Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments.

BACKGROUND: Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS: Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS: In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS: Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Effects of rurality and distance to care on perinatal outcomes over a 1-year period during the COVID-19 pandemic.

PURPOSE: Our aim was to investigate the roles of rurality and distance to care on adverse perinatal outcomes and COVID-19 seroprevalence at the time of delivery over a 1-year period. METHODS: Data were collected from the electronic medical record on all pregnant patients who delivered at a single, large, Midwest academic medical center over 1 year. Rurality was classified using standard Rural-Urban Commuting Area codes. Geographic Information System tools were used to map outcomes. Data were analyzed with univariate and multivariate models, controlling for Body Mass Index (BMI), insurance status, and parity. FINDINGS: A total of 2,497 patients delivered during the study period; 20% of patients were rural (n = 499), 18.6% were micropolitan (n = 466), and 61.4% were metropolitan (n = 1,532). 10.4% of patients (n = 259) were COVID-19 seropositive. Rural patients did not experience higher rates of any measured adverse outcomes than metropolitan patients; micropolitan patients had increased odds of preterm labor (OR = 1.41, P = .022) and pre-eclampsia (OR = 1.78, P<.001). Patients living 30+ miles away from the medical center had increased odds of preterm labor (OR = 1.94, P<.001), pre-eclampsia (OR = 1.73, P = .002), and infant admission to the neonatal intensive care unit (OR = 2.12, P<.001), as well as lower gestational age at delivery (ß = -9.2 days, P<.001) and birth weight (ß = -206 grams, P<.001). CONCLUSION: Distance to care, rather than rurality, was the key predictor of multiple adverse perinatal outcomes in this cohort of deliveries over a 1-year period. Our study suggests that rurality should not be used as a standalone indicator of access to care without further knowledge of the specific barriers affecting a given population.

Hospital Rurality and Gene Expression Profiling for Early-Stage Breast Cancer among Iowa Residents (2010-2018).

Objective: Given the challenges rural cancer patients face in accessing cancer care as well as the slower diffusion and adoption of new medical technologies among rural providers, the aim of our study was to examine trends in gene expression profiling (GEP) testing and evaluate the association between hospital rurality and receipt of GEP testing. Methods: Data from the Iowa Cancer Registry (ICR) were used to identify women with newly diagnosed, histologically confirmed breast cancer from 2010 through 2018 who met eligibility criteria for GEP testing. Patients were allocated to the hospitals where their most definitive surgical treatment was received, and Rural-Urban Commuting Area codes were used to categorize hospitals into urban (N = 43), large rural (N = 16), and small rural (N = 48). Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression to evaluate the association between hospital rurality and GEP test use, adjusting for demographic and clinical characteristics. The association between test result and treatment received was assessed among patients who received Oncotype DX (ODX) testing. Results: Of 6,726 patients eligible for GEP test use, 46% (N = 3,069) underwent testing with 95% receiving ODX. While overall GEP testing rates increased over time from 42% between 2010 and 2012 to 51% between 2016 and 2018 (P trend < 0.0001), use continued to be the lowest among patients treated at hospitals in small rural areas. The odds of GEP testing remained significantly lower among patients treated at hospitals located in small rural areas (aOR 0.55; 95% CI 0.43-0.71), after adjusting for demographic and clinical characteristics. ODX recurrence scores were highly correlated with chemotherapy use across all strata of hospital rurality. Conclusions: GEP testing continues to be underutilized, especially among those treated at small rural hospitals. Targeted interventions aimed at increasing rates of GEP testing to ensure the appropriate use of adjuvant chemotherapy may improve health outcomes and lower treatment-related costs.

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study.

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs. Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov).

Sepsis is a severe condition that results from infection. In addition to costly care, sepsis is a leading cause of death and disability. When comparing outcomes, those treated for sepsis in lower volume emergency departments fare worse and rural emergency departments often have lower patient volumes. While telehealth has been shown to improve sepsis care, the effect of telehealth on costs and long-term outcomes for patients is unclear. This study will use Medicare claims data to compare outcomes for people with sepsis in rural emergency departments who had video telehealth used with those who did not have video telehealth used, with the goal of measuring how telehealth affects healthcare costs, hospital readmissions and deaths after hospital discharge.

LINKING GPS DATA TO GIS DATABASES IN NATURALISTIC STUDIES: EXAMPLES FROM DRIVERS WITH OBSTRUCTIVE SLEEP APNEA.

In naturalistic studies, it is vital to give appropriate context when analyzing driving behaviors. Such contextualization can help address the hypotheses that explore a) how drivers perform within specific types of environment (e.g., road types, speed limits, etc.), and b) how often drivers are exposed to such specific environments. In order to perform this contextualization in an automated fashion, we are using Global Positioning System (GPS) data obtained at 1 Hz and merging this with Geographic Information Systems (GIS) databases maintained by the Iowa Department of Transportation (DOT). In this paper, we demonstrate our methods of doing this based on data from 43 drivers with obstructive sleep apnea (OSA). We also use maps from GIS software to illustrate how information can be displayed at the individual drive or day level, and we provide examples of some of the challenges that still need to be addressed.

Fire and grazing influences on rates of riparian woody plant expansion along grassland streams.

Grasslands are threatened globally due to the expansion of woody plants. The few remaining headwater streams within tallgrass prairies are becoming more like typical forested streams due to rapid conversion of riparian zones from grassy to wooded. Forestation can alter stream hydrology and biogeochemistry. We estimated the rate of riparian woody plant expansion within a 30 m buffer zone surrounding the stream bed across whole watersheds at Konza Prairie Biological Station over 25 years from aerial photographs. Watersheds varied with respect to experimentally-controlled fire and bison grazing. Fire frequency, presence or absence of grazing bison, and the historical presence of woody vegetation prior to the study time period (a proxy for proximity of propagule sources) were used as independent variables to predict the rate of riparian woody plant expansion between 1985 and 2010. Water yield was estimated across these years for a subset of watersheds. Riparian woody encroachment rates increased as burning became less frequent than every two years. However, a higher fire frequency (1-2 years) did not reverse riparian woody encroachment regardless of whether woody vegetation was present or not before burning regimes were initiated. Although riparian woody vegetation cover increased over time, annual total precipitation and average annual temperature were variable. So, water yield over 4 watersheds under differing burn frequencies was quite variable and with no statistically significant detected temporal trends. Overall, burning regimes with a frequency of every 1-2 years will slow the conversion of tallgrass prairie stream ecosystems to forested ones, yet over long time periods, riparian woody plant encroachment may not be prevented by fire alone, regardless of fire frequency.

Evidence of physiological decoupling from grassland ecosystem drivers by an encroaching woody shrub.

Shrub encroachment of grasslands is a transformative ecological process by which native woody species increase in cover and frequency and replace the herbaceous community. Mechanisms of encroachment are typically assessed using temporal data or experimental manipulations, with few large spatial assessments of shrub physiology. In a mesic grassland in North America, we measured inter- and intra-annual variability in leaf δ(13)C in Cornus drummondii across a grassland landscape with varying fire frequency, presence of large grazers and topographic variability. This assessment of changes in individual shrub physiology is the largest spatial and temporal assessment recorded to date. Despite a doubling of annual rainfall (in 2008 versus 2011), leaf δ(13)C was statistically similar among and within years from 2008-11 (range of -28 to -27‰). A topography*grazing interaction was present, with higher leaf δ(13)C in locations that typically have more bare soil and higher sensible heat in the growing season (upland topographic positions and grazed grasslands). Leaf δ(13)C from slopes varied among grazing contrasts, with upland and slope leaf δ(13)C more similar in ungrazed locations, while slopes and lowlands were more similar in grazed locations. In 2011, canopy greenness (normalized difference vegetation index - NDVI) was assessed at the centroid of individual shrubs using high-resolution hyperspectral imagery. Canopy greenness was highest mid-summer, likely reflecting temporal periods when C assimilation rates were highest. Similar to patterns seen in leaf δ(13)C, NDVI was highest in locations that typically experience lowest sensible heat (lowlands and ungrazed). The ability of Cornus drummondii to decouple leaf physiological responses from climate variability and fire frequency is a likely contributor to the increase in cover and frequency of this shrub species in mesic grassland and may be generalizable to other grasslands undergoing woody encroachment.

Timing of climate variability and grassland productivity.

Future climates are forecast to include greater precipitation variability and more frequent heat waves, but the degree to which the timing of climate variability impacts ecosystems is uncertain. In a temperate, humid grassland, we examined the seasonal impacts of climate variability on 27 y of grass productivity. Drought and high-intensity precipitation reduced grass productivity only during a 110-d period, whereas high temperatures reduced productivity only during 25 d in July. The effects of drought and heat waves declined over the season and had no detectable impact on grass productivity in August. If these patterns are general across ecosystems, predictions of ecosystem response to climate change will have to account not only for the magnitude of climate variability but also for its timing.

Linking plant growth responses across topographic gradients in tallgrass prairie.

Aboveground biomass in grasslands varies according to landscape gradients in resource availability and seasonal patterns of growth. Using a transect spanning a topographic gradient in annually burned ungrazed tallgrass prairie, we measured changes in the height of four abundant C(4) grass species, LAI, biomass, and cumulative carbon flux using two closely located eddy flux towers. We hypothesized that seasonal patterns of plant growth would be similar across the gradient, but the magnitude of growth and biomass accumulation would vary by topographic position, reflecting spatial differences in microclimate, slope, elevation, and soil depth. Thus, identifying and measuring local growth responses according to topographic variability should significantly improve landscape predictions of aboveground biomass. For most of the growth variables measured, classifying topography into four positions best captured the inherent spatial variability. Biomass produced, seasonal LAI and species height increased from the upland and break positions to the slope and lowland. Similarly, cumulative carbon flux in 2008 was greater in lowland versus upland tower locations (difference of 64 g m(-2) by DOY 272). Differences in growth by topographic position reflected increased production of flowering culms by Andropogon gerardii and Sorghastrum nutans in lowland. Varying growth responses by these species may be a significant driver of biomass and carbon flux differences by topographic position, at least for wet years. Using a digital elevation model to classify the watershed into topographic positions, we performed a geographically weighted regression to predict landscape biomass. The minimum and maximum predictions of aboveground biomass for this watershed had a large range (86-393 t per 40.4 ha), illustrating the drastic spatial variability in growth within this annually-burned grassland.

Functional consequences of climate change-induced plant species loss in a tallgrass prairie.

Future climate change is likely to reduce the floristic diversity of grasslands. Yet the potential consequences of climate-induced plant species losses for the functioning of these ecosystems are poorly understood. We investigated how climate change might alter the functional composition of grasslands for Konza Prairie, a diverse tallgrass prairie in central North America. With species-specific climate envelopes, we show that a reduction in mean annual precipitation would preferentially remove species that are more abundant in the more productive lowland positions at Konza. As such, decreases in precipitation could reduce productivity not only by reducing water availability but by also removing species that inhabit the most productive areas and respond the most to climate variability. In support of this prediction, data on species abundance at Konza over 16 years show that species that are more abundant in lowlands than uplands are preferentially reduced in years with low precipitation. Climate change is likely to also preferentially remove species from particular functional groups and clades. For example, warming is forecast to preferentially remove perennials over annuals as well as Cyperaceae species. Despite these predictions, climate change is unlikely to unilaterally alter the functional composition of the tallgrass prairie flora, as many functional traits such as physiological drought tolerance and maximum photosynthetic rates showed little relationship with climate envelope parameters. In all, although climatic drying would indirectly alter grassland productivity through species loss patterns, the insurance afforded by biodiversity to ecosystem function is likely to be sustained in the face of climate change.

Habitat acquisition strategies for grassland birds in an urbanizing landscape.

Habitat protection for grassland birds is an important component of open space land acquisition in suburban Chicago. We use optimization decision models to develop recommendations for land protection and analyze tradeoffs between alternative goals. One goal is to acquire (and restore if necessary) as much grassland habitat as possible for a given budget. Because a viable habitat for grassland birds consists of a relatively large core area with additional parcels of grassland habitat nearby, the second goal is to minimize total pairwise distance between newly protected parcels and large existing reserves. We also use the concept of an effective grassland habitat area, which considers influences that neighboring land covers have on grassland habitat suitability. We analyze how the parcels selected for protection change as total protected effective area is traded off against total distance. As area is weighted more heavily, the selected parcels are scattered and unconnected. As total distance is weighted more heavily, the selected parcels coalesce around core reserves but protect less area. The differences in selected parcels as we change the objective function weights are caused by the differences in price per unit of effective habitat area across parcels. Parcels located in close proximity to the existing cores have relatively high prices per hectare of effective grassland area as a consequence of high restoration costs and adverse influences from roads, urban areas and/or forestland. As a result, these parcels have lower priority for selection when the area objective is weighted more heavily for a given budget.