Care continuity impacts medicare expenditures of older adults: Fact or fiction?

BACKGROUND: Older adults with cardiometabolic conditions are typically seen by multiple providers. Management by multiple providers may compromise care continuity and increase health expenditures for older adults, which may partly explain the inverse association between continuity and Medicare expenditures found in prior studies. This study sought to examine whether all-cause admission, outpatient expenditures or total expenditures were associated with the number of prescribers of cardiometabolic medications. METHODS: Medicare fee-for-service beneficiaries with diabetes (n = 100,191), hypertension (n = 299,949) or dyslipidemia (n = 243,598) living in 10 states were identified from claims data. The probability of an all-cause hospital admission in 2011 was estimated via logistic regression and Medicare (outpatient, total) expenditures in 2011 were estimated using generalized linear models, both as a function of the number of prescribers in 2010. Regressions were adjusted for demographic characteristics, Medicaid status, number of prescriptions, and 17 chronic conditions. RESULTS: In all three cohorts, older adults with more prescribers in 2010 had modestly higher adjusted odds of all-cause inpatient admission than older adults with a single prescriber. Compared to a single prescriber, outpatient and total expenditures in 2011 were 3-10% higher for older adults with diabetes and multiple prescribers, 2-6% higher for older adults with hypertension and multiple prescribers, and 2-5% higher for older adults with dyslipidemia and multiple prescribers. CONCLUSIONS AND IMPLICATIONS: These results provide some evidence that older adults with multiple prescribers also have modestly higher Medicare utilization than those with a single prescriber; thus care continuity may impact patient utilization. LEVEL OF EVIDENCE: Level III (retrospective cohort analysis).

Fully textured monolithic perovskite/silicon tandem solar cells with 25.2% power conversion efficiency.

Tandem devices combining perovskite and silicon solar cells are promising candidates to achieve power conversion efficiencies above 30% at reasonable costs. State-of-the-art monolithic two-terminal perovskite/silicon tandem devices have so far featured silicon bottom cells that are polished on their front side to be compatible with the perovskite fabrication process. This concession leads to higher potential production costs, higher reflection losses and non-ideal light trapping. To tackle this issue, we developed a top cell deposition process that achieves the conformal growth of multiple compounds with controlled optoelectronic properties directly on the micrometre-sized pyramids of textured monocrystalline silicon. Tandem devices featuring a silicon heterojunction cell and a nanocrystalline silicon recombination junction demonstrate a certified steady-state efficiency of 25.2%. Our optical design yields a current density of 19.5 mA cm-2 thanks to the silicon pyramidal texture and suggests a path for the realization of 30% monolithic perovskite/silicon tandem devices.

Predominant bacteria and patterns of antibiotic susceptibility in urinary tract infection in children with spina bifida.

BACKGROUND: Urinary tract infection is more common in children with spina bifida (SB) than neurologically intact children, and Escherichia coli is the most common urinary pathogen in the general pediatric population. Less is known of the pathogens responsible for urinary tract infections (UTI) in the pediatric SB population or their evolving antimicrobial resistance patterns. The goal of this study is to determine the epidemiology and antimicrobial resistance patterns of SB-associated urinary pathogens. METHODS: Between January 1996 and August 2013, 231 patients aged 1 month to 18 years were identified with a diagnosis of SB-NB and at least one symptomatic urinary tract infection (UTI) event (Table). Two-hundred and thirty-one normally voiding children with a single symptomatic UTI were age-matched based on age at diagnosis of UTI at a 1:1 ratio. Chi-square tests and Generalized Estimating Equation analysis, controlling for clinicopathological factors, were performed to compare rates of pathogen-associations with UTI between groups and likelihood of UTI with multi-drug resistant (MDR) organisms. RESULTS: Children in the SB-NB group had a higher rate of non-E. coli UTI compared with controls (64% vs. 41%, p < 0.01), particularly associated with Klebsiella species the SB-NB group had an overall higher infection rate with MDR organisms (21% vs. 10%, p < 0.01) and E. coli isolates, with a trend towards increased rates of antibiotic resistance to aminoglycosides, fluoroquinolones, cephalosporins, extended spectrum ß-lactams, and TMP-SMZ. Additionally, patients in the SB-NB group had a 10-fold increase of urosepsis with 57% of events caused by MDR organisms. CONCLUSIONS: Children with SB-NB are more likely to have non-E. coli UTI, UTIs with MDR organisms, and urosepsis than the general pediatric population.

Prescriber continuity and medication availability in older adults with cardiometabolic conditions.

BACKGROUND: Many older adults have multiple conditions and see multiple providers, which may impact their use of essential medications. OBJECTIVE: We examined whether the number of prescribers of these medications was associated with the availability of medications, a surrogate for adherence, to manage diabetes, hypertension or dyslipidemia. METHODS: A retrospective cohort of 383,145 older adults with diabetes, hypertension or dyslipidemia in the US Medicare program living in 10 states. The association between the number of prescribers of cardiometabolic medications in 2010 and medication availability (proportion of days with medication on hand) in 2011 was estimated via logistic regression, controlling for patient demographic characteristics and chronic conditions. RESULTS: Medicare beneficiaries with diabetes, hypertension and/or dyslipidemia had an average of five chronic conditions overall, obtained 10-12 medications for all conditions and most often had one prescriber of cardiometabolic medications. In adjusted analyses, the number of prescribers was not significantly associated with availability of oral diabetes agents but having more prescribers is associated with increased medication availability in older Medicare beneficiaries with dyslipidemia or hypertension. CONCLUSION: The incremental addition of new prescribers may be clinically reasonable for complex patients but creates the potential for coordination problems and informational discontinuity over time. Health systems may want to identify complex patients with multiple prescribers to minimize care fragmentation.

Prescriber Continuity and Disease Control of Older Adults.

BACKGROUND: Medicare beneficiaries with multiple chronic conditions are typically seen by multiple providers, particularly specialists. Clinically appropriate referrals to multiple specialists may compromise the continuity of care for multiple chronic condition beneficiaries and create care plans that patients may find challenging to reconcile, which may impact patient outcomes. OBJECTIVE: The objective was to examine whether glycemic control or lipid control was associated with the number of prescribers of cardiometabolic medications. RESEARCH DESIGN, SUBJECTS, AND MEASURES: A retrospective cross-sectional cohort analysis of 51,879 elderly Medicare fee-for-service beneficiaries with diabetes and 129,762 beneficiaries with dyslipidemia living in 10 east coast states. Glycemic control was defined as having an HbA1c<7.5. Lipid control was defined as an low-density lipoprotein<100 for beneficiaries with heart disease or diabetes or an low-density lipoprotein<130 for all other beneficiaries. We examined the association between the number of prescribers of cardiometabolic medications and disease or lipid control in 2011 through logistic regression, controlling for age, sex, race, Medicaid enrollment, 17 chronic conditions and state-fixed effects. RESULTS: Among beneficiaries with diabetes, 76% with one prescriber had well-controlled diabetes in 2011, which decreased to 65% for beneficiaries with 5+ prescribers. In adjusted analyses, Medicare beneficiaries with 3 or more prescribers were less likely to have glycemic control than beneficiaries with a single prescriber. Among those with dyslipidemia, nearly all (91%-92%) beneficiaries had lipid control. After adjustment for demographics and comorbidity burden, beneficiaries with 3 prescribers were less likely to have lipid control than beneficiaries with a single prescriber. CONCLUSIONS: Multiple prescribers were associated with worse disease control, possibly because patients with more severe diabetes or dyslipidemia have multiple prescribers or because care fragmentation is associated with worse disease control.

Gastric Bypass Surgery Leads to Long-term Remission or Improvement of Type 2 Diabetes and Significant Decrease of Microvascular and Macrovascular Complications.

OBJECTIVES: The aim of the study was to compare long-term outcomes of 2 groups of morbidly obese patients with type 2 diabetes mellitus-1 managed by Roux-en-Y gastric bypass surgery and a comparable group managed medically. METHODS: The present study was a single-institution retrospective study. Of the 173 obese patients with type 2 diabetes mellitus undergoing gastric bypass surgery between January 2000 and July 2004, 78 patients (45%) were followed for at least 10 years. The control group consisted of 80 diabetic obese patients from the same period with similar body mass index, age, race, and severity of diabetes. The median follow-up was 11 years for both the groups. RESULTS: The group undergoing gastric bypass surgery had greater percentage of excess weight loss than the control group-66% versus -1.6%, respectively. Forty-one patients (52.6%) in the surgery group had complete remission of diabetes and 5 (6.4%) had partial remission. Twelve patients (15.4%) had diabetes recurrence after initial remission. No patient in the control group had remission of diabetes. Compared with the control group, the group undergoing gastric bypass surgery had a significantly reduced incidence of microvascular complications-46.3% versus 11.5%, and macrovascular complications-20.3% versus 5%, respectively (P < 0.01). CONCLUSIONS: In this study, we demonstrated that after 10 years of follow-up, Roux-en-Y gastric bypass surgery, compared with nonsurgical medical management, resulted in significantly greater weight loss, reduction in hemoglobin A1c, and use of antidiabetic medications, and very importantly a lower incidence of both microvascular and macrovascular complications in obese patients with type 2 diabetes.

Utilization of surgical procedures and racial disparity in the treatment of urinary incontinence after prostatectomy.

AIMS: To analyze the rates of incontinence procedures after radical prostatectomy, and define the variables associated with them. METHODS: We conducted an IRB approved retrospective review of patients with prostate cancer who underwent radical prostatectomy at a single institute from January 1998 to December 2012. Logistic regression and time to event analyses were performed to ascertain variables associated with receipt of incontinence procedure after prostatectomy. RESULTS: Four thousand four hundred one men underwent radical prostatectomy (69.8% open, 30.1% laparoscopic or robotic) of whom 74.3% were white Caucasian and 22.1% were African-American. Overall, 165 (3.7%) patients underwent a total of 191 procedures for male urethral sling or artificial urinary sphincter placement. African-American men received fewer incontinence procedures than white Caucasian men (2.1% versus 4.3%, P = 0.001); and with a longer delay after prostatectomy than white Caucasian men (28.3 months versus 19.9 months, P = 0.029). Men who had a laparoscopic or robotic prostatectomy received an incontinence procedure earlier than men who had an open prostatectomy (17.6 months versus 24.4 months, P = 0.0001). On multivariate analysis, age at prostatectomy, diagnosis of incontinence, and race were independently associated with receiving an incontinence procedure. CONCLUSIONS: The overall rate of incontinence surgery after radical prostatectomy is low at 3.7%. African-American men receive incontinence procedures at a lower rate and with a longer delay after prostatectomy than white Caucasian men. Further studies are needed to define the reasons for this racial disparity in urinary incontinence surgery in the prostate cancer survivor. Neurourol. Urodynam. 35:733-737, 2016. © 2015 Wiley Periodicals, Inc.

Environmental Changes in MoTe2 Excitonic Dynamics by Defects-Activated Molecular Interaction.

Monolayers of group VI transition metal dichalcogenides possess direct gaps in the visible spectrum with the exception of MoTe2, where its gap is suitably located in the infrared region but its stability is of particular interest, as tellurium compounds are acutely sensitive to oxygen exposure. Here, our environmental (time-dependent) measurements reveal two distinct effects on MoTe2 monolayers: For weakly luminescent monolayers, photoluminescence signal and optical contrast disappear, as if they are decomposed, but yet remain intact as evidenced by AFM and Raman measurements. In contrast, strongly luminescent monolayers retain their optical contrast for a prolonged amount of time, while their PL peak blue-shifts and PL intensity saturates to slightly lower values. Our X-ray photoelectron spectroscopy measurements and DFT calculations suggest that the presence of defects and functionalization of these defect sites with O2 molecules strongly dictate their material properties and aging response by changing the excitonic dynamics due to deep or shallow states that are created within the optical band gap. Presented results not only shed light on environmental effects on fundamental material properties and excitonic dynamics of MoTe2 monolayers but also highlight striking material transformation for metastable 2D systems such as WTe2, silicone, and phosphorene.

Nanoimprint lithography for high-efficiency thin-film silicon solar cells.

We demonstrate high-efficiency thin-film silicon solar cells with transparent nanotextured front electrodes fabricated via ultraviolet nanoimprint lithography on glass substrates. By replicating the morphology of state-of-the-art nanotextured zinc oxide front electrodes known for their exceptional light trapping properties, conversion efficiencies of up to 12.0% are achieved for micromorph tandem junction cells. Excellent light incoupling results in a remarkable summed short-circuit current density of 25.9 mA/cm(2) for amorphous top cell and microcrystalline bottom cell thicknesses of only 250 and 1100 nm, respectively. As efforts to maximize light harvesting continue, our study validates nanoimprinting as a versatile tool to investigate nanophotonic effects of a large variety of nanostructures directly on device performance.