Disparities in Enrollment in Medicare Advantage Plans With Dental Benefits.

This cross-sectional study evaluates the association of Medicare beneficiaries' sociodemographic characteristics with having Medicare Advantage plans that cover oral health services.

Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines.

INTRODUCTION: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. METHODS: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. RESULTS: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4(P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004). CONCLUSION: By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.

Accidental paediatric ingestion of amlodipine after pharmacy dispensing error.

Incorrect dispensing of medications by community pharmacies can lead to accidental poisonings. This may not be considered by emergency medicine physicians in patients describing vague symptoms. We present a case of a paediatric ingestion of amlodipine, resulting from a community pharmacy dispensing error, that was recognized by the child's mother, and consider the liability implications.

Evaluation of Adherence to Emergency Department Point-of-Care Ultrasound Documentation and Billing Following Intervention.

Background: Over the past few years, both the scope and utility of point-of-care ultrasound (POCUS) have tremendously expanded in the clinical setting. Despite this growth, few studies have evaluated the compliance, documentation, and billing of POCUS in the emergency department (ED). The objective of this study was to evaluate the compliance of billing and documentation of POCUS and determine if a single, individualized e-mail feedback can help improve billing and documentation. Methods: We performed a 6-week prospective review of ED POCUSs performed. Following this review, all emergency physicians were sent an individualized e-mail regarding their ultrasound performance including the total number of ultrasounds, ultrasounds per shift, and breakdown of specific ultrasound types. Following this intervention, we collected data from an additional 6 weeks regarding ultrasound billing performance. Results: A total of 1532 POCUS scans were recorded for data collection. Eight hundred and five scans were enrolled in the preintervention group and 727 scans in the postintervention group. Twelve different types of POCUS scans were recorded. The preintervention group had documented 484/805 scans resulting in a 60.1% (confidence interval [CI] 56.7%-63.5%) documentation ratio. The postintervention group had documented 521/727 resulting in a 71.7% (CI 68.2%-74.9%) documentation ratio. Conclusion: The implementation of timely quality assurance with continuous billing reminders is essential for the maintenance and fiscal sustainability of an emergency medicine ultrasound program. Future studies should further elucidate and quantify the financial impact of modifiable factors within EDs' ultrasound documentation and billing practices.

Dental care use and other population characteristics of older Americans with self-reported chronic conditions in the health and retirement study.

OBJECTIVES: To analyze relative differences in oral health care utilization, oral health, and other population characteristics of older Americans with respect to self-reported chronic conditions in the health and retirement study. METHODS: Differences in estimated percentages of those with specific chronic conditions by selected attributes were tested for statistical significance with standardized normal Z tests and logistic regressions. All estimates were based on weighted data from 1992 to 2016 Early Release RAND HRS Longitudinal file. SE estimates for the percentages accounted for the complex sample design of the survey. RESULTS: We establish that the strength of the associations between regular use of dental care and the absence of a chronic condition is similar in magnitude to having a college education, living in a high-income family, never smoking, not having certain functional limitations, and being under 65 years of age. DISCUSSION: These cross-sectional findings establish the relative strength of relationships between dental care use, oral health status, and other population characteristics and eight diagnosed conditions. Further work beyond the scope of this paper is needed to confirm these results as either attributes of those with the disease or causal risk factors for the onset of the condition.

A Case Report on Distinguishing Emphysematous Pyelitis and Pyelonephritis on Point-of-care Ultrasound.

INTRODUCTION: Point-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN). CASE REPORT: A 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with "dirty shadowing" within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation. CONCLUSION: Distinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.

A Case Report on Detecting Porcelain Gallbladder form Wall-Echo-Shadow Sign on Point-of-Care Ultrasound.

Point-of-Care Ultrasound (POCUS) is a rapidly growing means of accelerated diagnosis for various conditions. This case report demonstrates POCUS use to differentiate porcelain gallbladder (PGB) from wall-echo-shadow (WES) sign. A 75-year-old female presented for evaluation of elevated liver function tests (LFTs). Upon arrival, she had no acute complaints with unremarkable vital signs, aside from elevated blood pressure of 155/79 mmHg. Review of LFTs demonstrated elevation of total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP). Physical examination and review of systems were unremarkable. POCUS revealed common bile duct dilatation with cholelithiasis and sludge. While these findings may be confused with a WES sign, POCUS also revealed a hyperechoic gallbladder wall (GBW) with shadowing and irregular clumps of echo. The hyperechoic GBW with irregular shadowing heightened the suspicion for PGB. Computed tomography scan confirmed the presence of PGB. The patient had a stent placed near the common hepatic duct stricture and was advised to return for cholecystectomy. She was readmitted three months later due to bacteremia, likely caused by gallbladder obstruction in the setting of gallbladder cancer. Point of care ultrasound can be used to identify PGB. Because PGB has been associated with gallbladder carcinoma, prompt diagnosis is vital in early and aggressive treatment. In this case report, we demonstrate a reliable method in properly diagnosing PGB through POCUS. Topics: Point-of-care ultrasound, ultrasound, porcelain gallbladder, WES sign, wall-echo-shadow sign.

Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock.

INTRODUCTION: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis. METHODS: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values. RESULTS: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm-20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS. CONCLUSION: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

Does covering routine dental care for the Medicare population produce cost savings in Medicare? A preliminary 2-year analysis.

OBJECTIVES: We estimated the association between the use of preventive dental care and medical use and expense for older persons over a 2-year period to determine if a Medicare dental benefit for routine care could result in potential cost savings in Medicare. METHODS: We relied on 2008-2014 Medical Expenditure Panel Survey data to estimate separate logistic and lognormal ordinary least squares regressions to analyze the influence of year 1 preventive dental care on either year 1 or year 2 use and expenses for total health care, office-based care, outpatient care, inpatient stays, emergency department visits, and prescription drugs. RESULTS: Our findings provide evidence over a 2-year period that a Medicare dental benefit for routine care could produce an increase in office-based visits and expense. We also found that older persons currently using routine dental care have healthier lifestyles and greater access to care and use of preventive medical care than current nonusers. CONCLUSION: Our results affirm the need for a longer-term study to provide any conclusive evidence as to the ultimate impact of a Medicare dental benefit on other health care use and expenses.

The demand for preventive and restorative dental services among older adults.

Many older Americans have poor access to dental care, resulting in a high prevalence of oral health problems. Because traditional Medicare does not include dental care benefits, only older Americans who are employed, have post-retirement dental benefits or spousal coverage, or enroll in certain Medicare Advantage plans are able to obtain dental care coverage. We seek to determine the extent to which poor access to dental insurance and high out-of-pocket costs affect dental service use by the elderly. Using the 2007-2015 Medical Expenditure Panel Survey and supplemental data on dental care prices, we estimate a demand system for preventive dental services and basic and major restorative services. Selection into dental and medical insurance is addressed using a correlated random effects panel data specification. Consistent with prior studies of the nonelderly population, dental service use was not sensitive to out-of-pocket prices. However, private dental insurance increased preventive service use by 25%, and dental coverage through Medicaid increased basic and major service use by 23% and 36%, respectively. The use of services was more responsive to dental insurance for women than men. These estimates suggest that a Medicare dental benefit could significantly increase dental service use by older Americans.

Diversity in the use of specialized dental services by older adults in the United States.

OBJECTIVES: We estimated the use of any dental services and the use of specific types of dental services conditional on any dental use for adults 50 and over in the United States to analyze: a) disparities in the use of specialized dental services and b) whether older adults receiving routine dental care use fewer expensive specialized dental services. METHODS: We relied on data tabulations and estimated logistic regressions from the 2014 Medical Expenditure Panel Study to analyze the influence of various covariates such as age, race/ethnicity, education, dental insurance, income, and health status on the likelihood of a) using any dental care and b) using routine dental care (prophylaxis, examinations, bitewings, etc.) and specialized services for restorative, periodontal, oral surgery, or prosthetic dental care conditional on using any dental care. RESULTS: We found a) lower use of specialized services among higher income, more educated, healthier, nonminority older adults and b) association between lower use of routine dental care and higher use of expensive restorative, oral surgery, and prosthetic dental services. CONCLUSIONS: Our study identifies diversity in the use of specialized dental services among an older adult population and suggests that more widespread use of routine dental services could potentially improve oral health and limit the need for expensive specialized dental care for this population.

Disparity in dental out-of-pocket payments among older adult populations: a comparative analysis across selected European countries and the USA.

BACKGROUND: The current study addresses the extent to which diversity exists in dental out-of-pocket (OOP) payments across population subgroups within and between the USA and selected European countries. This represents the final paper in a series in which the previous two papers addressed diversity in dental coverage and dental utilisation, respectively, using similar data and methods. METHOD: We used data from the 2006/2007 Health and Retirement Study (HRS) and from the 2004-2006 Survey of Health, Ageing and Retirement in Europe (SHARE) for respondents ≥51 years of age. We estimated the impacts of dental-care coverage and of demographic, socio-economic and health status on the likelihood and amount of dental OOP payments. RESULTS: In the USA, older persons with the least education, lowest income and worst health are most likely to pay nothing OOP for their dental care and, for persons with an OOP payment, the amount of this payment increases with income and education and is higher for persons who are uninsured and in fair or poor health. However, these results were not consistently found in the 10 European countries we studied. CONCLUSIONS: European countries classified according to social welfare state or the presence of social health insurance (SHI) showed no effect on the likelihood of making payments OOP for dental care nor, when OOP payments were made, on the amounts paid. Variation in generosity of coverage and procedures reimbursed by insurance, even within countries with SHI, as well as differing needs, tastes and access to care across countries, contribute to this finding.

Barriers to oral health across selected European countries and the USA.

In this review we consider oral-health access among older adults within and between the USA and various European countries with regard to possible primary financial and modifiable secondary non-financial factors. For older adults, the likelihood of using dental services has been associated, in the health literature, with a multiplicity of factors. These factors are traditionally classified into predisposing, enabling and need categories, and can be further classified into modifiable and non-modifiable subcategories. This raises the question of which single factor or group of factors has the most influence in keeping older adults from seeking care, and how these influences might differ between the USA and various other (European) countries. As it turns out, there is variation in the magnitude of effects across certain measurable potential barriers, but generally it takes a combination of characteristics associated with non-use to have a substantial impact.

Phage-mediated horizontal gene transfer of both prophage and heterologous DNA by ϕBB-1, a bacteriophage of Borrelia burgdorferi.

Horizontal gene transfer (HGT) in Borrelia burgdorferi, the Lyme disease agent, is likely mediated by bacteriophage. Studies of the B. burgdorferi phage, ϕBB-1 and its role in HGT have been hindered by the lack of an assay for readily characterizing phage-mediated DNA movement (transduction). Here we describe an in vitro assay in which a clone of B. burgdorferi strain CA-11.2A encoding kanamycin resistance on a ϕBB-1 prophage is co-cultured with different clones encoding gentamicin resistance on a shuttle vector; transduction is monitored by enumerating colonies selected in the presence of both kanamycin and gentamicin. When both clones used in the assay were derived from CA-11.2A, the frequency of transduction was 1.23 × 10-6 transductants per cell, and could be increased 5-fold by exposing the phage-producing strain to 5% ethanol. Transduction was also demonstrated between the CA-11.2A clone and clones of both high-passage B. burgdorferi strain B31 and low-passage, virulent B. burgdorferi strain 297, although with lower transduction frequencies. The transductant in the 297 background produced phage capable of transducing another B. burgdorferi clone: this is the first experimental demonstration of transduction from a clone of a virulent strain. In addition to prophage DNA, small Escherichia coli-derived shuttle vectors were also transduced between co-cultured B. burgdorferi strains, suggesting both a broad role for the phage in the HGT of heterologous DNA and a potential use of the phage as a molecular tool. These results enhance our understanding of phage-mediated transduction as a mechanism of HGT in the Lyme disease spirochetes. Furthermore, the reagents and techniques developed herein will facilitate future studies of phage-mediated HGT, especially within the tick vector and vertebrate host.

Differences Among Older Adults in the Types of Dental Services Used in the United States.

The purpose of this article is to explore differences in the socioeconomic, demographic characteristics of older adults in the United States with respect to their use of different types of dental care services. The 2008 Health and Retirement Study (HRS) collected information about patterns of dental care use and oral health from individuals aged 55 years and older in the United States. We analyze these data and explore patterns of service use by key characteristics before modeling the relationship between service use type and those characteristics. The most commonly used service category was fillings, inlays, or bonding, reported by 43.6% of those with any utilization. Just over one third of those with any utilization reported a visit for a crown, implant, or prosthesis, and one quarter reported a gum treatment or tooth extraction. The strongest consistent predictors of use type are denture, dentate, and oral health status along with dental insurance coverage and wealth. Our results provide insights into the need for public policies to address inequalities in access to dental services among an older US population. Our findings show that lower income, less wealthy elderly with poor oral health are more likely to not use any dental services rather than using only preventive dental care, and that cost prevents most non-users who say they need dental care from going to the dentist. These results suggest a serious access problem and one that ultimately produces even worse oral health and expensive major procedures for this population in the future.

Disparity in dental attendance among older adult populations: a comparative analysis across selected European countries and the USA.

BACKGROUND: The current study addresses the extent to which diversity in dental attendance across population subgroups exists within and between the USA and selected European countries. METHOD: The analyses relied on 2006/2007 data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and 2004-2006 data from the Health and Retirement Study (HRS) in the USA for respondents≥51 years of age. Logistic regression models were estimated to identify impacts of dental-care coverage, and of oral and general health status, on dental-care use. RESULTS: We were unable to discern significant differences in dental attendance across population subgroups in countries with and without social health insurance, between the USA and European countries, and between European countries classified according to social welfare regime. Patterns of diverse dental use were found, but they did not appear predominately in countries classified according to welfare state regime or according to the presence or absence of social health insurance. CONCLUSIONS: The findings of this study suggest that income and education have a stronger, and more persistent, correlation with dental use than the correlation between dental insurance and dental use across European countries. We conclude that: (i) higher overall rates of coverage in most European countries, compared with relatively lower rates in the USA, contribute to this finding; and that (ii) policies targeted to improving the income of older persons and their awareness of the importance of oral health care in both Europe and the USA can contribute to improving the use of dental services.

A Research Note on Transitions in Out-of-Pocket Spending on Dental Services.

OBJECTIVE: We analyze correlates of the direction and magnitude of changes in out-of-pocket (OOP) payments for dental care by older Americans over a recent 4-year period. METHODS: We analyzed data from the 2006 and 2008 waves of the Health and Retirement Study. We estimated multinomial logistic models of the direction and linear regression models of the amounts of OOP changes over survey periods. RESULTS: Financial-based factors were more strongly associated with the direction and magnitude of changing self-payments for dental care than were health factors. DISCUSSION: Findings suggested that dental coverage, income, and wealth and changes in these financial factors were more strongly correlated with the persistence of and changes in OOP payments for dental care over time than were health status and changes in health status. The sensitivity to dental coverage changes should be considered as insurance and retirement policy reforms are deliberated.

Dental use and expenditures for older uninsured Americans: the simulated impact of expanded coverage.

OBJECTIVE: To determine if providing dental insurance to older Americans would close the current gaps in dental use and expenditure between insured and uninsured older Americans. DATA SOURCES/STUDY SETTING: We used data from the 2008 Health and Retirement Survey (HRS) supplemented by data from the 2006 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: We compared the simulated dental use and expenditures rates of newly insured persons against the corresponding rates for those previously insured. DATA COLLECTION/EXTRACTION METHODS: The HRS is a nationally representative survey administered by the Institute for Social Research (ISR). The MEPS is a nationally representative household survey sponsored by the Agency for Healthcare Research and Quality (AHRQ). PRINCIPAL FINDINGS: We found that expanding dental coverage to older uninsured Americans would close previous gaps in dental use and expense between uninsured and insured noninstitutionalized Americans 55 years and older. CONCLUSIONS: Providing dental coverage to previously uninsured older adults would produce estimated monthly costs net of markups for administrative costs that comport closely to current market rates. Estimates also suggest that the total cost of providing dental coverage targeted specifically to nonusers of dental care may be less than similar costs for prior users.

Disparity in dental coverage among older adult populations: a comparative analysis across selected European countries and the USA.

BACKGROUND: Insurance against the cost of preventing and treating oral diseases can reduce inequities in dental-care use and oral health. The purpose of this study was to examine the extent of variation in dental insurance coverage for older adult populations within and between the USA and various European countries. METHOD: The analyses relied on 2006-2007 data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and on 2004-2006 data from the Health and Retirement Study (HRS) in the USA for respondents 51 years of age and older. A series of logistic regression models was estimated to identify disparities in dental coverage. RESULTS: The highest extent of significant insurance differences between various population subgroups was found for the USA. In comparison with southern and eastern European countries, a lower number of significant differences in coverage was found for Scandinavian countries. Countries categorised as having comprehensive public insurance coverage showed a tendency towards less insurance variation within their populations than did countries categorised as not having comprehensive public coverage. The exceptions were Poland and Switzerland. CONCLUSIONS: The findings of the present study suggest that significant variations in dental coverage exist within all elderly populations examined and that the extent of inequalities also differs between countries. By and large, the observed variations corroborate the perception that population dental coverage is more equally distributed under public subsidy. This could be relevant information for decision makers who seek to improve policies in order to provide more equitable dental coverage.

The effect of dental insurance on the use of dental care for older adults: a partial identification analysis.

We evaluate the impact of dental insurance on the use of dental services using a potential outcomes identification framework designed to handle uncertainty created by unknown counterfactuals-that is, the endogenous selection problem-and uncertainty about the reliability of self-reported insurance status. Using data from the health and retirement study, we estimate that utilization rates of adults older than 50 years would increase from 75% to around 80% under universal dental coverage.