Temporal Patterns of High-Spend Subgroups Can Inform Service Strategy for Medicare Advantage Enrollees.

BACKGROUND: Most healthcare costs are concentrated in a small proportion of individuals with complex social, medical, behavioral, and clinical needs that are poorly met by a fee-for-service healthcare system. Efforts to reduce cost in the top decile have shown limited effectiveness. Understanding patient subgroups within the top decile is a first step toward designing more effective and targeted interventions. OBJECTIVE: Segment the top decile based on spending and clinical characteristics and examine the temporal movement of individuals in and out of the top decile. DESIGN: Retrospective claims data analysis. PARTICIPANTS: UnitedHealthcare Medicare Advantage (MA) enrollees (N = 1,504,091) continuously enrolled from 2016 to 2019. MAIN MEASURES: Medical (physician, inpatient, outpatient) and pharmacy claims for services submitted for third-party reimbursement under Medicare Advantage, available as International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and National Drug Codes (NDC) claims. KEY RESULTS: The top decile was segmented into three distinct subgroups characterized by different drivers of cost: (1) Catastrophic: acute events (acute myocardial infarction and hip/pelvic fracture), (2) persistent: medications, and (3) semi-persistent chronic conditions and frailty indicators. These groups show different patterns of spending across time. Each year, 79% of the catastrophic group dropped out of the top decile. In contrast, 68-70% of the persistent group and 36-37% of the semi-persistent group remained in the top decile year over year. These groups also show different 1-year mortality rates, which are highest among semi-persistent members at 17.5-18.5%, compared to 12% and 13-14% for catastrophic and persistent members, respectively. CONCLUSIONS: The top decile consists of subgroups with different needs and spending patterns. Interventions to reduce utilization and expenditures may show more effectiveness if they account for the different characteristics and care needs of these subgroups.

Characterization of Spatial Air Pollution Patterns Near a Large Railyard Area in Atlanta, Georgia.

Railyards are important transportation hubs, and they are often situated near populated areas with high co-located density of manufacturing, freight movement and commercial enterprises. Emissions occurring within railyards can affect nearby air quality. To better understand the air pollution levels in proximity to a major railyard, an intensive mobile air monitoring study was conducted in May 2012 around a major railyard area in Atlanta, GA, constituted of two separate facilities situated side-by-side. A total of 19 multi-hour mobile monitoring sessions took place over different times of day, days of the week, and under a variety of wind conditions. High time resolution measurements included black carbon (BC), particle number concentration (PN), particle optical extinction (EXT), oxides of nitrogen (NO, NO2, NOy), carbon monoxide (CO), and speciated air toxics. Urban background was estimated to contribute substantially (>70%) to EXT and CO, whereas BC, oxides of nitrogen (NOx) and toluene had comparably low background contributions (<30%). Mobile monitoring data were aggregated into 50 meter spatial medians by wind categories, with categories including low speed wind conditions (<0.5 m s-1) and, for wind speeds above that threshold, by wind direction relative to the railyard. Spatial medians of different pollutants measured had a wide range of correlation-gas-phase air toxics (benzene, toluene, acetaldehyde) had moderate correlation with each other (r = 0.46⁻0.59) and between toluene and CO (r = 0.53), but lower correlation for other pairings. PN had highest correlation with oxides of nitrogen (r = 0.55⁻0.66), followed by BC (r = 0.4), and lower correlation with other pollutants. Multivariate regression analysis on the full set of 50 m medians found BC and NO as having the strongest relationship to railyard emissions, in comparison to their respective background levels. This was indicated by an increase associated with transiting through the yard and inverse relationship with distance from the railyard; NO and BC decreased by a factor of approximately 0.5 and 0.7 over 1 km distance of the railyard boundary, respectively. Low speed, variable wind conditions were related to higher concentrations of all measured parameters.

Assessment of Uinta Basin Oil and Natural Gas Well Pad Pneumatic Controller Emissions.

In the fall of 2016, a field study was conducted in the Uinta Basin Utah to improve information on oil and natural gas well pad pneumatic controllers (PCs). A total of 80 PC systems at five oil sites (supporting six wells) and three gas sites (supporting 12 wells) were surveyed, and emissions data were produced using a combination of measurements and engineering emission estimates. Ninety-six percent of the PCs surveyed were low actuation frequency intermittent vent type. The overall whole gas emission rate for the study was estimated at 0.36 scf/h with the majority of emissions occurring from three continuous vent PCs (1.0 scf/h average) and eleven (14%) malfunctioning intermittent vent PC systems (1.6 scf/h average). Oil sites employed, on average 10.3 PC systems per well compared to 1.5 for gas sites. Oil and gas sites had group average PC emission rates of 0.28 scf/h and 0.67 scf/h, respectively, with this difference due in part to site selection procedures. The PC system types encountered, the engineering emissions estimate approach, and comparisons to measurements are described. Survey methods included identification of malfunctioning PC systems and emission measurements with augmented high volume sampling and installed mass flow meters, each providing a somewhat different picture of emissions that are elucidated through example cases.

South Philadelphia passive sampler and sensor study.

UNLABELLED: From June 2013 to March 2015, in total 41 passive sampler deployments of 2 wk duration each were conducted at 17 sites in South Philadelphia, PA, with results for benzene discussed here. Complementary time-resolved measurements with lower cost prototype fenceline sensors and an open-path ultraviolet differential optical absorption spectrometer were also conducted. Minimum passive sampler benzene concentrations for each sampling period ranged from 0.08 ppbv to 0.65 ppbv, with a mean of 0.25 ppbv, and were negatively correlated with ambient temperature (-0.01 ppbv/°C, R(2) = 0.68). Co-deployed duplicate passive sampler pairs (N = 609) demonstrated good precision with an average and maximum percent difference of 1.5% and 34%, respectively. A group of passive samplers located within 50 m of a refinery fenceline had a study mean benzene concentration of 1.22 ppbv, whereas a group of samplers located in communities >1 km distant from facilities had a mean of 0.29 ppbv. The difference in the means of these groups was statistically significant at the 95% confidence level (p < 0.001). A decreasing gradient in benzene concentrations moving away from the facilities was observed, as was a significant period-to-period variation. The highest recorded 2-wk average benzene concentration for the fenceline group was 3.11 ppbv. During this period, time-resolved data from the prototype sensors and the open-path spectrometer detected a benzene signal from the west on one day in particular, with the highest 5-min path-averaged benzene concentration measured at 24 ppbv. IMPLICATIONS: Using a variation of EPA's passive sampler refinery fenceline monitoring method, coupled with time-resolved measurements, a multiyear study in South Philadelphia informed benzene concentrations near facilities and in communities. The combination of measurement strategies can assist facilities in identification and mitigation of emissions from fugitive sources and improve information on air quality complex air sheds.

South Philadelphia passive sampler and sensor study.

From June 2013 to March 2015, in total 41 passive sampler deployments of 2 wk duration each were conducted at 17 sites in South Philadelphia, PA, with results for benzene discussed here. Complementary time-resolved measurements with lower cost prototype fenceline sensors and an open-path ultraviolet differential optical absorption spectrometer were also conducted. Minimum passive sampler benzene concentrations for each sampling period ranged from 0.08 ppbv to 0.65 ppbv, with a mean of 0.25 ppbv, and were negatively correlated with ambient temperature (-0.01 ppbv/°C, R2 = 0.68). Co-deployed duplicate passive sampler pairs (N = 609) demonstrated good precision with an average and maximum percent difference of 1.5% and 34%, respectively. A group of passive samplers located within 50 m of a refinery fenceline had a study mean benzene concentration of 1.22 ppbv, whereas a group of samplers located in communities >1 km distant from facilities had a mean of 0.29 ppbv. The difference in the means of these groups was statistically significant at the 95% confidence level (p < 0.001). A decreasing gradient in benzene concentrations moving away from the facilities was observed, as was a significant period-to-period variation. The highest recorded 2-wk average benzene concentration for the fenceline group was 3.11 ppbv. During this period, time-resolved data from the prototype sensors and the open-path spectrometer detected a benzene signal from the west on one day in particular, with the highest 5-min path-averaged benzene concentration measured at 24 ppbv. IMPLICATIONS: Using a variation of EPA's passive sampler refinery fenceline monitoring method, coupled with time-resolved measurements, a multiyear study in South Philadelphia informed benzene concentrations near facilities and in communities. The combination of measurement strategies can assist facilities in identification and mitigation of emissions from fugitive sources and improve information on air quality complex air sheds.

Assessment of volatile organic compound and hazardous air pollutant emissions from oil and natural gas well pads using mobile remote and on-site direct measurements.

UNLABELLED: Emissions of volatile organic compounds (VOCs) and hazardous air pollutants (HAPs) from oil and natural gas production were investigated using direct measurements of component-level emissions on pads in the Denver-Julesburg (DJ) Basin and remote measurements of production pad-level emissions in the Barnett, DJ, and Pinedale basins. Results from the 2011 DJ on-site study indicate that emissions from condensate storage tanks are highly variable and can be an important source of VOCs and HAPs, even when control measures are present. Comparison of the measured condensate tank emissions with potentially emitted concentrations modeled using E&P TANKS (American Petroleum Institute [API] Publication 4697) suggested that some of the tanks were likely effectively controlled (emissions less than 95% of potential), whereas others were not. Results also indicate that the use of a commercial high-volume sampler (HVS) without corresponding canister measurements may result in severe underestimates of emissions from condensate tanks. Instantaneous VOC and HAP emissions measured on-site on controlled systems in the DJ Basin were significantly higher than VOC and HAP emission results from the study conducted by Eastern Research Group (ERG) for the City of Fort Worth (2011) using the same method in the Barnett on pads with low or no condensate production. The measured VOC emissions were either lower or not significantly different from the results of studies of uncontrolled emissions from condensate tanks measured by routing all emissions through a single port monitored by a flow measurement device for 24 hr. VOC and HAP concentrations measured remotely using the U.S. Environmental Protection Agency (EPA) Other Test Method (OTM) 33A in the DJ Basin were not significantly different from the on-site measurements, although significant differences between basins were observed. IMPLICATIONS: VOC and HAP emissions from upstream production operations are important due to their potential impact on regional ozone levels and proximate populations. This study provides information on the sources and variability of VOC and HAP emissions from production pads as well as a comparison between different measurement techniques and laboratory analysis protocols. On-site and remote measurements of VOC and HAP emissions from oil and gas production pads indicate that measurable emissions can occur despite the presence of control measures, often as a result of leaking thief hatch seals on condensate tanks. Furthermore, results from the remote measurement method OTM 33A indicate that it can be used effectively as an inspection technique for identifying oil and gas well pads with large fugitive emissions.

Assessment of methane emissions from oil and gas production pads using mobile measurements.

A new mobile methane emissions inspection approach, Other Test Method (OTM) 33A, was used to quantify short-term emission rates from 210 oil and gas production pads during eight two-week field studies in Texas, Colorado, and Wyoming from 2010 to 2013. Emission rates were log-normally distributed with geometric means and 95% confidence intervals (CIs) of 0.33 (0.23, 0.48), 0.14 (0.11, 0.19), and 0.59 (0.47, 0.74) g/s in the Barnett, Denver-Julesburg, and Pinedale basins, respectively. This study focused on sites with emission rates above 0.01 g/s and included short-term (i.e., condensate tank flashing) and maintenance-related emissions. The results fell within the upper ranges of the distributions observed in recent onsite direct measurement studies. Considering data across all basins, a multivariate linear regression was used to assess the relationship of methane emissions to well age, gas production, and hydrocarbon liquids (oil or condensate) production. Methane emissions were positively correlated with gas production, but only approximately 10% of the variation in emission rates was explained by variation in production levels. The weak correlation between emission and production rates may indicate that maintenance-related stochastic variables and design of production and control equipment are factors determining emissions.

Field assessment of the effects of roadside vegetation on near-road black carbon and particulate matter.

One proposed method for reducing exposure to mobile source air pollution is the construction or preservation of vegetation barriers between major roads and nearby populations. This study combined stationary and mobile monitoring approaches to determine the effects of an existing, mixed-species tree stand on near-road black carbon (BC) and particulate matter concentrations. Results indicated that wind direction and time of day significantly affected pollutant concentrations behind the tree stand. Continuous sampling revealed reductions in BC behind the barrier, relative to a clearing, during downwind (12.4% lower) and parallel (7.8% lower) wind conditions, with maximum reductions of 22% during the late afternoon when winds were from the road. Particle counts in the fine and coarse particle size range (0.5-10 µm aerodynamic diameter) did not show change. Mobile sampling revealed BC concentration attenuation, a result of the natural dilution and mixing that occur with transport from the road, was more gradual behind the vegetation barrier than in unobstructed areas. These findings suggest that a mature tree stand can modestly improve traffic-related air pollution in areas located adjacent to the road; however, the configuration of the tree stand can influence the likelihood and extent of pollutant reductions.