Coverage and Access for Americans With Chronic Disease Under the Affordable Care Act: A Quasi-Experimental Study.

BACKGROUND: Half of Americans have at least 1 chronic disease. Many in this group, particularly racial/ethnic minorities, lacked insurance coverage and access to care before the Patient Protection and Affordable Care Act (ACA) was enacted. OBJECTIVE: To determine whether the ACA has had an effect on insurance coverage, access to care, and racial/ethnic disparities among adults with chronic disease. DESIGN: Quasi-experimental policy intervention. SETTING: Nationally representative, noninstitutionalized sample in the United States. PATIENTS: 606 277 adults aged 18 to 64 years with a chronic disease. INTERVENTION: Implementation of ACA provisions on 1 January 2014. MEASUREMENTS: Self-reported insurance coverage, having a checkup, having a personal physician, and not having to forgo a needed physician visit because of cost. RESULTS: After the ACA was implemented, insurance coverage increased by 4.9 percentage points (95% CI, 4.4 to 5.4), not having to forgo a physician visit increased by 2.4 percentage points (CI, 1.9 to 2.9), and having a checkup increased by 2.7 percentage points (CI, 2.2 to 3.4). Having a personal physician did not change (0.3 percentage points [CI, -0.2 to 0.8]). All outcomes varied considerably by state, and coverage increased more in states that expanded Medicaid. Although racial/ethnic minorities had greater improvements in some outcomes, approximately 1 in 5 black and 1 in 3 Hispanic persons with a chronic disease continued to lack coverage and access to care after ACA implementation. LIMITATION: The study examined data from only the first year of the ACA's major coverage expansion provisions. CONCLUSION: Although the ACA increased coverage and access for persons with chronic disease, substantial gaps remain, particularly for minorities and those in Medicaid nonexpansion states. PRIMARY FUNDING SOURCE: None.

Videotaping of surgical procedures and outcomes following extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer.

BACKGROUND: Video-recording of emerging minimally invasive surgical procedures is likely to become an integral component of patient record-keeping in the future for prostate cancer treatment. No prior work has shown the impact of videotaping of laparoscopic prostatectomy on patient outcomes. Our aim was to determine correlation between independent peer review of videotaping quality scores of extraperitoneal laparoscopic prostatectomy (ELRP) with complications, re-admissions, functional, and early oncological outcomes. STUDY DESIGN, SETTING, AND PARTICIPANTS: We conducted a single-institution prospective cohort study comparing videotaping quality scores with the outcomes of ELRP in men with localized prostate cancer. Videotaping of surgical procedures were scored by two experienced laparoscopic surgeons using a validated scoring method. Validated record-linkage methodology and self-reported questionnaires were used to assess surgical complications, re-admissions, functional, and oncological outcomes based on a common identifier called as community health index (CHI) number. Pearson correlation coefficients were calculated between the different covariates with statistical significance considered at P < 0.05. Multivariate analyses assessed oncological outcomes (positive surgical margins/biochemical recurrence), post-operative complications, and re-admission into hospital following initial hospital discharge with quality of surgical procedure. RESULTS: 200 men were recruited into the study. 51 (25.5%) participants had post-operative complications. Record-linkage methodology identified 18 (9%) participants had re-admissions within 90 days of the procedure. 13 (6.5%) of these men required percutaneous drainage with hospital stay following re-admissions ranged between 3 and 12 days. 10 (5.0%) participants had intra/peri-operative complications. 23 (11.5%) men reported to primary care physicians for various indications. Higher quality surgical technique videotaped scores (assessed by independent peer review) had a significant correlation with early continence recovery at 3 months post-procedure, (P = 0.013), but lost statistical significance with overall continence at 1 year. No statistical correlation was observed between videotaped scores and oncological outcomes (positive surgical margins/biochemical recurrence), post-operative complications, and readmission into hospital. CONCLUSIONS: Quality of surgical procedure assessed by independent third party videotaping score predicted early resumption of continence following extraperitoenal laparoscopic radical prostatectomy, however, it did not predict complications, oncological or functional outcome as assessed using patient reported outcomes at 12 months. J. Surg. Oncol. 2016;114:1016-1023. © 2016 Wiley Periodicals, Inc.

CETP inhibitors downregulate hepatic LDL receptor and PCSK9 expression in vitro and in vivo through a SREBP2 dependent mechanism.

BACKGROUND: CETP inhibitors block the transfer of cholesteryl ester from HDL-C to VLDL-C and LDL-C, thereby raising HDL-C and lowering LDL-C. In this study, we explored the effect of CETP inhibitors on hepatic LDL receptor (LDLR) and PCSK9 expression and further elucidated the underlying regulatory mechanism. RESULTS: We first examined the effect of anacetrapib (ANA) and dalcetrapib (DAL) on LDLR and PCSK9 expression in hepatic cells in vitro. ANA exhibited a dose-dependent inhibition on both LDLR and PCSK9 expression in CETP-positive HepG2 cells and human primary hepatocytes as well as CETP-negative mouse primary hepatocytes (MPH). Moreover, the induction of LDLR protein expression by rosuvastatin in MPH was blunted by cotreatment with ANA. In both HepG2 and MPH ANA treatment reduced the amount of mature form of SREBP2 (SREBP2-M). In vivo, oral administration of ANA to dyslipidemic C57BL/6J mice at a daily dose of 50 mg/kg for 1 week elevated serum total cholesterol by approximately 24.5% (p < 0.05%) and VLDL-C by 70% (p < 0.05%) with concomitant reductions of serum PCSK9 and liver LDLR/SREBP2-M protein. Finally, we examined the in vitro effect of two other strong CETP inhibitors evacetrapib and torcetrapib on LDLR/PCSK9 expression and observed a similar inhibitory effect as ANA in a concentration range of 1-10 µM. CONCLUSION: Our study revealed an unexpected off-target effect of CETP inhibitors that reduce the mature form of SREBP2, leading to attenuated transcription of hepatic LDLR and PCSK9. This negative regulation of SREBP pathway by ANA manifested in mice where CETP activity was absent and affected serum cholesterol metabolism.

Psychological benefits of virtual reality for patients in rehabilitation therapy.

CONTEXT: Whether virtual rehabilitation is beneficial has not been determined. OBJECTIVE: To investigate the psychological benefits of virtual reality in rehabilitation. DESIGN: An experimental group underwent therapy with a virtual-reality-based exercise bike, and a control group underwent the therapy without virtual-reality equipment. SETTING: Hospital laboratory. PATIENTS: 30 patients suffering from spinal-cord injury. INTERVENTION: A designed rehabilitation therapy. MAIN OUTCOME MEASURES: Endurance, Borg's rating-of-perceived-exertion scale, the Activation-Deactivation Adjective Check List (AD-ACL), and the Simulator Sickness Questionnaire. RESULTS: The differences between the experimental and control groups were significant for AD-ACL calmness and tension. CONCLUSION: A virtual-reality-based rehabilitation program can ease patients' tension and induce calm.

Driving performance assessment: effects of traffic accident location and alarm content.

According to accident statistics for Taiwan, the two most common traffic accident locations in urban areas are roadway segments and intersections. On roadway segments, most collisions are due to drivers not noticing the status of leading vehicle. At intersections, most collisions are due to the other driver failing to obey traffic signs. Using a driving simulator equipped with a collision warning system, this study investigated driving performance at different accident locations and between different alarm contents, and identified the relationship between crash occurrences and driving performance. Thirty participants, aged 20-29 years, were recruited in this study. Driving performance measures were perception-reaction time, movement-reaction time, speed and a crash. Experimental results indicated that due to different demands for processing information under different traffic conditions, driving performance differed at the two traffic accident locations. On a roadway segment, perception-reaction time for a beep was shorter than the time for a speech message. Nevertheless, at an intersection, a speech message was a great help to drivers and, thus, perception-reaction time was effectively reduced. In addition, logistic regression analysis indicates that perception-movement time had the greatest influence on crash occurrence.

The assessment of stability and reliability of a virtual reality-based intravenous injection simulator.

The aim of this study was to validate the feasibility of a virtual reality-based (without haptic feedback) intravenous injection system as an effective tool for computer-assisted instruction and training. The stability and reliability of the system were assessed. A personal computer, a needle/catheter device, and a data acquisition interface are included in this system. Using Virtual Reality Modeling Language, an interactive virtual environment was developed. Ten participants, ranging from 20 to 28 years of age, were recruited for this study. The self-learning and training procedures encompassed an intravenous catheterization process. The experimental results showed that after a few trials, the change in task time was not obvious in each trial, and the error frequency decreased slightly with more trials. High intraclass correlation coefficients also were obtained for task time and error frequency by analyzing the test-retest reliability. These results indicated that the system was stable and that the system reliability was acceptable.

Rectification of legibility distance in a driving simulator.

Visual differences lead to differences in the legibility distances of traffic signs between driving simulators and real road environments. To ensure that the legibility distance in a simulator is similar to that in the real world, this study proposes a theoretical equation for predicting legibility distance and a simple algorithm for determining the magnifying power of a traffic sign for a display system in a simulator. Experiments of traffic sign recognition using a simulator were conducted under quasi-static and dynamic driving conditions. On-road tests were also carried out under quasi-static and dynamic driving conditions. Thirty healthy and non-disabled volunteers were recruited. The experimental results showed that the proposed theoretical equation for predicting legibility distance and the simple algorithm for determining the magnifying power of traffic signs reduced the difference in legibility distances between the simulator and real road environment under quasi-static and dynamic driving conditions.

Evaluation of computer-assisted multimedia instruction in intravenous injection.

The purpose of this study was to develop a computer-assisted multimedia training course for intravenous injection and evaluate its effect on the knowledge and self-perceived performance of intravenous injection for novice nurses. Eighty-one novice nurses randomly assigned to the experimental group and control group participated a designed training procedure and took pretest and posttests. The test results were analyzed using statistical methods. From the study it could be concluded that the training course had a significant effect on the intravenous injection's knowledge. Besides, a high rate of satisfaction for the multimedia program showed the self-developed program was successful.