Bundled Payment Episodes Initiated by Physician Group Practices: Medicare Beneficiary Perceptions of Care Quality.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative incentivizes participating providers to reduce total Medicare payments for an episode of care. However, there are concerns that reducing payments could reduce quality of care. OBJECTIVE: To assess the association of BPCI with patient-reported functional status and care experiences. DESIGN: We surveyed a stratified random sample of Medicare beneficiaries with BPCI episodes attributed to participating physician group practices, and matched comparison beneficiaries, after hospitalization for one of the 18 highest volume clinical episodes. The sample included beneficiaries discharged from the hospital from February 2017 through September 2017. Beneficiaries were surveyed approximately 90 days after their hospital discharge. We estimated risk-adjusted differences between the BPCI and comparison groups, pooled across all 18 clinical episodes and separately for the five largest clinical episodes. PARTICIPANTS: Medicare beneficiaries with BPCI episodes (n=16,898, response rate=44.5%) and comparison beneficiaries hospitalized for similar conditions selected using coarsened exact matching (n=14,652, response rate=46.2%). MAIN MEASURES: Patient-reported functional status, care experiences, and overall satisfaction with recovery. KEY RESULTS: Overall, we did not find differences between the BPCI and comparison respondents across seven measures of change in functional status or overall satisfaction with recovery. Both BPCI and comparison respondents reported generally positive care experiences, but BPCI respondents were less likely to report positive care experience for 3 of 8 measures (discharged at the right time, -1.2 percentage points (pp); appropriate level of care, -1.8 pp; preferences for post-discharge care taken into account, -0.9 pp; p<0.05 for all three measures). CONCLUSIONS: The proportion of respondents with favorable care experiences was smaller for BPCI than comparison respondents. However, we did not detect differences in self-reported change in functional status approximately 90 days after hospital discharge, indicating that differences in care experiences did not affect functional recovery.

Patient-reported Outcomes Among Vulnerable Populations in the Medicare Bundled Payments for Care Improvement Initiative.

BACKGROUND: The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative tested whether episode-based payment models could reduce Medicare payments without harming quality. Among patients with vulnerabilities, BPCI appeared to effectively reduce payments while maintaining the quality of care. However, these findings could overlook potential adverse patient-reported outcomes in this population. RESEARCH DESIGN: We surveyed beneficiaries with 4 characteristics (Medicare-Medicaid dual eligibility; dementia; recent institutional care; or racial/ethnic minority) treated at BPCI-participating or comparison hospitals for congestive heart failure, sepsis, pneumonia, or major joint replacement of the lower extremity. We estimated risk-adjusted differences in patient-reported outcomes between BPCI and comparison respondents, stratified by clinical episode and vulnerable characteristic. MEASURES: Patient care experiences during episodes of care and patient-reported functional outcomes assessed roughly 90 days after hospitalization. RESULTS: We observed no differences in self-reported functional improvement between BPCI and comparison respondents with vulnerable characteristics. Patient-reported care experience was similar between BPCI and comparison respondents in 11 of 15 subgroups of clinical episode and vulnerability. BPCI respondents with congestive heart failure, sepsis, and pneumonia were less likely to indicate positive care experiences than comparison respondents for at least 1 subgroup with vulnerabilities. CONCLUSIONS: As implemented by hospitals, BPCI Model 2 was not associated with adverse effects on patient-reported functional status among beneficiaries who may be vulnerable to reductions in care. Hospitals participating in heart failure, sepsis or pneumonia bundled payment episodes should focus on patient care experience while implementing changes in care delivery.

Trends in ambulance transports and costs among Medicare beneficiaries, 2007-2018.

BACKGROUND: The primary purpose of this study was to evaluate trends in ambulance utilization and costs among Medicare beneficiaries from 2007 to 2018. Community characteristics associated with ambulance use and costs are also explored. METHODS: Aggregated county-level fee-for-service (FFS) Medicare beneficiary claims data from 2007 to 2018 were used to assess ambulance transports per 1000 FFS Medicare beneficiaries and standardized inflation-adjusted ambulance costs. Multivariable linear mixed models were used to quantify trends in ambulance utilization and costs and to control for confounders. RESULTS: A total of 37,675 county-years were included from 2007 to 2018. Ambulance transports per 1000 beneficiaries increased 15% from 299 (95% CI: 291.63, 307.30) to 345 (95% CI: 336.91, 353.10) from 2007 to 2018. Inflation-adjusted standardized per user costs exhibited an increasing (1.04, 95% CI: 1.04, 1.05), but non-linear relationship (0.996, 95% CI: 0.996, 0.996) over time with costs peaking in 2012. Indicators of lower socioeconomic status (SES) were associated with increases in both ambulance events and costs (p < .0001). A higher prevalence of Medicare beneficiaries utilizing Skilled Nursing Facilities was associated with increased levels of ambulance events per 1000 beneficiaries (95% CI: 8.06, 10.63). Rural location was associated with a 38% increase in ambulance costs (95% CI 1.30-1.47) compared to urban location. CONCLUSIONS: Numerous policy solutions have been proposed to address growing ambulance costs in the Medicare program. While ambulance transports and costs continue to increase, a bend in the ambulance cost curve is detected suggesting that one or more policies altered Medicare ambulance costs, although utilization has continued to grow linearly. Ambulance use and costs vary significantly with community-level factors. As policy makers consider how to address growing ambulance use and costs, targeting identified community-level factors associated with greater costs and utilization, and their root causes, may offer a targeted approach to addressing current trends.

Association of Participation in the Oncology Care Model With Medicare Payments, Utilization, Care Delivery, and Quality Outcomes.

IMPORTANCE: In 2016, the US Centers for Medicare & Medicaid Services initiated the Oncology Care Model (OCM), an alternative payment model designed to improve the value of care delivered to Medicare beneficiaries with cancer. OBJECTIVE: To assess the association of the OCM with changes in Medicare spending, utilization, quality, and patient experience during the OCM's first 3 years. DESIGN, SETTING, AND PARTICIPANTS: Exploratory difference-in-differences study comparing care during 6-month chemotherapy episodes in OCM participating practices and propensity-matched comparison practices initiated before (January 2014 through June 2015) and after (July 2016 through December 2018) the start of the OCM. Participants included Medicare fee-for-service beneficiaries with cancer treated at these practices through June 2019. EXPOSURES: OCM participation. MAIN OUTCOMES AND MEASURES: Total episode payments (Medicare spending for Parts A, B, and D, not including monthly payments for enhanced oncology services); utilization and payments for hospitalizations, emergency department (ED) visits, office visits, chemotherapy, supportive care, and imaging; quality (chemotherapy-associated hospitalizations and ED visits, timely chemotherapy, end-of-life care, and survival); and patient experiences. RESULTS: Among Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy, 483 319 beneficiaries (mean age, 73.0 [SD, 8.7] years; 60.1% women; 987 332 episodes) were treated at 201 OCM participating practices, and 557 354 beneficiaries (mean age, 72.9 [SD, 9.0] years; 57.4% women; 1 122 597 episodes) were treated at 534 comparison practices. From the baseline period, total episode payments increased from $28 681 for OCM episodes and $28 421 for comparison episodes to $33 211 for OCM episodes and $33 249 for comparison episodes during the intervention period (difference in differences, -$297; 90% CI, -$504 to -$91), less than the mean $704 Monthly Enhanced Oncology Services payments. Relative decreases in total episode payments were primarily for Part B nonchemotherapy drug payments (difference in differences, -$145; 90% CI, -$218 to -$72), especially supportive care drugs (difference in differences, -$150; 90% CI, -$216 to -$84). The OCM was associated with statistically significant relative reductions in total episode payments among higher-risk episodes (difference in differences, -$503; 90% CI, -$802 to -$204) and statistically significant relative increases in total episode payments among lower-risk episodes (difference in differences, $151; 90% CI, $39-$264). The OCM was not significantly associated with differences in hospitalizations, ED visits, or survival. Of 22 measures of utilization, 10 measures of quality, and 7 measures of care experiences, only 5 were significantly different. CONCLUSIONS AND RELEVANCE: In this exploratory analysis, the OCM was significantly associated with modest payment reductions during 6-month episodes for Medicare beneficiaries receiving chemotherapy for cancer in the first 3 years of the OCM that did not offset the monthly payments for enhanced oncology services. There were no statistically significant differences for most utilization, quality, and patient experience outcomes.

Noninvasive Neurally Adjusted Ventilatory Assist in Premature Infants Postextubation.

Background Neurally adjusted ventilatory assist (NAVA) has distinct advantages when used invasively compared with conventional ventilation techniques. Evidence supporting the use of noninvasive NAVA is less robust, especially in the very low birth weight (VLBW) population. Objective To determine whether synchronized noninvasive ventilation via neurally adjusted ventilatory assist (NIV NAVA) supports ventilation postextubation in premature infants. Methods A retrospective analysis of a cohort of twenty-four former VLBW (<1.5 kg) infants from July 2011 to October 2012. Decreased or unchanged capillary pCO2 after increasing NAVA support was used as a marker for adequately supported noninvasive ventilation. The Wilcoxon signed-rank test was used to compare pre- and post-NAVA intervention (α = 0.05). Results Ventilation improved after an increase in NIV NAVA level in 83% of the premature infants studied (20/24) with a decrease in median pCO2 by 5 mm Hg (p = 0.0001). Conclusion NIV NAVA can provide synchronized postextubation ventilatory support as measured by decreased pCO2 in premature infants.

Passive Smoke Exposure as a Risk Factor for Oral Clefts-A Large International Population-Based Study.

Maternal cigarette smoking is a well-established risk factor for oral clefts. Evidence is less clear for passive (secondhand) smoke exposure. We combined individual-level data from 4 population-based studies (the Norway Facial Clefts Study, 1996-2001; the Utah Child and Family Health Study, 1995-2004; the Norwegian Mother and Child Cohort Study, 1999-2009; and the National Birth Defects Prevention Study (United States), 1999-2007) to obtain 4,508 cleft cases and 9,626 controls. We categorized first-trimester passive and active smoke exposure. Multivariable logistic models adjusted for possible confounders (maternal alcohol consumption, use of folic acid supplements, age, body size, education, and employment, plus study fixed effects). Children whose mothers actively smoked had an increased risk of oral clefts (odds ratio (OR) = 1.27, 95% confidence interval (CI): 1.11, 1.46). Children of passively exposed nonsmoking mothers also had an increased risk (OR = 1.14, 95% CI: 1.02, 1.27). Cleft risk was further elevated among babies of smoking mothers who were exposed to passive smoke (OR = 1.51, 95% CI: 1.35, 1.70). Using a large pooled data set, we found a modest association between first-trimester passive smoking and oral clefts that was consistent across populations, diverse study designs, and cleft subtypes. While this association may reflect subtle confounding or bias, we cannot rule out the possibility that passive smoke exposure during pregnancy is teratogenic.

Phenotypic diversity in white adults with moderate to severe Class II malocclusion.

INTRODUCTION: Class II malocclusion affects about 15% of the population in the United States and is characterized by a convex profile and occlusal disharmonies. The specific etiologic mechanisms resulting in the range of Class II dentoskeletal combinations observed are not yet understood. Most studies describing Class II phenotypic diversity have used moderate sample sizes or focused on younger patients who later in life might outgrow their Class II discrepancies; such a focus might also preclude the visualization of adult Class II features. The majority have used simple correlation methods resulting in phenotypes that might not be generalizable to different samples and thus might not be suitable for studies of malocclusion etiology. The purpose of this study was to address these knowledge gaps by capturing the maximum phenotypic variations in a large sample of white Class II subjects selected with strict eligibility criteria and rigorously standardized multivariate reduction analyses. METHODS: Sixty-three lateral cephalometric variables were measured from the pretreatment records of 309 white Class II adults (82 male, 227 female; ages, 16-60 years). Principal component analysis and cluster analysis were used to generate comprehensive phenotypes to identify the most homogeneous groups of subjects, reducing heterogeneity and improving the power of future malocclusion etiology studies. RESULTS: Principal component analysis resulted in 7 principal components that accounted for 81% of the variation. The first 3 components represented variation on mandibular rotation, maxillary incisor angulation, and mandibular length. The cluster analysis identified 5 distinct Class II phenotypes. CONCLUSIONS: A comprehensive spectrum of Class II phenotypic definitions was obtained that can be generalized to other samples to advance our efforts for identifying the etiologic factors underlying Class II malocclusion.

Phenotypic diversity in white adults with moderate to severe Class III malocclusion.

INTRODUCTION: Class III malocclusion is characterized by a composite of dentoskeletal patterns that lead to the forward positioning of the mandibular teeth in relation to the maxillary teeth and a concave profile. Environmental and genetic factors are associated with this condition, which affects 1% of the population in the United States and imposes significant esthetic and functional burdens on affected persons. The purpose of this study was to capture the phenotypic variation in a large sample of white adults with Class III malocclusion using multivariate reduction methods. METHODS: Sixty-three lateral cephalometric variables were measured from the pretreatment records of 292 white subjects with Class II malocclusion (126 male, 166 female; ages, 16-57 years). Principal component analysis and cluster analysis were used to capture the phenotypic variation and identify the most homogeneous groups of subjects to reduce genetic heterogeneity. RESULTS: Principal component analysis resulted in 6 principal components that accounted for 81.2% of the variation. The first 3 components represented variation in mandibular horizontal and vertical positions, maxillary horizontal position, and mandibular incisor angulation. The cluster model identified 5 distinct subphenotypes of Class III malocclusion. CONCLUSIONS: A spectrum of phenotypic definitions was obtained replicating results of previous studies and supporting the validity of these phenotypic measures in future research of the genetic and environmental etiologies of Class III malocclusion.

Impact of the Comprehensive Care for Joint Replacement model on patient-reported outcomes.

OBJECTIVE: To determine whether the Comprehensive Care for Joint Replacement (CJR) model, a mandatory episode-based payment program for knee and hip replacement surgery, affected patient-reported measures of quality. DATA SOURCES: Surveys of Medicare fee-for-service beneficiaries who had hip or knee replacement surgery, collected between July 2018 and March 2019, secondary Medicare administrative data, the Provider of Services file, CJR and Bundled Payments for Care Improvement participant lists from the Centers for Medicare & Medicaid Services, and the Area Health Resource Files. STUDY DESIGN: In 2018, participation in the CJR model was mandatory for nearly all hospitals in 34 randomly selected, metropolitan statistical areas (MSAs) that had high historical Medicare payments for lower-extremity joint replacements surgery. The control group included 47 high-payment MSAs randomly assigned as controls. We estimated risk-adjusted differences in self-reported measures of functional status and pain, satisfaction with care, and caregiver help between respondents in CJR hospitals and respondents in hospitals located in the control group. DATA COLLECTION: We selected a census of CJR patients and an equal number of control patients to survey. We fielded two waves of surveys using a mail and phone protocol, yielding 8433 CJR and 9014 control respondents. PRINCIPAL FINDINGS: CJR respondents were slightly more likely to depend on caregivers for certain activities of daily living when they got home (either directly from the hospital or after an institutional post-acute care stay). On a 100-point scale, differences ranged from -2.6 points (p < 0.01) for help needed bathing to -1.7 points (p < 0.05) for help needed using the toilet. However, differences in eight measures of self-reported functional status approximately 90-120 days after hospital discharge were not statistically significant, ranging from -1.1% (p = 0.087) to 0.7% (p = 0.437). CONCLUSIONS: CJR did not harm patient health or affect patient satisfaction on average but did increase reliance on caregivers during recovery.

Medicare Beneficiary Factors Associated with Skilled Nursing Facility Lengths of Stay.

The objectives of this study are (1) to identify beneficiary-level characteristics associated with skilled nursing facility (SNF) length of stay (LOS), and (2) to determine if significant differences in LOS exist for vulnerable populations at the individual level or among nursing homes that serve a disproportionate share of vulnerable populations. This study employed 2014-2015 Medicare Long-Term Care Minimum Data Set (MDS v3.0) assessment, fee-for-service claims and enrollment, and 2014 Nursing Home Compare data to examine SNF LOS in Medicare beneficiaries. We used a hierarchical linear model to identify which beneficiary-level characteristics are associated with SNF LOS, while controlling for facility-level characteristics. After controlling for beneficiary-and facility-level characteristics, we found dual eligibility, racial or ethnic minority, depression, and Alzheimer's disease to be associated with longer Medicare covered SNF stays. We found that facilities that served higher proportions of dually eligible individuals tended to have higher average LOS compared to other facilities.

Association of the Oncology Care Model With Value-Based Changes in Use of Radiation Therapy.

PURPOSE: Radiation utilization for breast cancer and metastatic bone disease varies in modality, fractionation, and cost, despite evidence demonstrating equal effectiveness and consensus recommendations such as Choosing Wisely that advocate for higher value care. We assessed whether the Oncology Care Model (OCM), an alternative payment model for practices providing chemotherapy to patients with cancer, affected the overall use and value of radiation therapy in terms of Choosing Wisely recommendations. METHODS AND MATERIALS: We used Centers for Medicare & Medicaid Services administrative data to identify beneficiaries enrolled in traditional fee-for-service Medicare who initiated chemotherapy episodes at OCM and propensity-matched comparison practices. Difference-in-difference (DID) analyses evaluated the effect of OCM on overall use of postoperative radiation for breast cancer, use of intensity modulated radiation therapy and hypofractionation for breast cancer, and fractionation patterns for treatment of metastatic bone disease from breast or prostate cancer. We performed additional analyses stratified by the presence or absence of a radiation oncologist in the practice. RESULTS: Among 27,859 postoperative breast cancer episodes, OCM had no effect on overall use of radiation therapy after breast surgery (DID percentage point difference = 0.4%; 90% confidence interval [CI], -1.7%, 2.4%) or on use of intensity modulated radiation therapy in this setting (DID = -0.6; 90% CI, -3.1, 2.0). Among 19,366 metastatic bone disease episodes, OCM had no effect on fractionation patterns for palliation of bone metastases (DID for ≤10 fractions = -1.1%; 90% CI, -2.6%, 0.4% and DID for single fraction = -0.2%; 90% CI, -1.9%, 1.6%). Results were similar for practices with and without a radiation oncologist. We did not evaluate the effect of OCM on hypofractionated radiation after breast-conserving surgery owing to evidence of differential baseline trends. CONCLUSIONS: OCM had no effect on use of radiation therapy after breast-conserving surgery for breast cancer or on fractionation patterns for metastatic bone disease. Future payment models directly focused on radiation oncology providers may be better poised to improve the value of radiation oncology care.

The Oncology Care Model and Adherence to Oral Cancer Drugs: A Difference-in-Differences Analysis.

BACKGROUND: Adherence to oral cancer drugs is suboptimal. The Oncology Care Model (OCM) offers oncology practices financial incentives to improve the value of cancer care. We assessed the impact of OCM on adherence to oral cancer therapy for chronic myelogenous leukemia (CML), prostate cancer, and breast cancer. METHODS: Using 2014-2019 Medicare data, we studied chemotherapy episodes for Medicare fee-for-service beneficiaries prescribed tyrosine kinase inhibitors (TKIs) for CML, antiandrogens (ie, enzalutamide, abiraterone) for prostate cancer, or hormonal therapies for breast cancer in OCM-participating and propensity-matched comparison practices. We measured adherence as the proportion of days covered and used difference-in-difference (DID) models to detect changes in adherence over time, adjusting for patient, practice, and market-level characteristics. RESULTS: There was no overall impact of OCM on improved adherence to TKIs for CML (DID = -0.3%, 90% confidence interval [CI] = -1.2% to 0.6%), antiandrogens for prostate cancer (DID = 0.4%, 90% CI = -0.3% to 1.2%), or hormonal therapy for breast cancer (DID = 0.0%, 90% CI = -0.2% to 0.2%). Among episodes for Black beneficiaries in OCM practices, for whom adherence was lower than for White beneficiaries at baseline, we observed small improvements in adherence to high cost TKIs (DID = 3.0%, 90% CI = 0.2% to 5.8%) and antiandrogens (DID = 2.2%, 90% CI = 0.2% to 4.3%). CONCLUSIONS: OCM did not impact adherence to oral cancer therapies for Medicare beneficiaries with CML, prostate cancer, or breast cancer overall but modestly improved adherence to high-cost TKIs and antiandrogens for Black beneficiaries, who had somewhat lower adherence than White beneficiaries at baseline. Patient navigation and financial counseling are potential mechanisms for improvement among Black beneficiaries.

Medicare's Bundled Payments For Care Improvement Initiative Maintained Quality Of Care For Vulnerable Patients.

The Bundled Payments for Care Improvement (BPCI) initiative established four models to test whether linking payments for an episode of care could reduce Medicare payments while maintaining or improving quality. Evaluations concluded that model 2, the largest, generally lowered payments without reducing quality for the average beneficiary, but these global results could mask adverse findings among vulnerable subpopulations. We analyzed changes in emergency department visits, unplanned hospital readmissions, and all-cause mortality within ninety days of hospital discharge among beneficiaries with one or more of three vulnerable characteristics-dementia, dual eligibility for Medicare and Medicaid, and recent institutional care-in 105,458 beneficiary episodes in the period October 2013-December 2016. The results for twelve types of medical and surgical BPCI episodes were evaluated relative to results in matched comparison groups. Our findings suggest that BPCI model 2 did not adversely affect care quality for beneficiaries with vulnerabilities. While this conclusion does not discourage the further development of bundled payment models, policy makers should support ongoing research to ensure that vulnerable populations are not adversely affected by these approaches.

Candidate gene study for smoking, alcohol use, and body weight in a sample of pregnant women.

OBJECTIVE: Prenatal smoking, alcohol use, and obesity have significant effects on maternal and fetal health. However, not much is known about the genetic contributions to these risk factors among pregnant women. We evaluate the associations between several candidate genes and smoking, alcohol use, pre-pregnancy body weight, and weight gain during pregnancy in a sample of pregnant women. METHODS: The study analyzes a sample of about 1900 mothers from the Danish National Birth Cohort. We test the association between 1450 SNPs in/near 117 genes/loci and various risk factor measures. RESULTS: Only a few SNPs in FTO were significantly associated with pre-pregnancy obesity and body mass index (4 and 2 SNPs, respectively) after SNP-level correction for multiple testing. A few loci were significantly related to various smoking measures (any smoking, quitting and cigarette number) with gene/locus-level correction for multiple testing, but not after SNP-level correction. Similarly, some loci were significant for the alcohol measures at the gene/locus-level but not at SNP-level correction. CONCLUSION: The study suggests that the majority of the evaluated candidate genes may not play an important role in influencing these risk factors among pregnant women, highlighting the importance of other genetic factors and non-genetic contributors to their etiology.

Patterns of complementary and alternative medicine (CAM) use among dental patients.

OBJECTIVES: Complementary and alternative medicine (CAM) is a diverse collection of approaches used to prevent or treat diseases. The goal of this study was to examine relationships between dental patient characteristics and current usage of CAM therapies. METHODS: The CAM definition encompassed 24 therapies excluding prayer. Associations and trends in usage were assessed for gender, income, education, and age. Multivariable logistic and negative binomial models were used to identify factors impacting the use and number of CAM therapies used. RESULTS: In dental patients (n = 402), nearly 67 percent of subjects reported at least one CAM treatment. Gender was significantly associated with recent utilization of CAM, biological, manipulative (all P < 0.01), and mind-body (P = 0.04) therapies, as well as the number (P < 0.01) of therapies used. Higher education levels were significant in usage of any CAM, biological, and mind-body therapies (P < 0.01). CONCLUSION: A large proportion of dental patients reported use of CAM therapies. While CAM therapies and those who use them are diverse, given their widespread use, they clearly have potential impacts on the oral health of the public. Knowledge of the characteristics of dental patients who use CAM therapies is a first step in developing a broader understanding how CAM therapies and associated beliefs may affect oral health and public health programs.

Complementary and alternative medicine in predoctoral dental curricula: an exploratory survey of U.S. dental schools.

The purpose of this study was to identify the prevalence of complementary and alternative medicine (CAM) education in U.S. dental schools. A survey was administered via e-mail to each U.S. dental school's academic dean, and data were collected from respondents in a fillable PDF form submitted electronically to the study investigators. The survey asked respondents whether CAM was taught at the institution; if the response was yes, information was requested regarding the CAM therapies included, credentials of the instructor, number of hours taught, reason for teaching CAM, and format in which CAM was taught. Of the sixty dental schools contacted, twenty-two responded to the survey (37 percent response rate). Of these respondents, ten (45.5 percent) reported offering instruction in CAM as part of their predoctoral curricula. Herb/drug interactions were found to be taught with more frequency than any other CAM topic (in six out of the ten institutions). Limitations of the study are discussed, and suggestions for future studies are made.

Refinement of pointwise linear regression criteria for determining glaucoma progression.

PURPOSE: A variety of pointwise linear regression (PLR) criteria have been proposed for determining glaucomatous visual field progression. However, alternative PLR criteria have only been assessed on a limited basis. The purpose of this study was to evaluate a range of PLR slope and significance criteria to define a clinically useful progression decision rule for longitudinal visual field examinations. METHODS: Visual field data for each of 140 eyes (one per participant among 96 cases and 44 controls) were evaluated using the Humphrey Field Analyzer II program 24-2 Swedish interactive thresholding algorithm standard test strategy and Goldmann size III stimuli. The pointwise linear regression A2 (PLRA2) method was used to analyze the data, which included nine visual field examinations performed every 6 months for 4 years. Data from the Ocular Hypertension Treatment Study (OHTS) were used to validate the decision rule. RESULTS: Several slope criteria produced specificities of 0.90 or higher, particularly slope criteria of less than -1.2 dB/y. The use of the slope criterion less than -1.2 dB/y at a significance level of P < 0.04 for classification resulted in a hit rate of 0.38, more than a 2-fold increase compared with a commonly used standard slope criterion of less than -1.0 dB/y at a significance level of P < 0.01. A similar increase in the hit rate was shown for a slope of less than -1.2 dB/y and P < 0.04 compared with the standard criterion in the independent OHTS validation data. CONCLUSIONS: When systematically evaluating criteria for detecting glaucoma progression, PLR criteria can be refined by requiring a stricter slope criterion such as less than -1.2 dB/y and relaxing the significance criterion to P < 0.04. Increasing the hit rate of PLR will be useful for early detection and treatment of glaucoma.

Use of intravenous sedation in periodontal practice: a national survey.

BACKGROUND: In the early 1990s, much of the periodontal profession perceived an upcoming shift in services performed by periodontists as many patients began to expect sedation for periodontal surgery. As a result, in 1993 the American Academy of Periodontology began encouraging postgraduate periodontal programs to train residents in the use of conscious sedation. The purpose of this study is to investigate trends in the training of intravenous (i.v.) sedation in residency and its use in periodontal practice. METHODS: An 18-question survey was mailed to a sample of 1596 active periodontists throughout the United States and Canada. Thirty-seven percent (596) of the surveys were returned. Twenty-two retired periodontists responded and were excluded from the analysis. The data from the remaining 574 surveys were analyzed with a statistical software package. RESULTS: Approximately half (49.8%) of the survey respondents offer i.v. sedation in their practices. Among respondents who completed residency prior to 1996, 42.6% offer i.v. sedation compared with 64.2% of respondents who completed residency in 1996 or later. The number of i.v. sedations performed in residency was moderately correlated with the number of i.v. sedations personally performed in periodontal practice (Spearman r = 0.5169, P <0.0001). The largest percentage of periodontists using i.v. sedation (74.0%) was reported from American Academy of Periodontology District 5 (south central United States), whereas District 7 (New Jersey and New York) reported the lowest usage (15.6%). CONCLUSIONS: Approximately half of all periodontists provide i.v. sedation, with more recent periodontal graduates more likely to personally offer and administer i.v. sedation services for their patients. Regional differences exist in the use and training of i.v. sedation.

Complementary and alternative medicine usage by patients of a dental school clinic.

This pilot study investigated the prevalence and specific reasons for usage of complementary and alternative medicine (CAM) among patients of a dental school clinic. Four hundred and two patients completed a 30-page survey on CAM usage. A higher rate of CAM usage was found in this dental school clinic population than rates previously reported in a general population. More than three-quarters (76.1%) of the respondents reported using at least one CAM treatment in the past 12 months; 93.3% reported using at least one CAM treatment at some time in their lives. High rates of chiropractic use were found in this population. Tooth pain was the most frequently reported dental condition motivating CAM use. About 10% of dental school clinic patients use topical oral herbal and/or natural products to treat dental conditions, most frequently for preventive/oral health reasons or for tooth pain.

Comparison of perceptions of oral health-related quality of life in adolescents affected with ectodermal dysplasias relative to caregivers.

The objective of this study was to assess the perceived oral health-related quality of life (OHQoL) of adolescents affected with one of the ectodermal dysplasias (EDs). Data were collected from 2003 to 2007 in a cross-sectional study of a convenience sample of individuals affected by ED (n = 35) using the Child Perceptions Questionnaire (CPQ11-14) for children and the Parent-Caregiver Perceptions Questionnaire for their caregivers. The main findings of this study were that individuals who were affected with ED in the older age group (15- to 19-year-olds) perceived more functional problems than younger individuals (11- to 14-year-olds) (p= .04). Females with ED (n = 13) perceived more emotional problems than males (n = 22; p= .01). Although caregivers tended to report slightly higher OHQoL scores (indicating worse OHQoL), no significant differences were observed between children's and parents' total OHQoL and individual domains' median scores (p > .05). Thus, the perceptions of oral health and well-being may vary by age and gender for children who have ED. Caution is warranted concerning using parents as proxies for their children when assessing the child's OHQoL.