Disparities in Teleneurology Use in Medicaid Beneficiaries With Epilepsy by Practice Setting: Promoting Health Equity in Academic Centers.

BACKGROUND AND OBJECTIVES: Medicaid beneficiaries in many American academic medical centers can receive care in a separate facility than those not covered by Medicaid. We aimed to identify possible disparities in care by evaluating the association between facility type (integrated faculty practice or Medicaid-only outpatient clinic) and telehealth utilization in people with epilepsy. METHODS: We performed retrospective analyses using structured data from the Mount Sinai Health System electronic medical record data from January 2003 to August 2021. We identified people of all ages with epilepsy who were followed by an epileptologist after January 3, 2018, using a validated ICD-9-CM/10-CM coded case definition. We evaluated associations between practice setting and telehealth utilization, an outcome measure that captures the evolving delivery of neurologic care in a post-coronavirus disease 2019 era, using multivariable logistic regression. RESULTS: We identified 4,586 people with epilepsy seen by an epileptologist, including Medicaid beneficiaries in the Medicaid outpatient clinic (N = 387), Medicaid beneficiaries in the faculty practice after integration (N = 723), and non-Medicaid beneficiaries (N = 3,476). Patients not insured by Medicaid were significantly older (average age 40 years vs 29 in persons seen in Medicaid-only outpatient clinic and 28.5 in persons insured with Medicaid seen in faculty practice [p < 0.0001]). Medicaid beneficiaries were more likely to have drug-resistant epilepsy (DRE), with 51.94% of people seen in Medicaid-only outpatient clinic, 41.63% of Medicaid beneficiaries seen in faculty practice, and 37.2% of non-Medicaid beneficiaries having DRE (p < 0.0001). Medicaid outpatient clinic patients were less likely to have telehealth visits (phone or video); 81.65% of patients in the Medicaid outpatient clinic having no telehealth visits vs 71.78% of Medicaid beneficiaries in the faculty practice and 70.89% of non-Medicaid beneficiaries (p < 0.0001). In an adjusted logistic regression analysis, Medicaid beneficiaries had lower odds (0.61; 95% CI 0.46-0.81) of using teleneurology compared with all patients seen in faculty practice (p = 0.0005). DISCUSSION: Compared with the Medicaid-only outpatient clinic, we found higher telehealth utilization in the integrated faculty practice with no difference by insurance status (Medicaid vs other). Integrated care may be associated with better health care delivery in people with epilepsy; thus, future research should examine its impact on other epilepsy-related outcomes.

Descriptive Analysis of Patients Receiving Outpatient eConsults for Neurological Disorders in the United States.

Introduction: Interprofessional consultations ("eConsults"), which facilitate asynchronous specialist consultations, remain understudied in neurological disorders. We aimed to describe the patient population receiving eConsult services for neurological disorders nationwide and to conduct a comparative analysis between rural and urban patients within this eConsult cohort. Methods: We analyzed a dataset of U.S. outpatient claims from employer-sponsored commercial and Medicare plans. Using standardized mean differences, we compared clinical and sociodemographic patient characteristics between urban and rural patients within the eConsult group. Results: We identified 1,374 patients who had an eConsult order for a neurological disorder. Overall eConsult volume increased by 548.5% between 2019 and 2021. A majority of the cohort were aged 65 years or older (23.7%), had an eConsult order in 2021 (52.4%), and live in an urban area (90.4%). The primary diagnosis for our cohort was likely to be a sleep-wake disorder (21.9%), cerebrovascular disease (14.3%), neurological sign or symptom (14.2%), or headache (13.7%). In the secondary analysis, rural eConsult patients exhibited higher rates of primary diagnoses for traumatic brain injury, neuroophthalmic disorders, or neuropathy than their urban counterparts. Discussion: In this national sample of commercially insured patients, the utilization of eConsults for neurological conditions increased nationwide since 2019, especially for patients living in rural areas.

Health equity integrated epilepsy care and research: A narrative review.

BACKGROUND: With the unanimous approval of the Intersectoral Global Action Plan on epilepsy and other neurological disorders by the World Health Organization in May 2022, there are strong imperatives to work towards equitable neurological care. AIMS: Using epilepsy as an entry point to other neurologic conditions, we discuss disparities faced by marginalized groups including racial/ethnic minorities, Americans living in rural communities, and Americans with low socioeconomic status. MATERIALS AND METHODS: The National Institute on Minority Health Disparities Research Framework (NIMHD) was used to conduct a narrative review through a health equity lens to create an adapted framework for epilepsy and propose approaches to working towards equitable epilepsy and neurological care. RESULTS: In this narrative review, we identified priority populations (racial and ethnic minority, rural-residing, and low socioeconomic status persons with epilepsy) and outcomes (likelihood to see a neurologist, be prescribed antiseizure medications, undergo epilepsy surgery, and be hospitalized) to explore disparities in epilepsy and guide our focused literature search using PubMed. In an adapted NIMHD framework, we examined individual, interpersonal, community, and societal level contributors to health disparities across five domains: (1) behavioral, (2) physical/built environment, (3) sociocultural, (4) environment, and (5) healthcare system. We take a health equity approach to propose initiatives that target modifiable factors that impact disparities and advocate for sustainable change for priority populations. DISCUSSION: To improve equity, healthcare providers and relevant societal stakeholders can advocate for improved care coordination, referrals for epilepsy surgery, access to care, health informatics interventions, and education (i.e., to providers, patients, and communities). More broadly, stakeholders can advocate for reforms in medical education, and in the American health insurance landscape. CONCLUSIONS: Equitable healthcare should be a priority in neurological care.

Mental health issues assessment using tools during COVID-19 pandemic.

COVID-19 has brought distress among people as pandemic has impacted the globe not only economically or physically, but also psychologically by degrading their mental health. Several research were done in the past which tried to capture these issues but post-covid situation needs to be critically handled and analyzed so that corrective measures for cure and support can be taken. The current work is an attempt to observe the mental health issues (anxiety and depression) that occurred during the lockdown by combining a few pre-designed questionnaires. The online survey included 244 respondents (females = 126, males = 118) and when we thoroughly examined gender, age group, and occupational activity as three main factors, the results showed that female students aged 21-35 were affected more than male students of the same age group. In this study, we used a 4-item Geriatric Depression Scale (GDS-4) as a depression screening instrument and discovered that 225 out of total respondents were depressed. Using the Generalized Anxiety Disorder (GAD-7), a self-administered anxiety tool, we found 103 responders with mild, 87 with moderate, 12 with severe, and 42 with no anxiety symptoms. Patient Health Questionnaire (PHQ-9) showed the symptoms of mental disorders where 68 individuals had mild, 85 had moderate, 37 had moderately severe, 12 had severe, and 42 had no symptoms. With the help of multiple linear regression analysis, demographic data were evaluated, and later results were compared between GDS-4, GAD-7, and PHQ-9 using correlation coefficients. This will help practitioners and individuals to focus on their physiological health and adopt diagnostic measures.

Trends in the Utilization of Teleneurology and Other Healthcare Resources Prior to and During the COVID-19 Pandemic in an Urban, Tertiary Health System.

BACKGROUND: Patient groups traditionally affected by health disparities were less likely to use video teleneurology (TN) care during the initial COVID-19 pandemic surge in the United States. Whether this asymmetry persisted later in the pandemic or was accompanied with a loss of access to care remains unknown. METHODS: We conducted a retrospective cohort study using patient data from a multicenter healthcare system in New York City. We identified all established pediatric or adult neurology patients with at least two prior outpatient visits between June 16th, 2019 and March 15th, 2020 using our electronic medical record. For this established pre-COVID cohort, we identified telephone, in-person, video TN or emergency department visits and hospital admissions for any cause between March 16th and December 15th, 2020 ("COVID period"). We determined clinical, sociodemographic, income, and visit characteristics. Our primary outcome was video TN utilization, and our main secondary outcome was loss to follow-up during the COVID period. We used multivariable logistic regression to model the relationship between patient-level characteristics and both outcomes. RESULTS: We identified 23,714 unique visits during the COVID period, which corresponded to 14,170 established patients from our institutional Neurology clinics during the pre-COVID period. In our cohort, 4,944 (34.9%) utilized TN and 4,997 (35.3%) were entirely lost to follow-up during the COVID period. In the adjusted regression analysis, Black or African-American race [adjusted odds ratio (aOR) 0.60, 97.5%CI 0.52-0.70], non-English preferred language (aOR 0.49, 97.5%CI 0.39-0.61), Medicaid insurance (aOR 0.50, 97.5%CI 0.44-0.57), and Medicare insurance (aOR 0.73, 97.5%CI 0.65-0.83) had decreased odds of TN utilization. Older age (aOR 0.98, 97.5%CI 0.98-0.99), female sex (aOR 0.90 97.5%CI 0.83-0.99), and Medicaid insurance (aOR 0.78, 0.68-0.90) were associated with decreased odds of loss to follow-up. CONCLUSION: In the first 9 months of the COVID-19 pandemic, we found sociodemographic patterns in TN utilization that were similar to those found very early in the pandemic. However, these sociodemographic characteristics were not associated with loss to follow-up, suggesting that lack of TN utilization may not have coincided with loss of access to care.

Hospital readmissions in older adults with epilepsy in the US - A population-based study.

OBJECTIVE: Our objective was to determine proportions, causes, and predictors of 30-day readmissions among older adults with epilepsy. Understanding predictors of readmissions may inform future interventions aimed at reducing avoidable hospitalizations in this vulnerable population. METHODS: Individuals 65 years or older with epilepsy were identified using previously validated ICD-9-CM codes in any diagnostic position in the 2014 Nationwide Readmissions Database. Proportions of 30-day readmissions and causes of readmissions in older adults with epilepsy were compared to both older adults without and younger adults (18-64 years old) with epilepsy. We identified predictors of readmission in older adults with epilepsy using logistic regression. RESULTS: There were 92,030 older adults with, 3,166,852 older adults without, and 168,622 younger adults with epilepsy. Proportions of readmissions were higher in older adults with (16.2%) than older adults without (12.5%) and younger adults with epilepsy (15.1%). The main cause of readmission for older adults with and without epilepsy was septicemia, and epilepsy/seizure in younger adults with epilepsy. Predictors of 30-day readmissions in older adults with epilepsy were: non-elective admissions (OR 1.37, 95%CI 1.27-1.48), public insurance (Medicaid vs. private insurance OR 1.19, 95%CI 1.02-1.39; Medicare vs. private insurance OR 1.11, 95%CI 1.00-1.22), lower median household income for patient's zip code ($1-$39,999 vs. $66,000 + OR 1.15, 95% CI 1.08-1.22), hospital location in large metropolitan areas (OR 1.22, 95%CI 1.05-1.42), higher Charlson-Deyo comorbidity index (OR 1.11, 95%CI 1.10-1.02), and male sex (OR 1.04, 95%CI 1.00-1.09). SIGNIFICANCE: Our findings suggest that targeted interventions to reduce the risk of infection may potentially reduce readmission in older people with epilepsy, similarly to those without. Provision of coordinated care and appropriate discharge planning may reduce readmissions particularly in those who are males, are of lower socioeconomic status and with more comorbidities.

Nonelective hospital admissions, discharge disposition, and health services utilization in epilepsy patients: A population-based study.

OBJECTIVE: Identifying adverse outcomes and examining trends and causes of nonelective admissions among persons with epilepsy would be beneficial to optimize patient care and reduce health services utilization. We examined the association of epilepsy with discharge status, in-hospital mortality, length-of-stay, and charges. We also examined 10-year trends and causes of hospital admissions among those with and without epilepsy. METHODS: Nonelective hospital admission in persons with epilepsy was identified in the 2005-2014 National Inpatient Sample (NIS) using a validated International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) case definition. The NIS is the largest US all-payer database including patient and hospital-level variables, and represents hospitalizations in the general population. Descriptive statistics on trends and causes of admissions and multivariable regression analysis summarizing the association of epilepsy with the outcomes of interest are presented. RESULTS: Of 4 718 178 nonelective admissions in 2014, 3.80% (n = 179 461) were in persons with epilepsy. Admissions in persons with epilepsy increased from 14 636 to 179 461 (P < .0001) between 2005 and 2014. As compared to persons without epilepsy, hospital admissions in persons with epilepsy had higher odds of transfer to other facilities (odds ratio [OR] = 1.77, 95% confidence interval [CI]: 1.72-1.81, P < .0001), being discharged against medical advice (OR = 1.48, 95% CI: 1.38-1.59, P < .0001), and incurring 4% greater total charges (P < .0001). Epilepsy, convulsions, pneumonia, mood disorders, cerebrovascular disease, and septicemia were the top causes for admissions in those with epilepsy. SIGNIFICANCE: Future research should focus on designing targeted health care interventions that decrease the number of hospital admissions, reduce health services utilization, and increase the odds of discharge home in people with epilepsy.

Readmission to a different hospital following acute stroke is associated with worse outcomes.

OBJECTIVE: There is a high risk of readmission within 30 days of index acute ischemic stroke (AIS), but effect of readmission to a different hospital is not known. We performed a retrospective cohort study to assess our hypothesis that 30-day readmission outcomes after AIS are worse for those readmitted to another hospital vs the discharging hospital. METHODS: We utilized the 2013 Nationwide Readmissions Database to identify patients with index stroke admissions with ICD-9-CM codes. We identified all-cause readmissions with Clinical Classification Software. Outcomes included length of stay (LOS), total charges of hospitalization, and in-hospital mortality during 30-day readmission. Using linear and logistic regression, outcomes were compared in those readmitted to another hospital vs the discharging hospital. RESULTS: There were 194,549 patients included, with an average age of 80.0 ± 14.0 years; 51.2% were female; 24,545 were readmitted within 30 days, and 7,274 (29.6%) to a different hospital. Readmission to a different hospital was associated with an increased LOS of 1.0 days (95% confidence interval [CI] 0.7-1.2, p < 0.0001) and $7,677.28 (95% CI $5,496-$9,858, p < 0.0001) greater total charges. The odds ratio for in-hospital mortality during readmission was 1.2 for readmission to another hospital (95% CI 1.0-1.3, p = 0.0079). CONCLUSIONS: Readmission to another hospital within 30 days of AIS index admission was independently associated with longer LOS, increased total charges, and greater in-hospital mortality compared to readmission to the same hospital.

Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns.

BACKGROUND: Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy. METHODS: Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics. RESULTS: Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes. CONCLUSIONS: Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization.

Multidisciplinary Management of Hepatocellular Carcinoma Improves Access to Therapy and Patient Survival.

BACKGROUND: Given the complexity of managing hepatocellular carcinoma (HCC), it is widely accepted that a multidisciplinary team approach (tumor boards) offers the best approach to individualize therapy. The aim of this study was to determine utilization of therapies and outcomes for patients with HCC, comparing those managed through our multidisciplinary tumor board (MDTB) to those who were not. METHODS: A database analysis of all patients with HCC managed through our MDTB, from 2007 until 2011, was performed. A database of all patients with HCC from 2002 to 2011, not managed through MDTB, was similarly created. RESULTS: A total of 306 patients with HCC, from 2007 to 2011 were managed through our MDTB, in comparison with 349 patients, from 2002 to 2011 who were not. There were no significant differences in baseline demographic data or model for end-stage liver disease at presentation. Patients managed through MDTB were more likely to present at an earlier tumor stage and with lower serum alpha fetoprotein (AFP) (P=0.007). The odds of receiving any treatment for HCC was higher in patients managed through MDTB (odds ratio, 2.80; 95% confidence interval, 1.71-4.59; P<0.0001) independent of model for end-stage liver disease score, serum AFP, and tumor stage. There was significantly greater survival of patients managed through MDTB (19.1±2.5 vs. 7.6±0.9 mo, P<0.0001). Independent predictors for improved survival included management through MDTB, receipt of any HCC treatment, lower serum AFP, receipt of liver transplant, and T2 tumor stage. CONCLUSIONS: Patients with HCC managed through a MDTB had significantly higher rates of receipt of therapy and improved survival compared with those who were not.

Longitudinal Patterns of Emergency Department Visits: A Multistate Analysis of Medicaid Beneficiaries.

OBJECTIVE: The objective of this study was to examine the longitudinal patterns of emergency department (ED) visits among adult fee-for-service Medicaid. DATA SOURCES: Data were obtained from the Medicaid analytic eXtract files, Area Health Resource File, and County Health Rankings. STUDY DESIGN: A retrospective longitudinal study design, with four observations for each individual was used. The study population consisted of 33,393 Medicaid beneficiaries who met inclusion criteria. ED visits were time-lagged and time-varying patient-level factors were measured for each year. Time-invariant characteristics (gender and race/ethnicity) were measured in 2006. Multivariable hurdle models with logistic (ED use versus no ED use) and negative binomial regressions (ED visits among ED users) were used to analyze the ED visits over time. To account for correlation due to repeated observations, mixed effect models with robust standard errors were performed. PRINCIPAL FINDINGS: In both unadjusted and adjusted analysis, the likelihood of ED use did not change from year to year (AOR = 1.00, 95 percent CI: 0.99, 1.01). Among ED users, the estimated number of ED visits increased over time (IRR = 1.01, 95 percent CI: 1.01, 1.03). CONCLUSIONS: Primary care resources should be a major focus to reduce the increased burden on the EDs.

The effect of an affordable daycare program on health and economic well-being in Rajasthan, India: protocol for a cluster-randomized impact evaluation study.

BACKGROUND: The provision of affordable and reliable daycare services is a potentially important policy lever for empowering Indian women. Access to daycare might reduce barriers to labor force entry and generate economic opportunities for women, improve education for girls caring for younger siblings, and promote nutrition and learning among children. However, empirical evidence concerning the effects of daycare programs in low-and-middle-income countries is scarce. This cluster-randomized trial will estimate the effect of a community-based daycare program on health and economic well-being over the life-course among women and children living in rural Rajasthan, India. METHODS: This three-year study takes place in rural communities from five blocks in the Udaipur District of rural Rajasthan. The intervention is the introduction of a full-time, affordable, community-based daycare program. At baseline, 3177 mothers with age eligible children living in 160 village hamlets were surveyed. After the baseline, these hamlets were randomized to the intervention or control groups and respondents will be interviewed on two more occasions. Primary social and economic outcomes include women's economic status and economic opportunity, women's empowerment, and children's educational attainment. Primary health outcomes include women's mental health, as well as children's nutritional status. DISCUSSION: This interdisciplinary research initiative will provide rigorous evidence concerning the effects of daycare in lower-income settings. In doing so it will address an important research gap and has the potential to inform policies for improving the daycare system in India in ways that promote health and economic well-being. TRIAL REGISTRATION: (1) The ISRCTN clinical trial registry (ISRCTN45369145), http://www.isrctn.com/ISRCTN45369145 , registered on May 16, 2016 and (2) The American Economic Association's registry for randomized controlled trials (AEARCTR-0000774), http://www.socialscienceregistry.org/trials/774 , registered on July 15, 2015.

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension.

BACKGROUND: Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients. METHODS: Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses. RESULTS: Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003). CONCLUSIONS: History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

Changing Awareness of the Health Insurance Marketplace.

The Health Insurance Marketplace was designed to increase the affordability of health insurance. The success of the marketplace depends on people's awareness and use of it. In a statewide mail survey of West Virginians, we found that respondents' awareness of the West Virginia Health Insurance Marketplace increased from 2013 to 2014. However, large percentages of respondents continued to be unaware of the availability of federal subsidies and were unsure of their personal eligibility for these subsidies. It is essential that awareness and enrollment efforts continue and that they be expanded in novel ways to continue growth in access to health insurance through the marketplace.

Healthcare Expenditures Associated with Depression Among Individuals with Osteoarthritis: Post-Regression Linear Decomposition Approach.

BACKGROUND: Depression is common among individuals with osteoarthritis and leads to increased healthcare burden. The objective of this study was to examine excess total healthcare expenditures associated with depression among individuals with osteoarthritis in the US. DESIGN: Adults with self-reported osteoarthritis (n = 1881) were identified using data from the 2010 Medical Expenditure Panel Survey (MEPS). Among those with osteoarthritis, chi-square tests and ordinary least square regressions (OLS) were used to examine differences in healthcare expenditures between those with and without depression. Post-regression linear decomposition technique was used to estimate the relative contribution of different constructs of the Anderson's behavioral model, i.e., predisposing, enabling, need, personal healthcare practices, and external environment factors, to the excess expenditures associated with depression among individuals with osteoarthritis. All analysis accounted for the complex survey design of MEPS. KEY RESULTS: Depression coexisted among 20.6 % of adults with osteoarthritis. The average total healthcare expenditures were $13,684 among adults with depression compared to $9284 among those without depression. Multivariable OLS regression revealed that adults with depression had 38.8 % higher healthcare expenditures (p < 0.001) compared to those without depression. Post-regression linear decomposition analysis indicated that 50 % of differences in expenditures among adults with and without depression can be explained by differences in need factors. CONCLUSIONS: Among individuals with coexisting osteoarthritis and depression, excess healthcare expenditures associated with depression were mainly due to comorbid anxiety, chronic conditions and poor health status. These expenditures may potentially be reduced by providing timely intervention for need factors or by providing care under a collaborative care model.

Awareness and Interest in the West Virginia Health Insurance Marketplace.

The objective of this study is to examine the level of awareness of and interest in the Health Insurance Marketplace in West Virginia. Primary survey data were collected in July/August 2013 from a stratified sampling of West Virginians. A mailed survey was completed by respondents in a cross-sectional study. Key variables included general awareness of the Health Insurance Marketplace and the availability of subsidies, the individual mandate, interest in using the Marketplace, and perceptions of respondents' ability to qualify for financial assistance. A total of 6000 surveys were mailed containing a 9-page questionnaire; 1198 completed surveys were returned. Two months prior to launch, awareness of the Health Insurance Marketplace was low in West Virginia, yet interest in the Marketplace was higher among those most likely to benefit--the uninsured and residents likely to qualify for financial subsidies. West Virginians reported being familiar with the individual mandate. Efforts should be increased among government and nongovernment organizations at the federal, state, and local levels to heighten awareness of the Health Insurance Marketplace in West Virginia and, particularly, the availability of subsidies. Many, once made aware, expressed interest in learning more.

Restless legs syndrome in an appalachian primary care population: prevalence, demographic and lifestyle correlates, and burden.

BACKGROUND: Restless legs syndrome (RLS) is a common and distressing sensorimotor disorder of unknown etiology. While the epidemiology of RLS has been examined in several North American and European studies, research on RLS and RLS burden in poor, rural populations, including those residing in Appalachia, remains sparse. In this study, we investigated RLS prevalence in an Appalachian primary care population and examined the association of RLS to demographic factors, lifestyle characteristics, sleep quality, and mood disorders. METHODS: Participants of this anonymous survey study were community-dwelling adults aged ≥ 18 years visiting one of 4 West Virginia primary care clinics. Data gathered included detailed information on sleep patterns, demographic characteristics, lifestyle factors, and health/medical history; the survey also included questions specific to RLS diagnosis and severity. Response rates were excellent, with 68% of eligible adults contacted returning completed surveys (N = 1,424/2,087). Pregnant women (N = 65) and those with missing data on key variables (N = 142) were excluded from the analyses. RESULTS: Of the 1,217 participants included in the final analytic sample, 19.6% (18.2% with symptoms at least once/month) met the 4 IRLSSG diagnostic criteria in the absence of positional discomfort or leg cramps; 14.5% reported RLS symptoms at least once/week and 10.1% indicated symptoms ≥ 3×/week. Excluding respondents with diabetes, kidney disease, or anemia reduced these rates only slightly. Those with RLS were more likely to be older, female, lower income, unemployed, disabled, non-Hispanic white, and less likely to be college educated than those without RLS. Mood and sleep impairment were significantly elevated in those with RLS; after adjustment for demographic and lifestyle characteristics, health history, and other factors, those with RLS remained significantly more likely to indicate a history of depression (adjusted odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.4, 2.6) and anxiety (OR = 1.6, CI 1.1, 2.2), to report sleep impairment both 4 (OR = 2.4, CI 1.6, 3.7) and 7 days/week (OR = 1.8, CI 1.3, 2.4), and a mean sleep duration < 5 h/night (OR = 1.7, CI 1.2, 2.3). These associations increased in both strength and magnitude with increasing symptom frequency (p's for trend ≤ 0.01). CONCLUSIONS: Findings of this preliminary anonymous survey study suggest that RLS prevalence is high in this Appalachian primary care population and that RLS is associated with significant burden in terms of both mood and sleep impairment.