95% CI 0.92-0.99). The linear relationships were supported by the threshold effects identified in the categorical adherence measures. No linear association was identified with emergency department visits and inpatient stays. However, lower number of emergency department visits (RR 0.78, 95% CI 0.62-0.98) and inpatient stays (RR 0.56, 95% CI 0.35-0.91) were observed among adherent (> 4 h/night for ≥ 70% of the nights) patients. CONCLUSIONS: PAP usage was linearly associated with reduced number of inpatient and overall acute care visits, and lower likelihood of having positive costs from these visits. PAP usage was also associated with less emergency department visits and inpatient stays when comparing adherent patients to less adherent patients. CITATION: Kirsch DB, Yang H, Maslow AL, Stolzenbach M, McCall A. Association of positive airway pressure use with acute care utilization and costs. J Clin Sleep Med. 2019;15(9):1243-1250.

Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality.

BACKGROUND: Inpatient palliative care consultation (PCC) may reduce 30-day readmissions and inpatient mortality among seriously ill patients. OBJECTIVE: To evaluate the impact of timing of PCC on 30-day readmissions and inpatient mortality. DESIGN: Retrospective, observational study comparing risk-adjusted, observed-to-expected (O/E) 30-day readmissions and inpatient mortality among patients receiving inpatient PCC to all other inpatients. SETTING/SUBJECTS: Adult patients with hospital length of stay (LOS) <30 days, primary diagnoses of circulatory, infectious, respiratory, neoplasms, injury/poisoning, and digestive system were included from eight hospitals in a single health care system. RESULTS: Compared with non-PCC patients (n = 43,463), PCC patients (n = 6043) had a greater proportion of African Americans, Medicare, LOS ≥7 days, intensive care unit stays, discharges to skilled nursing facility and hospice, primary diagnoses of infections and neoplasms, comorbidities of congestive heart failure, cancer, and dementia, Charlson comorbidity score ≥8 (p < 0.001), and fewer males (p = 0.03). Adjusted readmission reduction attributed to PCC among 0-2-, 3-6-, and 7-30-day subgroups was 14.1%, 19.2%, and 16.4%, respectively (usual care O/E = 0.904 vs. subgroup O/Es = 0.764, 0.713, 0.741, respectively). Adjusted mortality reductions attributed to PCC among the 0-2- and 3-6-day subgroups were 19.4% and 19.1%, respectively. A 12% mortality increase was observed in the 7-30-day subgroup (usual care O/E = 0.738 vs. subgroup O/Es = 0.544, 0.547, 0.858, respectively). CONCLUSIONS: Inpatient PCC reduces 30-day readmissions and inpatient mortality with the greatest impact demonstrated within six days of hospital admission. Early PCC should be encouraged for eligible patients.

The effects of sedentary behavior on metabolic syndrome independent of physical activity and cardiorespiratory fitness.

BACKGROUND: To date, no longitudinal studies have examined the influence of sedentary behavior on metabolic syndrome development while accounting for cardiorespiratory fitness. PURPOSE AND METHODS: This prospective study examined the relationship between sedentary behavior and incident metabolic syndrome while considering the effects of physical activity and cardiorespiratory fitness on the association among 930 men enrolled in the Aerobics Center Longitudinal Study. RESULTS: A total of 124 men developed metabolic syndrome during 8974 person-years of exposure. After adjusting for covariates, men with middle and high sedentary behavior had 65% and 76% higher risks of developing metabolic syndrome, respectively, than men with low sedentary behavior (linear trend P = .011). This association remained significant after additional adjustment for activity status and cardiorespiratory fitness. Cardiorespiratory fitness and physical activity were also inversely associated with metabolic syndrome, even after adjustment for sedentary behavior. CONCLUSIONS: The findings highlight the importance of reducing sedentary behavior, increasing physical activity, and improving cardiorespiratory fitness for preventing metabolic syndrome.

Drug cost implications for antibiotic prophylaxis for dental procedures.

OBJECTIVE: To determine the potential economic impact from the practice of antibiotic prophylaxis for dental procedures. STUDY DESIGN: We estimated the prevalence of patients in the United States with 15 medical conditions and devices. We multiplied the prevalence for each patient population by the percentage of specialists recommending prophylaxis, then by the estimated number of dental office visits per year, and then by an average pharmacy cost to arrive at a total estimated range of annual cost for this practice. RESULTS: The 15 medical conditions and devices included in the present study involve upward of 20 million people and an estimated annual cost between $19,880,279 and $143,685,823. The actual cost may be far greater because of an underestimation of these prevalence figures and the use of antibiotic prophylaxis for additional patient populations. CONCLUSIONS: Our data suggest a significant cost for antibiotic prophylaxis in the dental practice setting and the need for evidence-based recommendations concerning this practice.

Examining the impact of 45 minutes of daily physical education on cognitive ability, fitness performance, and body composition of African American youth.

OBJECT: Increased importance on academic achievement has resulted in many school districts focusing on improved academic performance leading to reductions in physical education time. The purpose was to examine the effects of 45 minutes of daily physical education on the cognitive ability, fitness performance and body composition of African American elementary and middle school youth. METHODS: Participants completing the informed consent in grades 2nd to 8th were included in the study. A pre/posttest design was used with repeated measures analysis of variance. Experimental and control school participants were pretested on the cognitive measures (ie, Fluid Intelligence and Perceptual Speed) and Fitnessgram® physical fitness test items (eg, aerobic capacity, muscular strength and muscular endurance, body composition) in September 2009 and posttested in May 2010. RESULTS: Experimental elementary and middle school participants observed significantly greater improvements compared with control elementary and middle school participants on 7 of 16 fitness and body composition measures and on 8 of 26 cognitive measures. These fitness, body composition, and cognitive improvement differences were more noticeable among elementary and middle school females. CONCLUSIONS: Providing 45 minutes of daily physical education can perhaps increase cognitive ability while increasing fitness and decreasing the prevalence of overweight and obese youth.

Associations between sociodemographic characteristics and perceptions of the built environment with the frequency, type, and duration of physical activity among trail users.

INTRODUCTION: Rail trails are elements of the built environment that support the Task Force on Community Preventive Services' recommendation to create, or enhance access to, places for physical activity (PA). The purpose of this study was to examine the associations between sociodemographic characteristics and perceptions of the built environment with the frequency, type, and duration of PA among users of an urban, paved rail trail segment. METHODS: Interviewers conducted intercept surveys with 431 rail trail users and analyzed data by using logistic regression to estimate odds ratios between sociodemographic characteristics and perceptions of the built environment on the frequency, type, and duration of PA performed on the trail. RESULTS: Adults who used the trail in the cool months, traveled to the trail by a motorized vehicle, used the trail with others, and had some graduate school education visited the trail less often. Younger adults, men, whites, and those with some graduate school education were more likely to engage in vigorous activities on the trail. Adults who traveled to the trail by a motorized vehicle spent more time engaged in PA on the trail. CONCLUSION: Our results suggest that the most frequent users of a rail trail for PA are those who use the trail alone and travel to the trail by bicycle or on foot. Trails are an aspect of the built environment that supports active lifestyles, and future studies should evaluate different types of trails among more diverse populations and locations.

The association of natural elements with physical activity intensity during trail use by older adults.

BACKGROUND: Public health efforts to promote trail use among older adults could be an effective strategy for increasing physical activity among older adults. However, research is needed to better understand factors that influence older adults' use of trails. PURPOSE: To examine the association between variations in natural elements (ie, season, weather, temperature) and older adults' overall trail use and physical activity intensity during trail use. METHODS: A rail-trail in South Carolina was systematically evaluated (2006-2009) using The System for Observing Play and Recreation in Communities. RESULTS: The majority (74.2%) of the 1053 older trail users observed were walking; 25.9% were observed in vigorous activity. Older adults were most often observed using the trail in the spring (40.1%), sunny weather (76.8%), and moderate temperatures (56.2%). Significant differences in activity type by natural element variables were identified. CONCLUSIONS: When promoting trail use among older adults, natural elements should be considered.

Features and amenities of school playgrounds: a direct observation study of utilization and physical activity levels outside of school time.

BACKGROUND: A significant amount of research has examined whether park or playground availability is associated with physical activity. However, little research has examined whether specific features or amenities of parks or playgrounds, such as the number of unique types of playground equipment or the safety of the equipment is associated with utilization of the facility or physical activity levels while at the facility. There are no studies that use direct observation and a detailed park assessment to examine these associations. METHODS: Twenty urban schoolyards in the Midwest, ten of which were renovated, were included in this study. Using a detailed environmental assessment tool (i.e., Environmental Assessment of Public Recreation Spaces), information on a variety of playground attributes was collected. Using direct observation (i.e., System for Observing Play and Leisure Activity in Youth), the number of adults, girls and boys attending each schoolyard and their physical activity levels were recorded. Each schoolyard was observed ten times for 90 minutes each time outside of school hours. Clustered multivariable negative binomial regressions and linear regressions were completed to examine the association between playground attributes and utilization of the schoolyard and the proportion active on the playground, respectively. Effect modification by renovation status was also examined. RESULTS: At renovated schoolyards, the total number of play features was significantly associated with greater utilization in adults and girls; overall cleanliness was significantly associated with less utilization in girls and boys; and coverage/shade for resting features was significantly associated with greater utilization in adults and boys. At unrenovated schoolyards, overall safety was significantly associated with greater utilization in boys. No playground attribute was associated with the proportion active on the playground after adjusting for all other significant playground attributes. CONCLUSIONS: Having a large quantity of play features and shade at renovated playgrounds were positively associated with utilization of the schoolyard. Modifying playgrounds to have these features may increase the utilization of these facilities outside of school time. Additional research should explore what features and amenities are associated with increased physical activity levels of children and adults who utilize the facilities.

Fitness and adiposity as predictors of functional limitation in adults.

BACKGROUND: This study examined the associations of body mass index (BMI), waist circumference (WC), and cardiorespiratory fitness (CRF) with incident functional limitation (IFL) in adults. METHODS: Patients (n = 2400), 30+ years [mean age, 45.2 (SD, 8.3); 12% women], completed a baseline health examination during 1979 to 1995. CRF was quantified by age-and sex-specific thirds for maximal treadmill exercise test duration. Adiposity was assessed by BMI and WC (grouped for analysis according to clinical guidelines). Incident IFL was identified from mail-back surveys during 1995, 1999, and 2004. RESULTS: After adjusting for potential confounders and either BMI or WC, CRF was inversely related to IFL (P trend < .001). The association between BMI and IFL was significant after adjusting for all confounders (P trend = .002), but not after additional adjustment for CRF (P trend = .23). After controlling for all confounders and CRF, high WC was associated with greater odds of IFL in those aged 30 to 49; normal WC was associated with greater odds of IFL in those aged 50+. CONCLUSIONS: CRF was a significant predictor of IFL in middle aged and older adults, independent of overall or abdominal adiposity. Clinicians should consider the importance of preserving functional capacity by recommending regular physical activity for normal-weight and overweight individuals.

Youth physical activity resource use and activity measured by accelerometry.

OBJECTIVES: To examine whether use of physical activity resources (eg, parks) was associated with daily physical activity measured by accelerometry. METHODS: One hundred eleven adolescents completed a travel diary with concurrent accelerometry. The main exposure was self-reported use of a physical activity resource (none /1+ resources). The main outcomes were total minutes spent in daily (1) moderate-vigorous physical activity and (2) vigorous physical activity. RESULTS: Using a physical activity resource was significantly associated with total minutes in moderate-vigorous physical activity. African Americans and males had significantly greater moderate-vigorous physical activity. CONCLUSIONS: Results from this study support the development and use of physical activity resources.

Muscular strength is inversely related to prevalence and incidence of obesity in adult men.

The purpose of the study was to determine the relation between quintiles of muscular strength after adjustment for age and body weight, and excessive body fat (EBF) and excessive abdominal fat (EAF) when controlling for cardiorespiratory fitness (CRF) and other potential confounders. A two-phased cross-sectional and longitudinal study was conducted assessing the prevalence and incidence of EBF and EAF across quintiles of muscular strength. The sample included 3,258 men (mean age = 42.2 ± 8.9; weight (kg) = 81.2 ± 11.0; BMI = 25.3 ± 2.9; %fat = 19.4 ± 5.8; waist girth (cm) = 91.2 ± 9.0) who completed at least two clinical examinations as part of the Aerobics Center Longitudinal Study (ACLS). Muscular strength was assessed with tests of upper and lower body muscular strength using rack-mounted weights with participants placed into strength quintiles. CRF was measured by a modified Balke treadmill test, %fat via underwater weighing or seven-site skinfold measurements, and waist girth measured at the level of the umbilicus. EBF was defined as ≥25% and EAF was defined as >102 cm. There was a strong inverse gradient across quintiles of muscular strength for prevalence and incidence of EBF and EAF (P trend <0.01, each). With the lowest quintile serving as the referent, reductions in risk of EBF and EAF exceeded 70% for the highest strength quintile. Evidence suggests muscular strength may provide protection from EBF and EAF and their related comorbidities.

Muscular strength and incident hypertension in normotensive and prehypertensive men.

UNLABELLED: The protective effects of cardiorespiratory fitness (CRF) on hypertension (HTN) are well known; however, the association between muscular strength and incidence of HTN has yet to be examined. PURPOSE: This study evaluated the strength-HTN association with and without accounting for CRF. METHODS: Participants were 4147 men (age = 20-82 yr) in the Aerobics Center Longitudinal Study for whom an age-specific composite muscular strength score was computed from measures of a one-repetition maximal leg and a one-repetition maximal bench press. CRF was quantified by maximal treadmill exercise test time in minutes. Cox proportional hazards regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals of incident HTN events according to exposure categories. RESULTS: During a mean follow-up of 19 yr, there were 503 incident HTN cases. Multivariable-adjusted (excluding CRF) HR of HTN in normotensive men comparing middle- and high-strength thirds to the lowest third were not significant at 1.17 and 0.84, respectively. Multivariable-adjusted (excluding CRF) HR of HTN in baseline prehypertensive men comparing middle- and high-strength thirds to the lowest third were significant at 0.73 and 0.72 (P = 0.01 each), respectively. The association between muscular strength and incidence of HTN in baseline prehypertensive men was no longer significant after control for CRF (P = 0.26). CONCLUSIONS: The study indicated that middle and high levels of muscular strength were associated with a reduced risk of HTN in prehypertensive men only. However, this relationship was no longer significant after controlling for CRF.