Neurologist ambulatory care, health care utilization, and costs in a large commercial dataset.

OBJECTIVE: To determine the value of neurologist ambulatory care in chronic neurologic diseases in a large administrative claims dataset detailing costs, adverse events, and health care utilization. METHODS: The Optum proprietary claims dataset (2010-2012) was examined to describe direct health care costs, as well as specific outcome metrics for a large population of persons with chronic neurologic illnesses. In phase I of the study, we detail neurologist involvement and differences in annualized allowed third--party payments within episode treatment groups (ETGs) for 10 neurologic illnesses. For phase II, we examined health care utilization for ETGs of epilepsy, Parkinson disease (PD), stroke, and multiple sclerosis (MS) with and without neurologist involvement. Reported outcomes were unadjusted differences and odds ratios between treatment groups. RESULTS: For phase I, a total of 1,913,605 ETGs for 10 neurologic conditions were identified, 30.1% meeting criteria for neurologist involvement. All conditions had higher direct costs when neurologists were involved with care, ranging from a 25% increase for Alzheimer dementia to 100% more for MS care. In phase II, fractures, infections, emergent care, and inpatient admission were less with neurologist ambulatory care, while neurologist care was associated with greater utilization of disease-specific treatments (immunotherapies in MS anticoagulation in atrial fibrillation-associated stroke, deep brain stimulation and dopaminergic therapies in PD). CONCLUSION: Neurologist involvement with care is associated with greater unadjusted allowed payments, but fewer adverse events and less acute care utilization.

Community partnership to promote home fire safety in children with special needs.

BACKGROUND: Parents of children with special needs are vigilant as their child may have difficulty independently escaping a burning home. The purpose of this study was to evaluate if providing home fire safety information via a digital video disc (DVD) increases families' knowledge, behavior and ability regarding home fire safety. METHODS: A school based classroom intervention (using a home fire safety DVD) was provided to parents (n=40) of children with and without special needs to improve home fire safety knowledge, behavior and ability. In addition, parents seen at the Kentucky Commission for Children with Special Health Care Needs clinics (n=47) received the same intervention in cohorts of 1-2 children. For both groups, knowledge, and behavior were measured before and after intervention. Repeated measures ANOVA were used to test for differences between groups and over time. Significance was set at p<0.05. RESULTS: No difference in scores between pre- and post-test scores existed between groups (with special needs vs. without special needs, or classroom vs. individualized instruction). However, some differences were noted for some individual survey questions during post-hoc comparisons. Having a smoke alarm in the home (90% vs. 95%, p=0.029) and having a smoke alarm outside of where everyone sleeps (75% vs. 95%, p=0.005) increased over time and was retained. Having a fire escape plan increased at post intervention (58% vs. 79%, p=0.033), but returned to pre levels at follow-up (58%). Perceived knowledge (7.7 vs. 9.3, p<0.001) and ability (8.7 vs. 9.1, p=0.069) increased over time. IMPLICATION FOR PRACTICE: Parents of children with special needs had a significant increase in knowledge and behavior over those parents of children without special needs. They also perceived having a high fire safety ability. Many of the post-test questions/behaviors (e.g., capable of exiting home during a fire, etc.) were reported at 100%. The intervention was well received, but may not necessarily be needed. Focus for home fire safety may need to look at younger children and smaller families. Parents of special needs children may have had frequent interaction with health care professionals.

Impact of children with special needs on differences in fire-safety education priorities, preferred method of education, and parent actions.

Children with special needs are at a higher risk for the devastating effects caused by a burn injury (eg, pain, appearance, and mobility changes); however, little is known about their burn prevention (BP) needs. The purpose of this project was to determine the BP needs, preferred method of parent education, and the actions of parents and professionals caring for children with and without disabilities. A novel instrument measuring fire-safety education needs, priorities, preferred method of education, and BP actions was administered to a total of 150 parents and professionals caring for children with physical limitations (n = 41), vision impairment (n = 80), and controls (n = 29). Differences in each outcome variable among the groups were tested using χ tests for categorical variables. There was no difference in ranking between parents and professionals or among groups (disability, vision impaired, and control) in preferred BP safety areas (P > .05); however, there was a difference in their preferred method for education (P < .001) among the groups (disability, vision impaired, and control). In addition, there were differences in preferences of methods of education for classroom, DVD, and home inspection between parents and professionals (P < .05). Our results suggest that type of education method preferred may need to be tailored differently by group. These findings are preliminary and further research in this area is indicated. Information from this project will be used to develop and test a community-based intervention within a large metropolitan area in north central Kentucky.

Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials.

OBJECTIVES: This study sought to assess the effect of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers on all-cause mortality in patients with left ventricular (LV) systolic dysfunction according to gender, race, and the presence of diabetes. BACKGROUND: Major randomized clinical trials have established that ACE inhibitors and beta-blockers have life-saving benefits in patients with LV systolic dysfunction. Most patients enrolled in these trials were Caucasian men. Whether an equal effect is achieved in women, non-Caucasians, and patients with major comorbidities has not been established. METHODS: The authors performed a meta-analysis of published and individual patient data from the 12 largest randomized clinical trials of ACE inhibitors and beta-blockers to produce random effects estimates of mortality for subgroups. RESULTS: Data support beneficial reductions in all-cause mortality for the use of beta-blockers in men and women, the use of ACE inhibitors and some beta-blockers in black and white patients, and the use of ACE inhibitors and beta-blockers in patients with or without diabetes. Women with symptomatic LV systolic dysfunction probably benefit from ACE inhibitors, but women with asymptomatic LV systolic dysfunction may not have reduced mortality when treated with ACE inhibitors (pooled relative risk = 0.96; 95% confidence interval: 0.75 to 1.22). The pooled estimate of three beta-blocker studies supports a beneficial effect in black patients with heart failure, but one study assessing bucindolol reported a nonsignificant increase in mortality. CONCLUSIONS: Angiotensin-converting enzyme inhibitors and beta-blockers provide life-saving benefits in most of the subpopulations assessed. Women with asymptomatic LV systolic dysfunction may not achieve a mortality benefit when treated with ACE inhibitors.