Health insurance and transportation barriers impact access to epilepsy care in the United States.

PURPOSE: Inconsistent access to healthcare for people with epilepsy results in reduced adherence to antiseizure medications, increased seizure frequency, and fewer appropriate referrals for epilepsy surgery. Identifying and addressing factors that impede access to care should consequently improve patient outcomes. We hypothesized that health insurance and transportation affect access to outpatient neurology care for adults living with epilepsy in the United States (US). METHODS: We conducted a retrospective cross-sectional study of US adults with active epilepsy surveyed via the National Health Interview Survey (NHIS) in 2015 and 2017. We established whether patients reported seeing a neurologist in the past year and used multiple logistic regression to determine whether health insurance status and transportation access were associated with this outcome. RESULTS: We identified 735 respondents from 2015 and 2017, representing an estimated 2.98 million US adults with active epilepsy. After adjusting for socioeconomic and seizure-related co-variates, we found that a lack of health insurance coverage was associated with no epilepsy care in the past year (adjusted odds ratio [aOR] 0.22; 95 % confidence interval [CI]: 0.09 - 0.54). Delayed care due to inadequate transportation (aOR 0.42; 95 % CI: 0.19 - 0.93) also resulted in reduced patient access to a neurologist. CONCLUSION: Due to the inherent nature of their condition, people with epilepsy are less likely to have employer-sponsored health insurance or consistent driving privileges. Yet, these factors also impact patient access to neurological care. We must address transportation and insurance barriers through long-term investment and partnership between community, healthcare, and government stakeholders.

Predicting 30-day emergency department revisits.

OBJECTIVES: To develop a predictive model that hospitals or healthcare systems can use to identify patients at high risk of revisiting the emergency department (ED) within 30 days and thus reduce unnecessary ED use through proactive interventions. STUDY DESIGN: A retrospective analysis of fiscal years (FYs) 2013 and 2014 data from 4 Veterans Affairs hospitals in upstate New York. METHODS: This study developed a predictive model based on administrative data, a publicly available patient classification system, and logistic regression. The study data were from 4 Veterans Affairs hospitals in upstate New York; FY 2013 data were used to predict 30-day revisits in FY 2014. All 22,734 patients with ED visits were included in the analysis. The predictive variables were patient demographics, prior-year utilization, and comorbidities. To prevent overfitting, we validated the model by the split-sample method. The predictive power of the model is measured by C statistics. RESULTS: In the first model using only patient demographics, the C statistics were 0.568 (95% CI, 0.555-0.580) and 0.556 (95% CI, 0.543-0.568) for the development and validation samples, respectively. In the second model with prior-year utilization added, the C statistics were 0.748 (95% CI, 0.737-0.759) for both samples. In the final model with comorbidities added, the C statistics reached 0.773 (95% CI, 0.762-0.784) and 0.763 (95% CI, 0.753-0.774) for the development and validation samples, respectively. CONCLUSIONS: The predictive model we developed in this study is straightforward to implement and offers significantly higher predictive power than other models reported in the literature. Hospitals and healthcare systems can use it to identify high-risk "frequent flyers" for early interventions to reduce ED revisits.

Predicting 72-hour emergency department revisits.

OBJECTIVES: To develop a predictive model that hospitals or healthcare systems can use to identify patients at high risk of revisiting the ED within 72h so that appropriate interventions can be delivered. METHODS: This study employed multivariate logistic regression in developing the predictive model. The study data were from four Veterans medical centers in Upstate New York; 21,141 patients in total with ED visits were included in the analysis. Fiscal Year (FY) 2013 data were used to predict revisits in FY 2014. The predictive variables were patient demographics, prior year healthcare utilizations, and comorbidities. To avoid overfitting, we validated the model by the split-sample method. The predictive power of the model is measured by c-statistic. RESULTS: In the first model using only patient demographics, the c-statistics were 0.55 (CI: 0.52-0.57) and 0.54 (95% CI: 0.51-0.56) for the development and validation samples, respectively. In the second model with prior year utilization added, the c-statistics were 0.70 (95% CI: 0.68-0.72) for both samples. In the final model where comorbidities were added, the c-statistics were 0.74 (CI: 0.72-0.76) and 0.73 (95% CI: 0.71-0.75) for the development and validation samples, respectively. CONCLUSIONS: Reducing ED revisits not only lowers healthcare cost but also shortens wait time for those who critically need ED care. However, broad intervention for every ED visitor is not feasible given limited resources. In this study, we developed a predictive model that hospitals and healthcare systems can use to identify "frequent flyers" for early interventions to reduce ED revisits.

Mahjong playing and eye-hand coordination in older adults-a cross-sectional study.

[Purpose] Eye-hand coordination declines with age, but physical activity is known to slow down the degeneration. Playing mahjong involves lots of eye-hand coordination. The objective was to investigate the relationship between playing mahjong and eye-hand coordination in older adults using a fast finger-pointing paradigm. [Subjects and Methods] Forty-one community dwelling older adults aged sixty or above were recruited by convenience sampling in this cross-sectional study. They were tested on their ability to point quickly and accurately 1) toward a stationary visual target and 2) toward a moving visual target. [Results] The mahjong players demonstrated significantly better end-point accuracy when pointing with their non-dominant hand toward a stationary target. They also demonstrated significantly faster movement of their dominant hands; shorter reaction times and better end-point accuracy when pointing with their non-dominant hands toward a moving target. [Conclusion] Mahjong players have better eye-hand coordination than non-players. Playing mahjong could usefully be introduced to older adults as a leisure time activity.

Effectiveness of Exergaming Training in Reducing Risk and Incidence of Falls in Frail Older Adults With a History of Falls.

OBJECTIVE: To use Nintendo's Wii Fit balance board to determine the effectiveness of exergaming training in reducing risk and incidence of falls in older adults with a history of falls. DESIGN: Randomized controlled trial. SETTING: Nursing home for older adults. PARTICIPANTS: Adults aged 65 years and older (N=60). INTERVENTIONS: Participants who lived in a nursing home had 6 weeks of balance training with either Wii Fit equipment or conventional exercise. MAIN OUTCOME MEASURES: Physiological Profile Assessment scores and incidence of falls were observed with subsequent intention-to-treat statistical analyses. RESULTS: Physiological Profile Assessment scores and incidence of falls improved significantly in both groups after the intervention (all P<.01), but participants in the Wii Fit training group showed a significantly greater improvement in both outcome measures (P=.004 and P<.001, respectively). CONCLUSIONS: In institutionalized older adults with a history of falls, Wii Fit balance training was more effective than conventional balance training in reducing the risk and incidence of falls.

Revisiting hospital length of stay: what matters?

OBJECTIVES: To explore actionable information that can be used to reduce hospital acute care length of stay (LOS) and to assess racial and income disparities in LOS in an integrated healthcare network. STUDY DESIGN AND METHODS: Retrospective analysis of 8718 inpatients in an integrated healthcare network. The LOS was examined by using linear, log-linear, Poisson, generalized Poisson, and negative binomial (NB) models to control for confounding factors. The performances of the 5 models were compared, and the NB model was selected for the final analysis and report. RESULTS: Over 50% of the inpatients were not married. The LOS was 22% longer for the unmarried patients compared with their married counterparts after controlling for confounding factors. No income or racial disparities were found. CONCLUSIONS: The prolonged LOS of the unmarried patients and the potential lack of post discharge care support warrant greater attention from discharge planners at hospital level and from policy makers at both the national and local levels. Racial and income disparities are not unavoidable; the way in which care is paid for and delivered may play a role.

Sitting tai chi improves the balance control and muscle strength of community-dwelling persons with spinal cord injuries: a pilot study.

Objective. To investigate the effects of sitting Tai Chi on muscle strength, balance control, and quality of life (QOL) among survivors with spinal cord injuries (SCI). Methods. Eleven SCI survivors participated in the sitting Tai Chi training (90 minutes/session, 2 times/week for 12 weeks) and eight SCI survivors acted as controls. Dynamic sitting balance was evaluated using limits of stability test and a sequential weight shifting test in sitting. Handgrip strength was also tested using a hand-held dynamometer. QOL was measured using the World Health Organization's Quality of Life Scale. Results. Tai Chi practitioners achieved significant improvements in their reaction time (P = 0.042); maximum excursion (P = 0.016); and directional control (P = 0.025) in the limits of stability test after training. In the sequential weight shifting test, they significantly improved their total time to sequentially hit the 12 targets (P = 0.035). Significant improvement in handgrip strength was also found among the Tai Chi practitioners (P = 0.049). However, no significant within and between-group differences were found in the QOL outcomes (P > 0.05). Conclusions. Twelve weeks of sitting Tai Chi training could improve the dynamic sitting balance and handgrip strength, but not QOL, of the SCI survivors.

Reliability of dynamic sitting balance tests and their correlations with functional mobility for wheelchair users with chronic spinal cord injury.

The purpose of this study is to develop a reliable and valid tool for measuring the dynamic sitting balance of wheelchair users with spinal cord injury. The balance tests were performed in nine patients with chronic spinal cord injury (average of 17.2 years postinjury) between levels C6 and L1, while they were sitting in their wheelchairs and on a standardized stool (unsupported sitting), twice, 7 days apart. Limits of stability (LOS) and sequential weight shifting (SWS) were designed in this study. The balance tests measured participants' volitional weight shifting in multiple directions within their base of support. Their mobility scores on the Spinal Cord Independence Measure III were correlated with the balance test results. The LOS results showed moderate to excellent test-retest reliability (intraclass correlation coefficients ranged from 0.673 to 0.990) for both the wheelchair and the unsupported sitting. The SWS results showed moderate to excellent reliability (intraclass correlation coefficients ranged from 0.688 to 0.952). The LOS results correlated significantly with the Spinal Cord Independence Measure III mobility scores only in case of unsupported sitting, but the SWS test results showed significant correlations in both sitting conditions. To sum up, the sitting LOS and SWS tests are reliable and valid tools for assessing the dynamic sitting balance control of patients with spinal cord injury.

Racial, Income, and Marital Status Disparities in Hospital Readmissions Within a Veterans-Integrated Health Care Network.

Hospital readmission is an important indicator of health care quality and currently used in determining hospital reimbursement rates by Centers for Medicare & Medicaid Services. Given the important policy implications, a better understanding of factors that influence readmission rates is needed. Racial disparities in readmission have been extensively studied, but income and marital status (a postdischarge care support indicator) disparities have received limited attention. By employing three Poisson regression models controlling for different confounders on 8,718 patients in a veterans-integrated health care network, this study assessed racial, income, and martial disparities in relation to total number of readmissions. In contrast to other studies, no racial and income disparities were found, but unmarried patients experienced significantly more readmissions: 16%, after controlling for the confounders. These findings render unique insight into health care policies aimed to improve race and income disparities, while challenging policy makers to reduce readmissions for those who lack family support.

Predicting 30-day all-cause hospital readmissions.

Hospital readmission rate has been broadly accepted as a quality measure and cost driver. However, success in reducing readmissions has been elusive. In the US, almost 20 % of Medicare inpatients are rehospitalized within 30 days, which amounts to a cost of $17 billion. Given the skyrocketing healthcare cost, policymakers, researchers and payers are focusing more than ever on readmission reduction. Both hospital comparison of readmissions as a quality measure and identification of high-risk patients for post-discharge interventions require accurate predictive modeling. However, most predictive models for readmissions perform poorly. In this study, we endeavored to explore the full potentials of predictive models for readmissions and to assess the predictive power of different independent variables. Our model reached the highest predicting ability (c-statistic =0.80) among all published studies that used administrative data. Our analyses reveal that demographics, socioeconomic variables, prior utilization and Diagnosis-related Group (DRG) all have limited predictive power; more sophisticated patient stratification algorithm or risk adjuster is desired for more accurate readmission predictions.

Golfers have better balance control and confidence than healthy controls.

In a well-executed golf swing, golfers must maintain good balance and precise control of posture. Golfing also requires prolonged walking over uneven ground such as a hilly course. Therefore, repeated golf practice may enhance balance control and confidence in the golfers. The objective is to investigate whether older golfers had better balance control and confidence than non-golfing older, healthy adults. This is a cross-sectional study, conducted at a University-based rehabilitation center. Eleven golfers and 12 control subjects (all male; mean age: 66.2 ± 6.8 and 71.3 ± 6.6 years, respectively) were recruited. Two balance control tests were administered: (1) functional reach test which measured subjects' maximum forward distance in standing; (2) sensory organization test (SOT) which examined subjects' abilities to use somatosensory, visual, and vestibular inputs to control body sway during stance. The modified Activities-specific Balance Confidence (ABC) determined subject's balance confidence in daily activities. The golfers were found to achieve significantly longer distance in the functional reach test than controls. They manifested significantly better balance than controls in the visual ratio and vestibular ratio, but not the somatosensory ratio of the SOT. The golfers also reported significantly higher balance confidence score ratios. Furthermore, older adults' modified ABC score ratios showed positive correlations with functional reach, visual and vestibular ratios, but not with somatosensory ratio. Golfing is an activity which may enhance both the physical and psychological aspects of balance control. Significant correlations between these measures reveal the importance of the balance control under reduced or conflicting sensory conditions in older adults' balance confidence in their daily activities. Since cause-and-effect could not be established in the present cross-sectional study, further prospective intervention design is warranted.

Eye-hand coordination and its relationship with sensori-motor impairments in stroke survivors.

OBJECTIVE: To investigate eye-hand coordination in stroke survivors and its relationship with sensori-motor impairments and hand functioning in daily life. DESIGN: Cross-sectional study. SUBJECTS: Fifteen subjects with stroke (mean age 62.5 years (standard deviation (SD) 7.1); time post-stroke 5.2 years (SD 3.0)) recruited by convenience sampling. METHODS: A fast finger-pointing task towards a moving visual target was employed to investigate the differences between the subjects' affected and unaffected hands in terms of reaction time, movement time and accuracy. Their sensori-motor impairments in tactile sensation, handgrip strength, Fugl-Meyer scores and Jebsen Taylor Hand Function Test scores were measured. RESULTS: Significant differences were found between the affected and unaffected hands in terms of movement time and accuracy in finger pointing. Movement time was significantly correlated with tactile sensitivity, handgrip strength and total Fugl-Meyer score, while accuracy correlated with tactile sensitivity and total Fugl-Meyer score. Total scores on the hand function test also correlated significantly with reaction time and movement time. CONCLUSION: The stroke survivors had poorer eye-hand coordination, in terms of slower movement and reduced accuracy when using their affected hand. These performance measures were significantly correlated with several sensori-motor impairments. A significant correlation was also found between eye-hand coordination performance and hand function test scores.