Modestly increased use of colonoscopy when copayments are waived.

BACKGROUND & AIMS: Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use. METHODS: We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50-64 years at any point in FYs 2002-2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver. RESULTS: The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14-1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12-1.26). CONCLUSIONS: Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening.

Town-level comparisons may be an effective alternative in comparing rural and urban differences: a look at accidental traumatic brain injuries in North Texas children.

INTRODUCTION: Rural areas in the USA are generally poorer, more isolated, less populated, have older populations, and also unique work dynamics that fundamentally set them apart from urban areas. Additionally, funding and resources are limited in rural areas; a problem that may be exacerbated when looking specifically at town-level resources. One of the key problems in comparing US rural and urban areas, particularly at the county level, is that the resources available to individual towns within a particular county may not accurately reflect the resources available to the county as a whole. This leads to questions about the validity of county-level comparisons between rural and urban areas because of differences in town sizes and the resources availability at this level. The authors of this study attempted to assess this difference by analyzing data previously collected for a study examining pediatric traumatic brain injury among four levels of rurality: urban city, large town, small town, and isolated town. METHODS: This study employed Rural and Urban Commuting Area 2 (RUCA2) codes to determine if significant differences exist between small and large towns for pediatric traumatic brain injury. Patients were included in this study if they presented to Children's Medical Center Dallas with severe traumatic brain injury, and comparisons of injury severity and outcome were compared between small and large towns. Patient zip (postal) codes were collected and designated as either small or large town based on the corresponding RUCA2 code. RESULTS: A total of 444 patients were included in this study, with significant differences between large and small towns for Trauma Scores, Trauma Score and Injury Severity Score (TRISS) measures, and the total length of stay. CONCLUSION: This study has numerous limitations, yet it demonstrates that comparisons based on the RUCA code designations of large and small towns can be an effective means for understanding the differences at the town level, and also to better establish prevention strategies geared toward these differences.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Association of Non-High-Density Lipoprotein Cholesterol with Psychosocial Dysfunction in Children and Adolescents with Obesity.

BACKGROUND: Children with obesity have worse psychosocial functioning compared to their non-overweight peers. Adult studies suggest that several metabolic factors may participate in the etiology of depression in obesity. METHODS: We evaluated the association of several metabolic parameters with psychosocial dysfunction in children with obesity, through a retrospective review of electronic medical records in patients ages 6-17. All parents were asked to complete the Pediatric Symptom Checklist (PSC) questionnaire, a validated measurement of psychosocial dysfunction in children. RESULTS: PSC scores were available in 618 patients. Overall, 11.2% of patients had a PSC score ≥28, suggestive of psychosocial dysfunction. Non-high-density lipoprotein (HDL) cholesterol was associated with a higher PSC score (p = 0.02), after adjusting for age, sex, race, socioeconomic status, and BMI z-score. CONCLUSIONS: Consistent with adult studies, in children and adolescents with obesity, non-HDL cholesterol may play a role in the etiology of psychosocial dysfunction. Further studies are warranted.

Charges associated with pediatric head injuries: a five year retrospective review of 41 pediatric hospitals in the US.

BACKGROUND: Brain injuries are a significant public health problem, particularly among the pediatric population. Brain injuries account for a significant portion of pediatric injury deaths, and are the highest contributor to morbidity and mortality in the pediatric and young adult populations. Several studies focus on particular mechanisms of brain injury and the cost of treating brain injuries, but few studies exist in the literature examining the highest contributing mechanisms to pediatric brain injury and the billed charges associated with them. METHODS: Data were extracted from the Pediatric Health Information System (PHIS) from member hospitals on all patients admitted with diagnosed head injuries and comparisons were made between ICU and non-ICU admissions. Collected data included demographic information, injury information, total billed charges, and patient outcome. RESULTS: Motor vehicle collisions, falls, and assaults/abuse are the three highest contributors to brain injury in terms of total numbers and total billed charges. These three mechanisms of injury account for almost $1 billion in total charges across the five-year period, and account for almost half of the total charges in this dataset over that time period. CONCLUSIONS: Research focusing on brain injury should be tailored to the areas of the most pressing need and the highest contributing factors. While this study is focused on a select number of pediatric hospitals located throughout the country, it identifies significant contributors to head injuries, and the costs associated with treating them. © 2013 KUMS, All rights reserved.

Maternal depressive symptoms predict adolescent healthcare utilization and charges in youth with type 1 diabetes (T1D).

OBJECTIVE: To examine whether maternal depressive symptoms predict diabetes-related health care utilization and charges in adolescents with Type 1 diabetes. METHOD: Mothers of adolescents ages 11-18 with Type 1 diabetes completed the Center for Epidemiological Studies Depression Scale at enrollment and at 12-month follow-up. Demographic and disease-related variables, including HbA1c, were also assessed. Health care utilization data and charges for diabetes-related care (i.e., endocrine clinic visits, emergency room visits, and hospitalizations) for the period of 12 and 24 months following enrollment were assessed. RESULTS: Maternal depressive symptoms at enrollment predicted higher utilization/charges at 12- and 24-month follow-up, after controlling for demographic and disease-related variables and adolescent depressive symptoms. High maternal depressive symptoms at baseline were associated with $8,405 additional charges over the next 2 years. Adolescents of mothers with high depressive symptoms were twice as likely to have an emergency room visit and three times as likely to have a hospitalization. CONCLUSION: Maternal depressive symptoms are an independent predictor of health care utilization and charges in adolescents with Type 1 diabetes. Interventions aimed at identifying and treating depressive symptoms in mothers could not only enhance caregiver quality of life but could also be economically advantageous for payers and providers.

Economic impact of motorcycle helmets: from impact to discharge.

BACKGROUND: The economic impact of helmet use remains controversial. Previous studies of injured motorcyclists suggest a marginal inpatient hospital cost difference between helmeted and unhelmeted riders. The purpose of this study was to expand the economic analysis of motorcycle helmet utilization to the point of injury by including motorcycle crash patients who do not require hospital admission. METHODS: Prehospital motorcycle crash data were collected from the National Highway Transportation Safety Administration (NHTSA) General Estimates System (GES) database from 1994 to 2002 with respect to helmet use, injury severity, and transport to a hospital. A focused literature search yielded the hospital admission rates of helmeted and unhelmeted motorcyclists evaluated in the emergency department. The National Trauma Data Bank (NTDB) was queried from 1994 to 2002 to collect data including helmet use and hospital charges for injured motorcyclists. Cost analysis was performed by linkage of the queried databases and data from the literature. Statistical comparisons between groups were performed using an independent samples t test and chi analysis. RESULTS: The NHTSA GES database yielded 5,328 sample patients. 1,854 patients (34.8%) were unhelmeted and 3,474 (65.2%) were helmeted. Transport to a hospital was required of 78.6% of unhelmeted and 73.3% of helmeted patients (p < 0.01). Of motorcyclists evaluated in the emergency department, 39.9% of unhelmeted and 32.8% of helmeted patients required hospital admission. NTDB analysis of injured motorcyclists from the concomitant interval yielded 9,033 patients in whom helmet use data were available and 5,343 patients for whom associated hospital cost data were available. Unhelmeted motorcyclists incurred charges of 39,390 dollars + 1,436 dollars per injury, whereas helmeted motorcyclists incurred charges of 36,334 dollars + 1,232 dollars per injury. Mathematical extrapolation derived a charge of 12,353 dollars per unhelmeted and 8,735 dollars per helmeted motorcyclist for every crash with a difference of 3,618 dollars between helmeted and unhelmeted riders involved in a motorcycle crash. CONCLUSIONS: With a current estimate of 197,608 motorcycle crashes/year in which 69,163 riders were unhelmeted, the differential healthcare economic burden between unhelmeted and helmeted motorcyclists is approximately $250,231,734 per year and underscores the need for improved legislation to improve motorcycle helmet utilization.