Geographical Variation In Medication and Health Resource Use In Multiple Sclerosis.

BACKGROUND: Understanding disease-modifying therapy (DMT) use and healthcare resource utilization by different geographical areas among people living with multiple sclerosis (pwMS) may identify care gaps that can be used to inform policies and practice to ensure equitable care. METHODS: Administrative data was used to identify pwMS on April 1, 2017 (index date) in Alberta. DMT use and healthcare resource utilization were compared between those who resided in various geographical areas over a 2-year post-index period; simple logistic regression was applied. RESULTS: Among the cohort (n = 12,338), a higher proportion of pwMS who resided in urban areas (versus rural) received ≥ 1 DMT dispensation (32.3% versus 27.4%), had a neurologist (67.7% versus 63.9%), non-neurologist specialist (88.3% versus 82.9%), ambulatory care visit (87.4% versus 85.3%), and MS tertiary clinic visit (59.2% versus 51.7%), and a lower proportion had an emergency department (ED) visit (46.3% versus 62.4%), and hospitalization (20.4% versus 23.0%). Across the provincial health zones, there were variations in DMT selection, and a higher proportion of pwMS who resided in the Calgary health zone, where care is managed by MS tertiary clinic neurologists, had an outpatient visit to a neurologist or MS tertiary clinic versus those who resided in other zones where delivery of MS-related care is more varied. CONCLUSIONS: Urban/rural inequalities in DMT use and healthcare resource utilization appear to exist among pwMS in Alberta. Findings suggest the exploration of barriers with consequent strategies to increase access to DMTs and provide timely outpatient MS care management, particularly for those pwMS residing in rural areas.

Poststroke Care Pathways and Spasticity Treatment: A Retrospective Study in Alberta.

BACKGROUND: Limited evidence exists regarding care pathways for stroke survivors who do and do not receive poststroke spasticity (PSS) treatment. METHODS: Administrative data was used to identify adults who experienced a stroke and sought acute care between 2012 and 2017 in Alberta, Canada. Pathways of stroke care within the health care system were determined among those who initiated PSS treatment (PSS treatment group: outpatient pharmacy dispensation of an anti-spastic medication, focal chemo-denervation injection, or a spasticity tertiary clinic visit) and those who did not (non-PSS treatment group). Time from the stroke event until spasticity treatment initiation, and setting where treatment was initiated were reported. Descriptive statistics were performed. RESULTS: Health care settings within the pathways of stroke care that the PSS (n = 1,079) and non-PSS (n = 22,922) treatment groups encountered were the emergency department (86 and 84%), acute inpatient care (80 and 69%), inpatient rehabilitation (40 and 12%), and long-term care (19 and 13%), respectively. PSS treatment was initiated a median of 291 (interquartile range 625) days after the stroke event, and most often in the community when patients were residing at home (45%), followed by "other" settings (22%), inpatient rehabilitation (18%), long-term care (11%), and acute inpatient care (4%). CONCLUSIONS: To our knowledge, this is the first population based cohort study describing pathways of care among adults with stroke who subsequently did or did not initiate spasticity treatment. Areas for improvement in care may include strategies for earlier identification and treatment of PSS.

Disease-modifying therapy use and health resource utilisation associated with multiple sclerosis over time: A retrospective cohort study from Alberta, Canada.

BACKGROUND: Estimating multiple sclerosis (MS) prevalence and incidence, and assessing the utilisation of disease-modifying therapies (DMTs) and healthcare resources over time is critical to understanding the evolution of disease burden and impacts of therapies upon the healthcare system. METHODS: A retrospective population-based study was used to determine MS prevalence and incidence (2003-2019), and describe utilisation of DMTs (2009-2019) and healthcare resources (1998-2019) among people living with MS (pwMS) using administrative data in Alberta. RESULTS: Prevalence increased from 259 (95% confidence interval [CI]: 253-265) to 310 (95% CI: 304, 315) cases per 100,000 population, and incidence decreased from 21.2 (95% CI: 19.6-22.8) to 12.7 (95% CI: 11.7-13.8) cases per 100,000 population. The proportion of pwMS who received ≥1 DMT dispensation increased (24% to 31% annually); use of older platform injection therapies decreased, and newer oral-based, induction, and highly-effective therapies increased. The proportion of pwMS who had at least one MS-related physician, ambulatory, or tertiary clinic visits increased, and emergency department visits and hospitalizations decreased. CONCLUSIONS: Alberta has one of the highest rates of MS globally. The proportion of pwMS who received DMTs and had outpatient visits increased, while acute care visits decreased over time. The landscape of MS care appears to be rapidly evolving in response to changes in disease burden and new highly-effective therapies.

Identification of knowledge gaps in whole-genome sequence analysis of multi-resistant thermotolerant Campylobacter spp.

BACKGROUND: Campylobacter spp. is the most frequent cause of bacterial food-borne gastroenteritis and a high priority antibiotic resistant bacterium according to the World Health Organization (WHO). European monitoring of thermotolerant Campylobacter spp. does not reflect the global burden of resistances already circulating within the bacterial population worldwide. METHODS: We systematically compared whole genome sequencing with comprehensive phenotypic antimicrobial susceptibility, analyzing 494 thermotolerant Campylobacter poultry isolates from Vietnam and Germany. Any discrepancy was checked by repeating the wet lab and improving the dry lab part. Selected isolates were additionally analyzed via long-read Oxford Nanopore technology, leading to closed chromosomes and plasmids. RESULTS: Overall, 22 different resistance genes and gene variants (e. g. erm(B), aph(3')-IIIa, aph(2'')-If, catA, lnu(C), blaOXA, sat4) and point mutations in three distinct genes (gyrA, 23S rRNA, rpsL) associated with AMR were present in the Campylobacter isolates. Two AMR genes were missing in the database and one falsely associated with resistance. Bioinformatic analysis based on short-read data partly failed to identify tet(O) and aadE, when the genes were present as duplicate or homologous gene variants. Intriguingly, isolates also contained different determinants, redundantly conferring resistance to chloramphenicol, gentamicin, kanamycin, lincomycin and streptomycin. We found a novel tet(W) in tetracycline sensitive strains, harboring point mutations. Furthermore, analysis based on assemblies from short-read data was impaired to identify full length phase variable aad9, due to variations of the poly-C tract within the gene. The genetic determinant responsible for gentamicin resistance of one isolate from Germany could not be identified. GyrT86I, presenting the main determinant for (fluoro-)quinolone resistance led to a rare atypical phenotype of ciprofloxacin resistance but nalidixic acid sensitivity. Long-read sequencing predicted AMR genes were mainly located on the chromosome, and rarely on plasmids. Predictions from long- and short-read sequencing, respectively, often differed. AMR genes were often organized in multidrug resistance islands (MDRI) and partially located in proximity to transposase genes, suggesting main mobilization of resistance determinants is via natural transformation and transposition in Campylobacter. CONCLUSIONS: The results of this study suggest that there is frequent resistance gene duplication, mosaicism, and mutation leading to gene variation and truncation in Campylobacter strains that have not been reported in previous studies and are missing from databases. Furthermore, there is a need for deciphering yet unknown resistance mechanisms and resistance spread in thermotolerant Campylobacter spp. that may pose a challenge to global food safety.

Multiplex Real-Time PCR for the Detection of Tetracycline, Ciprofloxacin, and Erythromycin Resistance Determinants from Human and Foodborne Campylobacter jejuni and Campylobacter coli.

Campylobacter jejuni and Campylobacter coli are the predominant thermophilic species responsible for foodborne gastroenteritis worldwide. Elevated resistance to certain antibiotics was observed due to antimicrobial therapy in farm animals and humans, while reduced antimicrobial usage partially reduced antibiotic resistance. Monitoring the antimicrobial resistance demonstrated a substantial fraction of multi-resistant isolates, indicating the necessity of reliable tools for their detection. In this study, resistance determinants in 129 German and 21 Vietnamese isolates were selected to establish a novel multiplex real-time PCR (qPCR), facilitating the simultaneous detection of four resistance determinants. These comprised tet(O) gene variants associated with tetracycline resistance, point mutations GyrA_T86I and GyrA_T86V associated with ciprofloxacin resistance, and the erm(B) gene together with the point mutation A2075G in the 23S rRNA gene, associated with erythromycin resistance. Moreover, the performance of the qPCR assay was evaluated by comparing the results of qPCR to phenotypic antimicrobial resistance profiles, obtained with standardized EUCAMP3 microdilution panel, which showed 100% similarity (inclusivity and exclusivity). Variation in measurement methods, including qPCR machines and master mixes showed robustness, essential for laboratories. The assay can be used for the rapid detection of resistance determinants, and is beneficial for monitoring the spread of antibiotic resistance in C. jejuni and C. coli.

Health care cost of severe obesity and obesity-related comorbidities: A retrospective cohort study from Alberta, Canada.

BACKGROUND: Estimates of health care costs associated with severe obesity, and those attributable to specific health conditions among adults living with severe obesity are needed. METHODS: Administrative data was used to identify adults who previously received a procedure, and had (investigational cohort) or did not have (control cohort) a body mass index ≥ 35 kg/m2. Two-part models were used to estimate the incremental health care cost of severe obesity and related health conditions during a 1-year observation period. RESULTS: Adjusting for potential confounders, the total health care cost ratio was higher in the investigational (n = 220,190) versus control (n = 1,955,548) cohort (1.32 [95 % CI: 1.32, 1.33]) with a predicted incremental cost of $2221 (95 % CI $2184, $22,265) per person-year; costs were less when obesity-related health conditions were controlled for (1.13 [95 % CI: 1.13, 1.14]; $1097 [95 % CI: $1084, $1110] per person-year). Among those living with severe obesity, incremental costs associated with specific health conditions ranged from $737 (95 % CI: $747, $728) lower (dyslipidemia) to $12,996 (95 % CI: $12,512, $13,634) higher (peripheral vascular disease) per person-year. CONCLUSIONS: Adults living with severe obesity had greater costs than those without, largely driven by obesity-related health conditions. For the Alberta adult population with a severe obesity prevalence of 11 %, severe obesity may account for an estimated additional $453-918 million in health care costs per year. Findings of this study provide rationale for resources and strategies to prevent and manage obesity and its complications.

Trajectory of health care resources among adults stopping or reducing treatment frequency of botulinum toxin for chronic migraine treatment in Alberta, Canada.

OBJECTIVE: Understand health resource, medication use, and cost of adults with chronic migraine who received guideline-recommended onabotulinumtoxinA (botulinum toxin) treatment frequency and then continued or reduced/stopped. BACKGROUND: Botulinum toxin may be a beneficial treatment for chronic migraine; the trajectory of health resources utilization among those with continued or reduced/stopped use is unclear. METHODS: A retrospective population-based cohort study utilizing administrative data from Alberta, Canada (2012-2020), was performed. A cohort of adults who received ≥5 botulinum toxin treatment cycles for chronic migraine over 18 months (6-month run-in; 1-year pre-index period) were grouped into those who (1) continued use (≥3 treatments/year), or (2) stopped or reduced use (stopped for 6 months then received 0 or 1-2 treatments/year, respectively) over a 1-year post-index period. Health resources and medication use were described, and pre-post costs were assessed. A second cohort that received ≥3 treatments/year immediately followed by 1 year of stopped or reduced use was considered in sensitivity analysis. RESULTS: Pre-post health resource, medication use, and costs were similar among those with continued use (n = 3336). Among those who stopped or reduced use (n = 1099; 756 stopped, 343 reduced), health resource, medication use, and costs were lower in the post- (total median per-person cost [IQR]: all-cause $4851 [$8090]; migraine-related $835 [$1915]) versus pre- (all-cause $6096 [$7207]; migraine-related $2995 [$1950]) index period (estimated cost ratios [95% CI]: total all-cause 0.86 [0.79, 0.95]; total migraine-related 0.44 [0.40, 0.48]). In the second cohort (n = 3763), return to continued use (≥3 treatments/year) occurred in up to 70.4% in those with reduced use. CONCLUSIONS: Of adults treated with botulinum toxin for chronic migraine, 75.2% had continued use, stable health resource and medication use, and costs over a 2 year period. In those that stopped/reduced use, the observed lower health resource and migraine medication use may indicate improved symptom control, but the resumption of guideline-recommended treatment intervals after reduced use was common.

Analgesic Use Among Adults with a Trauma-Related Emergency Department Visit: A Retrospective Cohort Study from Alberta, Canada.

INTRODUCTION: A better understanding of current acute pain-driven analgesic practices within the emergency department (ED) and upon discharge will provide foundational information in this area, as few studies have been conducted in Canada. METHODS: Administrative data were used to identify adults with a trauma-related ED visit in the Edmonton area in 2017/2018. Characteristics of the ED visit included time from initial contact to analgesic administration, type of analgesics dispensed during and upon being discharged home directly from the ED (≤ 7 days after), and patient characteristics. RESULTS: A total of 50,950 ED visits by 40,505 adults with trauma were included. Analgesics were administered in 24.2% of visits, of which non-opioids were dispensed in 77.0% and opioids were dispensed in 49.0%. Time to analgesic initiation occurred more than 2 h after first contact. Upon discharge, 11.5% received a non-opioid and 15.2% received an opioid analgesic, among whom 18.5% received a daily dose ≥ 50 morphine milligram equivalents (MME) and 30.2% received > 7 days of supply. Three hundred and seventeen adults newly met criteria for chronic opioid use after the ED visit, among whom 43.5% received an opioid dispensation upon discharge; of these individuals, 26.8% had a daily dose ≥ 50 MME and 65.9% received > 7 days of supply. CONCLUSIONS: Findings can be used to inform optimization of analgesic pharmacotherapy practices for the treatment of acute pain, which may include reducing the time to initiation of analgesics in the ED, as well as close consideration of recommendations for acute pain management upon discharge to provide ideal patient-centered, evidence-informed care.

Health resource utilization and cost before versus after initiation of second-generation long-acting injectable antipsychotics among adults with schizophrenia in Alberta, Canada: a retrospective, observational single-arm study.

BACKGROUND: Long-acting injectable (LAI) antipsychotics, along with community treatment orders (CTOs), are used to improve treatment effectiveness through adherence among individuals with schizophrenia. Understanding real-world medication adherence, and healthcare resource utilization (HRU) and costs in individuals with schizophrenia overall and by CTO status before and after second generation antipsychotic (SGA)-LAI initiation may guide strategies to optimize treatment among those with schizophrenia. METHODS: This retrospective observational single-arm study utilized administrative health data from Alberta, Canada. Adults (≥ 18 years) with schizophrenia who initiated a SGA-LAI (no use in the previous 2-years) between April 1, 2014 and March 31, 2016, and had ≥ 1 additional dispensation of a SGA-LAI were included; index date was the date of SGA-LAI initiation. Medication possession ratio (MPR) was determined, and paired t-tests were used to examine mean differences in all-cause and mental health-related HRU and costs (Canadian dollars), comprised of hospitalizations, physician visits, emergency department visits, and total visits, over the 2-year post-index and 2-year pre-index periods. Analyses were stratified by presence or absence of an active CTO during the pre-index and/or post-index periods. RESULTS: Among 1,211 adults with schizophrenia who initiated SGA-LAIs, 64% were males with a mean age of 38 (standard deviation [SD] 14) years. The mean overall antipsychotic MPR was 0.39 (95% confidence interval [CI] 0.36, 0.41) greater during the 2-year post-index period (0.84 [SD 0.26]) compared with the 2-year pre-index period (0.45 [SD 0.40]). All-cause and mental health-related HRU and costs were lower post-index versus pre-index (p < 0.001) for hospitalizations, physician visits, emergency department visits, and total visits; mean total all-cause HRU costs were $33,788 (95% CI -$38,993, -$28,583) lower post- versus pre-index ($40,343 [SD $68,887] versus $74,131 [SD $75,941]), and total mental health-related HRU costs were $34,198 (95%CI -$39,098, -$29,297) lower post- versus pre-index ($34,205 [SD $63,428] versus $68,403 [SD $72,088]) per-patient. Forty-three percent had ≥ 1 active CTO during the study period; HRU and costs varied according to CTO status. CONCLUSIONS: SGA-LAIs are associated with greater medication adherence, and lower HRU and costs however the latter vary according to CTO status.

Challenging the "gold standard" of colony-forming units - Validation of a multiplex real-time PCR for quantification of viable Campylobacter spp. in meat rinses.

Campylobacter jejuni is the leading bacterial food-borne pathogen in Europe. Despite the accepted limits of cultural detection of the fastidious bacterium, the "gold standard" in food microbiology is still the determination of colony-forming units (CFU). As an alternative, a live/dead differentiating qPCR has been established, using propidium monoazide (PMA) as DNA-intercalating crosslink agent for inactivating DNA from dead, membrane-compromised cells. The PMA treatment was combined with the addition of an internal sample process control (ISPC), i.e. a known number of dead C. sputorum cells to the samples. The ISPC enables i), monitoring the effective reduction of dead cell signal by the light-activated DNA-intercalating dye PMA, and ii), compensation for potential DNA losses during processing. Here, we optimized the method for routine application and performed a full validation of the method according to ISO 16140-2:2016(E) for the quantification of live thermophilic Campylobacter spp. in meat rinses against the classical enumeration method ISO 10272-2:2017. In order to render the method applicable and cost-effective for practical application, the ISPC was lyophilized to be distributable to routine laboratories. In addition, a triplex qPCR was established to simultaneously quantify thermophilic Campylobacter, the ISPC and an internal amplification control (IAC). Its performance was statistically similar to the two duplex qPCRs up to a contamination level of 4.7 log10Campylobacter per ml of meat rinse. The limit of quantification (LOQ) of the alternative method was around 20 genomic equivalents per PCR reaction, i.e. 2.3 log10 live Campylobacter per ml of sample. The alternative method passed a relative trueness study, confirming the robustness against different meat rinses, and displayed sufficient accuracy within the limits set in ISO 16140-2:2016(E). Finally, the method was validated in an interlaboratory ring trial, confirming that the alternative method was fit for purpose with a tendency of improved repeatability and reproducibility compared to the reference method for CFU determination. Campylobacter served as a model organism, challenging CFU as "gold standard" and could help in guidance to the general acceptance of live/dead differentiating qPCR methods for the detection of food-borne pathogens.

Association between buprenorphine/naloxone and high-dose opioid analgesic prescribing in Kentucky, 2012-2017.

INTRODUCTION: Buprenorphine/naloxone treatment is a highly effective treatment for opioid use disorder decreasing illicit opioid use and both all-cause and opioid-involved overdose mortality. The purpose of this study was to investigate the relationships between buprenorphine/naloxone prescribing and high-dose opioid analgesic prescribing (HDOAP) over time. METHODS: This longitudinal study used 2012-2017 Kentucky All Schedule Prescription Electronic Reporting data and cross-lagged structural equation analysis. For each quarter-county observation, HDOAP rate (per 1,000 residents with opioid analgesic prescriptions) was used to predict buprenorphine/naloxone prescribing rate at the next quarter, and simultaneously buprenorphine/naloxone prescribing rate was used to predict HDOAP at the next quarter, accounting for baseline socioeconomic status, medical needs for opioid analgesics, and heroin availability. RESULTS: On average, HDOAP rates in Kentucky decreased by more than 10% (p < .0001) and buprenorphine/naloxone prescribing rates increased by more than 5% (p < .0001) per quarter over the study period. Every one-per-thousand higher HDOAP rate in an earlier quarter was associated with a 0.01/1,000 increase in the buprenorphine/naloxone prescribing rate in a later quarter (p = .009). Conversely, a one-unit higher buprenorphine/naloxone prescribing rate in an earlier quarter was associated with a 0.01/1,000 reduction in the HDOAP rate in a subsequent quarter (p = .017). CONCLUSIONS: Our results indicate a significant reciprocal relationship between HDOAP and buprenorphine/naloxone prescribing and a clinically meaningful effect of buprenorphine/naloxone prescribing on reducing HDOAP. Future studies on buprenorphine/naloxone treatment expansion should take into account this bi-directional association in the context of longitudinal data and evaluate for public health benefits beyond the reduction of HDOAP.

Trends and Patterns of Opioid Analgesic Prescribing: Regional and Rural-Urban Variations in Kentucky From 2012 to 2015.

PURPOSE: Increased opioid analgesic prescribing (OAP) has been associated with increased risk of prescription opioid diversion, misuse, and abuse. We studied regional and rural-urban variations in OAP trends in Kentucky, from 2012 to 2015, and examined potential county-level risk and protective factors. METHODS: This study used prescription drug monitoring data. Marginal models employing generalized estimating equations were used to model repeated counts of residents with opioid analgesic prescriptions within county-quarter, 2012-2015, with offset for resident population, by rural-urban classification exposure, and adjusting for time-varying socioeconomic and relevant health status measures. FINDINGS: There were significant downward trends in rates of residents receiving dispensed opioid analgesic prescriptions, with no regional or rural/urban differences in the degree of decline over time. The adjusted models showed the Kentucky Appalachian region retained a significantly higher rate of residents with opioid analgesic prescriptions per 1,000 residents (30% higher than Central Kentucky and 19% higher than Kentucky Delta regions). Residents of nonmetropolitan not adjacent-to-metropolitan counties had significantly higher adjusted rates of OAP (33% higher than metropolitan counties and 17% higher compared to nonmetropolitan adjacent-to-metropolitan counties). The rate of OAP was significantly positively associated with emergency department visit injury rates and negatively associated with buprenorphine/naloxone prescribing rates. CONCLUSIONS: Information on OAP trends and patterns will be used by Kentucky stakeholders to inform targeted interventions. Further research is needed to evaluate the availability and accessibility of nonopioid pain treatment in rural counties and the role of geography and time/distance traveled as risk factors for increased OAP.

Internal sample process control improves cultivation-independent quantification of thermotolerant Campylobacter.

Quantification of Campylobacter is challenging and one major reason is the fact that bacteria lose cultivability due to cold or oxygen stress during storage at retail. Alternative live/dead discriminatory qPCR currently lacks standardization and might overestimate live cells in the presence of dead cells. In this study an internal sample process control (ISPC) was developed. The ISPC consists of a specified number of peroxide-killed C. sputorum cells to be added to each sample in order to monitor (i) the level of reduction of the signal from dead cells and (ii) DNA losses during sample processing. A species-specific fragment of the 16S rRNA gene of C. sputorum was selected as real-time PCR target, based on its similar size and gene copy number compared to the C. jejuni/coli/lari target and confirmed in an exclusivity study. Extension of the amplification oligonucleotides for the target of thermotolerant Campylobacter improved real-time PCR efficiency, rendering the method suitable for quantification according to international standards. Concordant PCR signal variation of both C. jejuni and C. sputorum targets in co-inoculated chicken rinses verified the suitability of the ISPC. This provides a crucial step towards implementation of cultivation-independent quantification for improved food safety of fastidious bacteria.

Interrupted time series design to evaluate the effect of the ICD-9-CM to ICD-10-CM coding transition on injury hospitalization trends.

BACKGROUND: Implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) in the U.S. on October 1, 2015 was a significant policy change with the potential to affect established injury morbidity trends. This study used data from a single state to demonstrate 1) the use of a statistical method to estimate the effect of this coding transition on injury hospitalization trends, and 2) interpretation of significant changes in injury trends in the context of the structural and conceptual differences between ICD-9-CM and ICD-10-CM, the new ICD-10-CM-specific coding guidelines, and proposed ICD-10-CM-based framework for reporting of injuries by intent and mechanism. Segmented regression analysis was used for statistical modeling of interrupted time series monthly data to evaluate the effect of the transition to ICD-10-CM on Kentucky hospitalizations' external-cause-of-injury completeness (percentage of records with principal injury diagnoses supplemented with external-cause-of-injury codes), as well as injury hospitalization trends by intent or mechanism, January 2012-December 2017. RESULTS: The segmented regression analysis showed an immediate significant drop in external-cause-of-injury completeness during the transition month, but returned to its pre-transition levels in November 2015. There was a significant immediate change in the percentage of injury hospitalizations coded for unintentional (3.34%) and undetermined intent (- 3.39%). There were immediate significant changes in the level of injury hospitalization rates due to poisoning, suffocation, struck by/against, other transportation, unspecified mechanism, and other specified not elsewhere classifiable mechanism. Significant change in slope after the transition (without immediate level change) was identified for assault, firearm, cut/pierce, and motor vehicle traffic injury rates. The observed trend changes reflected structural and conceptual features of ICD-10-CM coding (e.g., poisoning and suffocations are now captured via diagnosis codes only), new coding guidelines (e.g., requiring coding of injury intent as "accidental" if it is unknown or unspecified), and CDC proposed external-cause-of-injury code groupings by injury intent and mechanism. Researchers can replicate this methodology assessing trends in injuries or other ICD-10-CM-coded conditions using administrative billing data sets. CONCLUSIONS: The CDC 's Proposed Framework for Presenting Injury Data Using ICD-10-CM External Cause of Injury Codes provided a logical transition from the ICD-9-CM-based matrix on injury hospitalization trends by intent and mechanism. Our findings are intended to raise awareness that changes in the ICD-10-CM coding system must be understood to assure accurate interpretation of injury trends.

Disparities in women's cancer-related quality of life by Southern Appalachian residence.

PURPOSE: The purpose was to determine whether Appalachian residence alone or in combination with violence was linked to poorer quality of life (QOL). METHODS: Women recently diagnosed and included in either the Kentucky or North Carolina Cancer Registries were interviewed by phone between 2009 and 2015 (n = 3320; mean age = 56.74). Response rates were similar by state (40.1 in Kentucky and 40.9% in North Carolina). Appalachian (N = 990) versus non-Appalachian residents (N = 2330) were hypothesized to have poorer QOL defined as (a) lower Functional Assessment of Cancer Therapy-General (FACT-G) scores and (b) more symptoms of depression, stress, or comorbid physical conditions. Lifetime intimate partner or sexual violence was first investigated as a moderator then mediator of regional differences. Multiple analyses of covariance (MANCOVA) models were used. RESULTS: Violence modified the effect of Appalachian residence on poorer QOL outcomes; FACT-G total scores (p = .02) were lowest for women living in Appalachia who had additionally experienced violence. Socioeconomic indicators appeared to mediate or explain differences in QOL outcomes by Appalachian residence such that when adjusting for income, education and insurance, Appalachian residence remained associated only with poorer physical QOL outcomes (p < .05). CONCLUSIONS: While violence rates did not differ by residence, the combined effect of living in Appalachia and experiencing violence resulted in significantly greater impact on poorer QOL among women recently diagnosed with cancer. Clinical consideration of patients' residence, socioeconomic status and violence experienced may help identify and mitigate the longer-term impact of these identifiable factors associated with poorer QOL.

Heroin and fentanyl overdoses in Kentucky: Epidemiology and surveillance.

BACKGROUND: The study aims to describe recent changes in Kentucky's drug overdose trends related to increased heroin and fentanyl involvement, and to discuss future directions for improved drug overdose surveillance. METHODS: The study used multiple data sources (death certificates, postmortem toxicology results, emergency department [ED] records, law enforcement drug submissions, and prescription drug monitoring records) to describe temporal, geographic, and demographic changes in drug overdoses in Kentucky. RESULTS: Fentanyl- and heroin-related overdose death rates increased across all age groups from years 2011 to 2015 with the highest rates consistently among 25-34-year-olds. The majority of the heroin and fentanyl overdose decedents had histories of substantial exposures to legally acquired prescription opioids. Law enforcement drug submission data were strongly correlated with drug overdose ED and mortality data. The 2016 crude rate of heroin-related overdose ED visits was 104/100,000, a 68% increase from 2015 (62/100,000). More fentanyl-related overdose deaths were reported between October, 2015, and September, 2016, than ED visits, in striking contrast with the observed ratio of >10 to 1 heroin-related overdose ED visits to deaths. Many fatal fentanyl overdoses were associated with heroin adulterated with fentanyl; <40% of the heroin overdose ED discharge records listed procedure codes for drug screening. CONCLUSIONS: The lack of routine ED drug testing likely resulted in underreporting of non-fatal overdoses involving fentanyl and other synthetic drugs. In order to inform coordinated public health and safety responses, drug overdose surveillance must move from a reactive to a proactive mode, utilizing the infrastructure for electronic health records.

Stakeholder perceptions of a total market approach to family planning in Viet Nam.

Viet Nam has high modern contraceptive prevalence (68%), with most services received through the public sector. As the country transitions to middle-income status, Viet Nam's donors have ceased donations of contraceptive supplies, causing a large projected shortfall in the family planning budget. In response, the Ministry of Health has decided to prioritize free or subsidized contraceptives for poor and vulnerable groups, while enhancing social marketing and sales of contraceptives in the free market. To support planning for this "total market approach", a descriptive exploratory study was conducted with 38 public and private sector family planning stakeholders to gain their perceptions of the proposals. There was a high level of support for government leadership of public-private coordination and stewardship of the entire family planning system. Key information gaps were identified regarding how the reforms can promote equitable access to family planning and financial sustainability in pricing. The government's experience with this transition may yield valuable guidance for other settings.

Cost-effectiveness analysis of active management of third-stage labour in Vietnam.

Active management of the third stage of labour (AMTSL) using oxytocin substantially reduces postpartum haemorrhage (PPH), a leading cause of maternal mortality. An economic analysis of the use of AMTSL was conducted as part of an intervention study in Thanh Hoa Province, Vietnam. A spreadsheet was used to calculate various scenarios and estimate the costs and outcomes of the routine use of AMTSL with oxytocin in Uniject compared with oxytocin in ampoules, and AMTSL compared with no AMTSL. We estimated the health outcomes from probabilities that were generated from the effectiveness portion of the AMTSL intervention project. The study also estimates the costs of treating PPH and the net incremental costs of AMTSL (costs and savings); examines the impact of different scenarios of PPH rate and Uniject cost; and estimates the potential cost per PPH case and PPH death averted. The additional net cost per woman of providing AMTSL with ampoules was just US dollar 0.20 in the base case; using Uniject devices added only US dollar 0.08 more per woman to the ampoule cost. Varying the rate of PPH had the biggest effect; if the underlying PPH rate were 8%, the incremental cost of AMTSL drops to just US dollar 0.07 per woman with ampoules and the cost to avert a case of PPH is US dollar 2.10 with ampoules and US dollar 4.52 with Uniject. The low net incremental cost of AMTSL suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women's health without adding much to national health care costs.

Does a novel prefilled injection device make postpartum oxytocin easier to administer? Results from midwives in Vietnam.

OBJECTIVE: to assess the acceptability of the Uniject prefilled injection device for delivery of oxytocin in the third stage of labour, and the effect of the device on overall willingness to perform active management of the third stage of labour (AMTSL). DESIGN: descriptive study that used baseline and post-intervention questionnaires. SETTING: three districts in northern Vietnam. The study population consisted of 52 midwives from two districts where AMTSL was already practiced, and 35 midwives from a district where AMTSL was introduced as part of the study. MEASUREMENTS AND FINDINGS: the majority of midwives reported that the Uniject device was easier to use and preferable compared with ampoules and standard syringes. They found the training materials easy to understand. KEY CONCLUSIONS: the use of a prefilled injection device overcame many of the barriers cited by midwives with regard to the use of oxytocin in ampoules, such as trying to break ampoules and fill syringes in a hurry. This device enabled midwives to deliver the correct dose of oxytocin in the third stage of labour in a safe and timely way, while attending to the other needs of the mother and her newborn baby. IMPLICATIONS FOR PRACTICE: use of a prefilled injection device for oxytocin may increase the acceptability and practice of AMTSL in primary level facilities, thus reducing maternal mortality due to postpartum haemorrhage.