Peripheral Neuropathy in Older People Is Associated with Reduced Life Expectancy.

INTRODUCTION: We analyzed data from a prospective cohort of older primary care patients to determine whether the presence of peripheral neuropathy (PN) was associated with premature mortality and to investigate potential mechanisms. METHODS: PN was defined as the presence of 1 or more bilateral lower extremity sensory deficits detectable by physical examination. Mortality was determined from key contacts and Internet sources. Statistical models were used to evaluate the association between PN and mortality. RESULTS: Bilateral lower extremity neurological deficits were common, reaching 54% in those 85 and older. PN was strongly associated with earlier mortality. Mean survival time for those with PN was 10.8 years, compared with 13.9 years for subjects without PN. PN was also indirectly associated through impaired balance. CONCLUSIONS: In this relatively healthy cohort of older primary care patients, PN detectable by physical examination was extremely common and strongly associated with earlier mortality. One possible mechanism involves loss of balance, though our data were insufficient to determine whether poor balance led to injurious falls or to less-specific declines in health. These findings may warrant further studies to determine the causes of age-associated PN and potential impact of early detection and balance improvement and other fall prevention strategies.

Prospective Bundled Payments in a Changing Environment: The Experience of a Self-Funded, State-Sponsored Plan.

BACKGROUND: Healthcare reimbursement, which has traditionally been based on the quantity of services delivered, is currently moving toward value-based reimbursement-a system that addresses the quantity, quality, and cost of services. One such arrangement has been the evolution of bundled payments for a specific procedure or for an episode of care, paid prospectively or through post-hoc reconciliation. OBJECTIVE: To evaluate the impact of instituting bundled payments that incorporate facility charges, physician fees, and all ancillary charges by the State of Oklahoma HealthChoice public employee insurance plan. METHOD: From January 1 through December 31, 2016, HealthChoice, a large, government-sponsored Oklahoma health plan, implemented a voluntary, prospective, bundled payment system with network facilities, called Select. The Select program allows members at the time of certification of the services to opt to use participating facilities for specified services at a bundled rate, with deductible and coinsurance covered by the health plan. That is, the program allows any plan member to choose either a participating Select facility with no out-of-pocket costs or standard benefits at a participating network facility. RESULTS: During 2016, more than 7900 procedures were performed for 5907 patients who chose the Select arrangement (also designated as the intervention group). The most common outpatient Select procedures were for cardiology, colonoscopy, and magnetic resonance imaging scans. The most common inpatient procedures for Select-covered patients were in 6 diagnosis-related groups covering spinal fusions, joint replacement surgeries, and percutaneous coronary artery stenting. The allowable costs were similar for bundled procedures at ambulatory surgery centers and at outpatient hospital facilities; the allowable costs for patients not in the Select program (mean, $813) were lower at ambulatory surgery centers than at outpatient hospital departments (mean, $3086) because of differences in case mix. Patients in the Select system who had outpatient procedures had significantly fewer subsequent claims than those who were not in Select for hospitalization (1.7% vs 2.5%, respectively) and emergency department visits (4.4% vs 11.5%, respectively) in the 30 days postprocedure. Quality measures (eg, wound infection and reoperation) were similar for patients who were and were not in the Select group and had procedures. Surgical complication (ie, return to surgery) rates were higher for the Select group. CONCLUSION: The Select program demonstrated promising results during its first year of operation, suggesting that prospective bundled payment arrangements can be implemented successfully. Further research on reimbursement mechanisms, that is, how to pay physicians and facilities, and quality of outcomes is needed, especially with respect to which procedures are most suitable for this payment arrangement.

Do older people benefit from having a confidant? An Oklahoma Physicians Resource/Research Network (OKPRN) study.

OBJECTIVE: The objective was to determine whether having a confidant was associated with improved health-related quality of life (HRQoL) or survival in older, community-dwelling individuals. METHODS: This prospective cohort study included 23 family physician members of the Oklahoma Physicians Research/Resource Network in 9 practices and 852 community-dwelling adults 65 or older participating in the Oklahoma Longitudinal Assessment of Health Outcomes of Mature Adults Studies. Longitudinal models analyzed changes in self-administered Quality of Well-Being (QWB-SA) scores over an average (S.D.) of 2.51 (1.28) years. Cox proportional hazards models assessed variables possibly associated with mortality over an average survival time (+/-S.D.) of 9.22 (3.24) years. We controlled for chronic illnesses, baseline age, gender, marital status, income, race, BMI, education and specified Medical Outcomes Study Short Form-36 (SF-36) domain scores. RESULTS: Initially, 740 participants (87%) had a confidant. Being married was strongly associated with having a confidant (91.9% vs. 77.8%, p<0.0001). A confidant was associated with better SF-36 domain scores (p<0.0001), less morbidity, higher baseline QWB-SA scores and favorable changes in QWB-SA (p<0.0001). Unadjusted risk of death (37.8% vs 46.4%, p=0.08) was not lower. Kaplan-Meier confidant status survival curves were not statistically different (p=0.16). CONCLUSIONS: Older people with a confidant demonstrated enhanced HRQoL maintenance over the short term, but not greater survival.

Does patient assessment of the quality of the primary care they receive predict subsequent outcomes?: An Oklahoma Physicians Resource/Research Network (OKPRN) study.

BACKGROUND: We analyzed data from a cohort of 782 older patients assembled in 1999 to 2000 to determine whether their baseline assessments of the quality of their primary care measured using the Components of Primary Care Index (CPCI) were associated with subsequent changes in health-related quality of life and/or survival. METHODS: Longitudinal growth curve models were used to analyze changes in Quality of Well-Being scores over an average of 2.07 years. Cox proportional hazards models were used to identify variables associated with mortality over an average of 8.91 years (6,966 person-years). To reduce confounding by severity of illness, subjects were stratified into 3 groups based on disability and use rates. Within subgroups, we controlled for number of chronic illnesses and scores on the General Health subscale of the Medical Outcomes Study Short Form-36. We also controlled for baseline age, gender, marital status, income, body mass index, educational attainment, duration of the relationship with current primary care physician, and number of visits to the primary care physician in the year before enrollment. Analyses took into account clustering of patients within primary care physician. RESULTS: Neither total CPCI nor any CPCI subscale score was associated with Quality of Well-Being Self-administered Scale change over time or survival. CONCLUSIONS: Assuming that effective primary care results in better health-related quality of life and longer survival and that the CPCI captures important primary care attributes, older patients' level of satisfaction with the quality of their primary care may not be a good surrogate measure of effectiveness.

Does the African-American-white mortality gap persist after playing professional basketball? A 59-year historical cohort study.

PURPOSE: The African-American-white mortality gap for males in the United States is 6 years in favor of whites. Participation in professional sport may moderate this ethnic disparity. The historical cohort of professional basketball players, with nearly equal numbers of African-American and white players, can provide a natural experiment that may control for the classic confounders of income, education, socioeconomic status (SES), and physical factors related to mortality. The objectives of this study are to assess mortality and calculate survival for the overall study population and within ethnicity. METHODS: Data were combined from several publicly available sources. The cohort was analyzed to compare longevity among all players, and for players stratified by ethnicity, with the general U.S. population. RESULTS: The final dataset included 3366 individuals, of whom 56.0% were African American. Results suggest white players live 18 months longer than their African-American colleagues. African-American players gained 9 years on their respective referent and live longer than white men in the general public. After controlling for covariates, we found that African-American players have a 75% increased risk of death compared with white players, a statistically significant gap (p < .0001, 95% confidence interval 1.41-2.44). CONCLUSIONS: The African-American-white mortality gap for males is largely ameliorated (1.5 years vs. 6.1 years) in professional basketball but still persists.

Assessment of the clinical outcome of a symptom-based outpatient hyperglycemia protocol.

INTRODUCTION: Acute hyperglycemia (blood glucose [BG] ≥400 mg/dL) is common in primary care. An outpatient protocol was developed to streamline the treatment of acute hyperglycemia. The objective was to determine if an outpatient hyperglycemia protocol could achieve a BG level of <300 mg/dL within 4 hours. METHODS: Adult diabetic patients with acute symptomatic hyperglycemia (>400 mg/dL) without acute illness were recruited. Enrolled patients were managed with a protocol that included administration of 0.15 units/kg rapid-acting insulin given subcutaneously, hydration, hourly fingerstick blood sugars (FSBS), laboratory assessment, tailored diabetes education, and follow-up within 72 hours. Independent variables for data analysis included age, baseline FSBS, sodium, potassium, chloride, blood urea nitrogen, serum creatinine, CO(2), venous glucose, and etiology (medications, diet, personal stress). RESULTS: For the 27 patients enrolled, the average initial FSBS level (n=23) was 484 mg/dL, the average final FSBS level (n=27) was 274 mg/dL, and average time to achieve BG levels of <300 mg/dL was 2.35 hours. The protocol was successful in 20 patients (74%). The causes for seven protocol failures were nonclinical in nature. The patients' weight and total time to goal were significantly associated with odds of protocol success. Personal stress significantly correlated with protocol failure. The protocol success group had a higher sodium level than the failure group (P=0.01). Weight and baseline BG showed decreased odds of protocol success (P=0.05 and P=0.04, respectively). CONCLUSIONS: Results of this pilot study suggest acute hyperglycemia without other acute illness can be managed on an outpatient basis. Outpatient interventions to addres s acute hyperglycemia need further investigation. Managing acute hyperglycemia in the outpatient setting could potentially decrease hospital admissions for hyperglycemic hyperosmolar syndrome and mild diabetic ketoacidosis.

Does patient assessment of the quality of the primary care they receive predict subsequent outcomes? An Oklahoma Physicians Resource/Research Network (OKPRN) study.

INTRODUCTION: We analyzed data from a cohort of 782 older patients assembled in 1999 to 2000 to determine whether baseline patient assessments of the quality of the primary care services they had received, measured using the Components of Primary Care Index (CPCI), were associated with subsequent changes in health-related quality of life (HRQoL) and/or survival. METHODS: Longitudinal growth curve models were used to analyze changes in Quality of Well-Being (QWB-SA) scores over an average (S.D.) of 2.07 (1.07) years. Cox proportional hazards models were used to identify variables associated with mortality over an average of 8.26 years (6460 person-years). To reduce confounding by severity of illness, subjects were stratified into disabled, nondisabled high utilizers of primary care, and nondisabled low utilizers. Within subgroups, we controlled for number of chronic illnesses and scores on the General Health subscale of the Medical Outcomes Study Short Form-36 (SF-36). We also controlled for baseline age, sex, marital status, income, body mass index, educational attainment, duration of the relationship with current primary care physician (PCP), and number of visits to the PCP in the year before enrollment. Analyses took into account clustering of patients within PCP. RESULTS: Neither total CPCI nor any CPCI subscale score was associated with QWB-SA change over time. Higher ratings of Coordination of Care were associated with reduced survival in the disabled and nondisabled high utilizer subgroups (P = .007). CONCLUSIONS: Assuming that effective primary care results in better HRQoL and longer survival and that the CPCI captures important primary care attributes, older patients' level of satisfaction with the quality of their primary care may not be a good surrogate measure of effectiveness.

Left-handedness in professional basketball: prevalence, performance, and survival.

Performance and handedness data were examined for 3,647 professional basketball players who participated in at least five games during the period between 1946 and 2009. Left-handed players comprised 5.1% of all professional basketball players compared to the 11% prevalence in the general population. Left-handers had better performance averages, in terms of the number of points, rebounds, and blocks over their careers, as well as other measures, and had significantly longer careers than right-handed players. Handedness was not significantly related to mean or median life expectancy.

The prognostic implications of night sweats in two cohorts of older patients.

BACKGROUND: When asked, a significant number of patients report having experienced night sweats. Those who do are more likely to report decreased physical health, mental health, and quality of life. In most cases the cause of night sweats is unknown. We therefore do not know how much to worry about patients with this symptom. The present study examined associations between night sweats and mortality. METHODS: We used logistic regression and proportional hazards analyses to investigate potential predictors of mortality, including night sweats reported at baseline, among 2 different cohorts of people older than 65 years of age (n = 682 and n = 852) who were followed for an average of 7.3 and 7.5 years, respectively. RESULTS: Patients who reported night sweats were not more likely to die or to die sooner than those who did not report night sweats after controlling for age, sex, body mass index, education, and income. This held true as well for patients who reported more severe night sweats among the cohort in which the severity of night sweats was quantified. CONCLUSIONS: Patients who report night sweats on a primary care health history questionnaire do not seem, on average, to be at increased risk for mortality.

The health consequences of peripheral neurological deficits in an elderly cohort: an Oklahoma Physicians Resource/Research Network Study.

OBJECTIVES: To determine whether the belief that loss of deep tendon reflexes and vibratory sensation in the ankles in older patients is of no great consequence is valid. DESIGN: Four-year longitudinal cohort study. SETTING: Primary care practice-based research network. PARTICIPANTS: Six hundred four noninstitutionalized individuals aged 65 and older with no self-reported medical conditions known to cause peripheral neuropathy (PN), recruited from the practices of 23 primary care physicians in central Oklahoma. MEASUREMENTS: Annual standardized peripheral neurological examination performed by two research nurses plus a questionnaire that included self-reported measures of health, health-related quality of life (HRQoL Quality of Well-Being--Self Administered (QWB-SA) and Health Utilities Index-3 (HUI-3), physical functioning--(Medical Outcomes Study 36-item Short Form Survey (SF-36)), falls, and use of healthcare services. Deaths were determined from participant contacts, primary care physicians, and the Social Security death index. RESULTS: One hundred sixty of 604 participants had symmetrical peripheral neurological deficits (SPNDs). After controlling for age, sex, race, education, income, body mass index, HRQoL, physical functioning, self-rated health, cognitive test score, and a variety of medical conditions, SPNDs were associated with earlier hospitalization (P=.03); greater mortality (P<.001); and declines in HRQoL (QWB-SA, P<.001), self-rated health (P=.02) physical functioning (SF-36, P=.005), and bodily pain (SF-36, P=.001). CONCLUSION: SPNDs of undetermined cause, found in older patients on physical examination, appear to be associated with greater morbidity and mortality.

Childhood obesity onset in an urban American Indian health clinic.

OBJECTIVES: To determine the relationship between gender and the age of onset of overweight and obesity for American Indian children between the ages of 2 and 12 years old. METHODS: Using a retrospective study design, medical charts were reviewed, recording the body mass index (BMI) at different ages of 100 American Indian children (male and female) who were followed regularly (defined as having at least two visits within a 3 year period) at an urban Indian Clinic in Oklahoma City and seen at least once between the years 1995-2000. RESULTS: Males were associated with an earlier mean onset of overweight and obesity compared to females. Blood quantum and tribal affiliation were not statistically significant predictors. CONCLUSIONS: Health clinics treating American Indian children should begin targeting youth under age 9 for obesity prevention and physical fitness activities.

Utilization and value of personal digital assistants on an epidemiology final examination.

BACKGROUND: The utility of personal digital assistants (PDAs) in basic science medical education is uncertain. DESCRIPTION: Student outcomes on an epidemiology course final examination for academic years 2003 and 2004 were examined. Students were given permission to use PDAs on the final examination, and self-selected whether these instruments were used. Performance on the examination based on use of a PDA and whether students thought it was useful for the examination was compared. EVALUATION: A total of 389 students took the final examination, with an 88% response rate to the survey questions. No statistically significant differences were found on final examination scores. No trends toward significance were found on analyses of the total examination, specific topical domains, or on specific questions where a PDA might be expected to be especially useful. CONCLUSIONS: From this study, it can be concluded that use of PDAs and whether students thought they might be helpful had no measurable effect on performance on an epidemiology final examination. Further delineation of the possible use of PDAs in a basic science course and on the final examination is indicated.

Lewis and Clark treat a case of paralysis: speculation on the etiology of the problem.

In their monumental journey across North America and back, the explorers Lewis and Clark encountered and treated a Native American Chief with flaccid paralysis of about five years duration. The etiology of the paralysis is unclear from the historical sources. Intracranial, spinal cord, neuropathic, neuromuscular and muscular diagnoses are possible. The diagnosis that appears best to fit the case, however, is conversion disorder. In spite of limited diagnostic and treatment resources, the unfortunate man was apparently treated successfully.