Change in self-reported health: A signal for early intervention in a medicare population.

BACKGROUND: Health plans and risk-bearing provider organizations seek information sources to inform proactive interventions for patients at risk of adverse health events. Interventions should take into account the strong relationship between social context and health. This retrospective cohort study of a Medicare Advantage population examined whether a change in self-reported health-related quality of life (HRQOL) signals a subsequent change in healthcare needs. METHODS: A retrospective longitudinal analysis of administrative claims data was conducted for participants in a Medicare Advantage plan with prescription drug coverage (MAPD) who responded to 2 administrations of the Centers for Disease Control and Prevention 4-item Healthy Days survey within 6-18 months during 2015-2018. Changes in HRQOL, as measured by the Healthy Days instrument, were compared with changes in utilization and costs, which were considered to be a reflection of change in healthcare needs. RESULTS: A total of 48,841 individuals met inclusion criteria. Declining HRQOL was followed by increases in utilization and costs. An adjusted analysis showed that every additional unhealthy day reported one year after baseline was accompanied by an $8 increase in monthly healthcare costs in the subsequent six months for the average patient. CONCLUSIONS: Declining HRQOL signaled subsequent increases in healthcare needs and utilization. IMPLICATIONS: Findings suggest that HRQOL assessments in general, and the Healthy Days instrument in particular, could serve as a leading indicator of the need for interventions designed to mitigate poor health outcomes and rising healthcare costs. LEVEL OF EVIDENCE: III.

Association Between Primary Care Payment Model and Telemedicine Use for Medicare Advantage Enrollees During the COVID-19 Pandemic.

This cohort study examines the association between the primary care payment model and telemedicine use for Medicare Advantage enrollees during the COVID-19 pandemic.

Does a Free Office Visit Affect Primary Care-Seeking Behavior? A Study of New Exchange Health Plan Enrollees in Mississippi.

BACKGROUND: Given the positive association between primary care and overall health, several health plans are offering doctors' visits without patient copay, with the intent to increase primary care use. However, the effectiveness of these offers has not been established in the literature. OBJECTIVE: To evaluate the impact of a free primary care provider (PCP) office visit offered by a health plan on primary care-seeking behaviors. METHODS: This nonrandomized concurrent control study used event/trials logistic regression to compare the differences in primary care utilization between new exchange enrollees in Mississippi who were offered a free nonpreventive PCP visit and concurrent controls from Georgia and Tennessee who were not offered a free visit, between January 1, 2014, and December 31, 2014, which was the first year of the exchange plans. Regression models adjusted for age, sex, plan type, rural-urban designation, and enrollment month. Visits to alternative sites of care were also assessed. RESULTS: The adjusted number of nonpreventive PCP visits did not differ between the states (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.97-1.00). Mississippi residents were significantly more likely to go to the emergency department than the Georgia-Tennessee cohort (OR, 1.33; 95% CI, 1.28-1.39), but they were less likely to visit an urgent care center (OR, 0.10; 95% CI, 0.09-0.11) or a retail clinic (OR, 0.13; 95% CI, 0.11-0.17) than their counterparts. CONCLUSIONS: Despite being eligible for a free nonpreventive visit, enrollees in Mississippi were no more likely than their counterparts in Georgia and Tennessee to visit a PCP. These findings suggest that removing the cost barrier alone may be insufficient to change primary care-seeking behaviors, and other barriers to care should be addressed.

Intraaortic balloon pump timing discrepancies in adult patients.

The objective of this clinical study was to quantify the incidence and magnitude of intraaortic balloon pump (IABP) inflation and deflation landmark discrepancies associated with the IABP catheter arterial pressure waveform. Cardiac surgery patients with an IABP inserted prior to surgery were recruited. Following cardiac exposure, a high-fidelity pressure catheter was inserted into the aortic root for digital recording. The radial artery pressure signal was simultaneously recorded from the patient monitor along with the arterial pressure and electrocardiogram waveforms from the IABP console while operating at 1:1 and 1:2 synchronization. In selected patients, recordings were obtained with the IABP timed to the high-fidelity aortic root waveform. In all 11 patients, inflation and deflation landmark delays were observed when comparing the aortic root waveforms to the IABP arterial pressure waveforms (inflation delay = 74 ± 29 [23-117] ms; deflation delay = 71 ± 37 [24-141] ms, mean ± standard deviation [min-max]). Delays were greater when compared to the radial artery waveform (inflation delay = 175 ± 50 [100-233] ms; deflation delay = 168 ± 52 [100-274] ms). In all cases, the landmark delays were statistically different from zero (P < 0.001). Diastolic augmentation and afterload reduction varied with waveform source. Conflicting indications of afterload reduction occurred in four patients. Timing to the aortic root waveform resulted in greater diastolic pressure augmentation and afterload reduction but mixed changes in stroke volume. Delay and distortion of the arterial waveform was consistently found when measured through the IABP catheter lumen. These delays can alter IABP efficacy and may be eliminated by using high-fidelity sensing of aortic pressure.

Clinical trial of chlorinated polyethylene for facial prosthetics.

PURPOSE: Extraoral maxillofacial prostheses have been fabricated with silicone elastomer for 50 years with few improvements. The objective of this controlled, randomized, prospective, double-blind, single-crossover, multicenter, phase III clinical trial was to determine the noninferiority of chlorinated polyethylene elastomer (CPE) to silicone elastomer for fabricating prostheses. MATERIALS AND METHODS: Forty-two patients were randomly assigned to wear a custom-made prosthesis fabricated from both materials for 4 months and asked to rate their satisfaction (0 = not satisfied, 10 = completely satisfied). Many other measures of prosthesis performance were investigated (see online appendices). RESULTS: Of the 28 patients who completed the study, 68% had used silicone prostheses previously. Overall, patients rated the silicone prosthesis higher than CPE (difference: 2.2, 95% confidence interval [CI]: 0.9 to 3.6, P = .017). Previous users had a stronger preference for silicone (difference: 3.3, 95% CI: 1.7 to 4.9, P = .001), while the 9 new users rated the two materials similarly (difference: 0.0, 95% CI: -2.1 to 2.1, P = 1.00). CONCLUSIONS: The noninferiority of CPE could not be established because of the early termination of the trial. Previous users of silicone prostheses preferred those made of silicone. However, new users expressed no preference between prostheses fabricated with the low-cost CPE or silicone. The authors have developed original clinical trial methodology for assessing extraoral maxillofacial prostheses.

Oral microbial and respiratory status of persons with mental retardation/intellectual and developmental disability: an observational cohort study.

OBJECTIVE: The objective of this study was to determine the prevalence of select microorganisms in oral biofilms and to investigate relationships between oral and respiratory status in persons with mental retardation/intellectual and developmental disabilities (IDD). STUDY DESIGN: We conducted a 6-month-long observational cohort study with 63 persons with IDD. Oral examinations, oral sampling, and medical record reviews were performed at baseline and then monthly. Polymerase chain reaction (PCR) was used to analyze all baseline oral samples for the presence of Streptococcus pneumoniae, Methicillin-resistant Staphylococcus aureus (MRSA), Prevotella melaninogenica, and Candida albicans. PCR analyses were also performed on participants' samples collected in the month before being diagnosed with a respiratory infection. RESULTS: All subjects had P. melaninogenica detected by PCR in their oral samples. Fifty-five percent (35 of 63) of participants had S. pneumoniae, MRSA, and C. albicans in their oral samples at baseline. No dental decay was detected clinically, oral hygiene was fair, and dysphagia was common. During the 6 months of the study, there were 22 respiratory infections (35% of participants)-12 pneumonias, 7 sinusitis, 1 bronchitis, and 1 upper respiratory tract infection. Participants with microorganisms in their baseline samples were significantly more likely to develop any respiratory infection and those who had poor oral status were significantly more likely to develop pneumonia. Almost 60% of participants who developed respiratory infections had the same microorganism detected in the sample collected in the month before infection as had been detected in their baseline sample. CONCLUSION: Potentially pathogenic microorganisms in the oral cavity and poor oral status significantly increased the risk of developing respiratory infections, including pneumonia, in persons with IDD. The results suggest that colonization with these microorganisms may persist despite routine tooth brushing. Meticulous comprehensive oral hygiene of the oral cavity may be needed to reduce oropharyngeal microbial load.

Acute public health consequences associated with hazardous substances released during transit, 1993-2000.

Massive quantities of hazardous substances are transported each day throughout the United States. While most arrive safely at their destination, uncontrolled releases of substances in transit do occur and have the potential of causing acute public health consequences for those individuals at or near the release. Data from 16 state health departments participating in the Agency for Toxic Substances and Disease Registry's (ATSDR) Hazardous Substances Emergency Events Surveillance (HSEES) system were analyzed to determine the public health consequences that occurred from actual releases in transit. Of the 9392 transportation events analyzed, 9.1% resulted in 2008 victims, including 115 deaths. The population groups injured most often were employees and the general public. The most common injury sustained was respiratory irritation. Evacuations were ordered in 5.5% of events effecting at least 63,686 people. Human error and equipment failure were the most common factors leading to events. These findings underscore the importance of job safety training, community planning, and effective emergency response to prevent adverse public health consequences from occurring or lessen their effect on the public.

Hazardous ammonia releases: public health consequences and risk factors for evacuation and injury, United States, 1993-1998.

Unplanned releases of ammonia lead more often to evacuation and injury than releases of other chemicals, but few studies have systematically investigated ammonia releases. We analyzed Hazardous Substances Emergency Events Surveillance system data for 1993-1998. Evacuation of a total of at least 40,680 persons resulted from 537 ammonia releases, and 248 ammonia releases led to injury of 1434 persons. Equipment failure and operator error were cited as factors contributing to ammonia releases 90% of the time. Eighty-seven percent of releases occurred at fixed facilities. Risk factors for evacuation and injury differed between the food-manufacturing industry and other industries. Indoor release was a consistent risk factor, whereas quantity of ammonia released was not always a risk factor. Preventive maintenance and worker training may be effective tools to reduce the burdens of hazardous ammonia releases.

Releases of hazardous substances in schools: data from the Hazardous Substances Emergency Events Surveillance system, 1993-1998.

This report describes the adverse public-health effects resulting from releases of hazardous substances in schools. Data were analyzed from emergency events reported to the Hazardous Substances Emergency Events Surveillance (HSEES) system by 14 participating states during 1993-1998. Compared with all other types of events, a higher proportion of school-related events resulted in victims (relative risk [RR] = 3.94, 95 percent confidence interval [CI] = 3.37-4.60) and in evacuation (RR = 5.76, 95 percent CI = 5.16-6.43). The most common cause of these events was operator error, followed in frequency by equipment failure, improper mixing, and deliberate releases. The majority of victims were exposed to spills emitting noxious gases, and their resulting symptoms were primarily associated with the respiratory tract.

Hazardous substances emergency events in the agriculture industry and related services in four mid-western states.

Analysis of Hazardous Substances Emergency Events Surveillance data reported from 14 participating states between 1993 and 1998 found that acute releases are seasonal. This seasonality was more prevalent in four Midwestern states during April-June and coincided with their planting season, suggesting an association of these releases with the agricultural industry. A more detailed analysis of events related to this industry in these states found that ammonia was the chemical most frequently released, and ammonia related events resulted in a significantly higher number of evacuations than all other events (OR = 10.7, [5.25-22.28]). A logistic regression model to identify risk factors for an event with victims found an increased risk for: (1) events with ammonia during April-June (adjusted OR = 3.57, [2.09-6.09]); (2) events in fixed-facilities during April-June (aOR = 3.74, [2.01-6.95]); and (3) events with multiple substances (aOR = 2.33, [1.05-5.17]). The most common causes for the events were equipment failure and operator error. Resulting injuries were mainly respiratory, ocular and traumatic, and included six deaths. Employing more stringent safety measures and educating employees and the public about the health hazards involved with agricultural chemicals may reduce injuries and help contain costs associated with the releases.