Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis.

STUDY OBJECTIVES: To examine the risk of increased health care utilization (HU) linked to individual sleep disorders in children with chronic medical conditions. METHODS: Medicaid claims data from a cohort of 16,325 children enrolled in the Coordinated Healthcare for Complex Kids (CHECK) project were used. Sleep disorders and chronic medical conditions were identified using International Classification of Diseases, Ninth, and 10th Revision, codes. Three HU groups were identified based on participants' prior hospitalizations and emergency department (ED) visits in the 12 months prior to enrollment: low (no hospitalization or ED visit), medium (1-2 hospitalizations or 1-3 ED visits), and high (≥ 3 hospitalizations or ≥ 4 ED visits). The odds of being in an increased HU group associated with specific sleep disorders after controlling for confounding factors were examined. RESULTS: Children with chronic medical conditions and any sleep disorder had nearly twice the odds (odds ratio = 1.83; 95% confidence interval: 1.67-2.01) of being in an increased HU group compared with those without a sleep disorder. The odds of being in the increased HU group varied among sleep disorders. Only sleep-disordered breathing (odds ratio = 1.51; 95% confidence interval : 1.17-1.95), insomnia (odds ratio = 1.46; 95% confidence interval : 1.06-2.02), and circadian rhythm sleep disorder (odds ratio = 2.45; 95% confidence interval : 1.07-5.64) increased those odds. Younger age and being White were also linked to increased HU. CONCLUSIONS: Sleep disorders are associated with increased risk of heightened HU (ED visits and/or hospitalizations) in children with chronic medical conditions. This risk varies by specific sleep disorders. These findings indicate the need for careful evaluation and management of sleep disorders in this high-risk cohort. CITATION: Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. J Clin Sleep Med. 2024;20(4):595-601.

Impact of Race on Immunization Status in Long-Term Care Facilities.

OBJECTIVES: This study examined the relationship between resident race and immunization status in long-term care facilities (LTCFs). Race was captured at the resident and the facility racial composition level. DESIGN: Thirty-six long-term care facilities varying in racial composition and size were selected for site visits. SETTING: LTCFs were urban and rural, CMS certified, and non-hospital administered. MEASUREMENTS: Chart abstraction was used to determine race, immunization, and refusal status for the 2010-2011 flu season (influenza 1), the 2011-2012 flu season (influenza 2), and the pneumococcal pneumonia vaccine for all residents over 65 years old. RESULTS: Thirty-five LTCFs submitted sufficient data for inclusion, and 2570 resident records were reviewed. Overall immunization rates were 70.5% for influenza 1, 74.1% for influenza 2, and 65.6% for pneumococcal pneumonia. Random effects logistic regression indicated that as the percent of Black residents increased, the immunization rate significantly decreased (immunization 1, p < 0.018, immunization 2, p < 0.002, pneumococcal pneumonia, p = 0.0059), independent of the effect of resident race which had less of an impact on rates. CONCLUSIONS: This study found considerable LTCF variation and racial disparities in immunization rates. Compared to Blacks, Whites were vaccinated at higher rates regardless of the LTCF racial composition. Facilities with a greater proportion of Black residents had lower immunization rates than those with primarily White residents. Facility racial mix is a stronger predictor of influenza immunization than resident race. Black residents had significantly higher vaccination refusal rates than White residents for immunization 2. Further studies examining LTCF-level factors that affect racial disparities in immunizations in LTCFs are needed.

Ebola Preparedness Resources for Acute-Care Hospitals in the United States: A Cross-Sectional Study of Costs, Benefits, and Challenges.

OBJECTIVE To assess resource allocation and costs associated with US hospitals preparing for the possible spread of the 2014-2015 Ebola virus disease (EVD) epidemic in the United States. METHODS A survey was sent to a stratified national probability sample (n=750) of US general medical/surgical hospitals selected from the American Hospital Association (AHA) list of hospitals. The survey was also sent to all children's general hospitals listed by the AHA (n=60). The survey assessed EVD preparation supply costs and overtime staff hours. The average national wage was multiplied by labor hours to calculate overtime labor costs. Additional information collected included challenges, benefits, and perceived value of EVD preparedness activities. RESULTS The average amount spent by hospitals on combined supply and overtime labor costs was $80,461 (n=133; 95% confidence interval [CI], $56,502-$104,419). Multivariate analysis indicated that small hospitals (mean, $76,167) spent more on staff overtime costs per 100 beds than large hospitals (mean, $15,737; P<.0001). The overall cost for acute-care hospitals in the United States to prepare for possible EVD cases was estimated to be $361,108,968. The leading challenge was difficulty obtaining supplies from vendors due to shortages (83%; 95% CI, 78%-88%) and the greatest benefit was improved knowledge about personal protective equipment (89%; 95% CI, 85%-93%). CONCLUSIONS The financial impact of EVD preparedness activities was substantial. Overtime cost in smaller hospitals was >3 times that in larger hospitals. Planning for emerging infectious disease identification, triage, and management should be conducted at regional and national levels in the United States to facilitate efficient and appropriate allocation of resources in acute-care facilities. Infect Control Hosp Epidemiol 2017;38:405-410.

Patient Attitudes Toward Orthopedic Surgeon Ownership of Related Ancillary Businesses.

BACKGROUND: Physician ownership of businesses related to orthopedic surgery, such as surgery centers, has been criticized as potentially leading to misuse of health care resources. The purpose of this study was to determine patients' attitudes toward surgeon ownership of orthopedic-related businesses. METHODS: We surveyed 280 consecutive patients at 2 centers regarding their attitudes toward surgeon ownership of orthopedic-related businesses using an anonymous questionnaire. Three surgeon ownership scenarios were presented: (1) owning a surgery center, (2) physical therapy (PT), and (3) imaging facilities (eg, Magnetic Resonance Imaging scanner). RESULTS: Two hundred fourteen patients (76%) completed the questionnaire. The majority agreed that it is ethical for a surgeon to own a surgery center (73%), PT practice (77%), or imaging facility (77%). Most (>67%) indicated that their surgeon owning such a business would have no effect on the trust they have in their surgeon. Although >70% agreed that a surgeon in all 3 scenarios would make the same treatment decisions, many agreed that such surgeons might perform more surgery (47%), refer more patients to PT (61%), or order more imaging (58%). Patients favored surgeon autonomy, however, believing that surgeons should be allowed to own such businesses (78%). Eighty-five percent agreed that patients should be informed if their surgeon owns an orthopedic-related business. CONCLUSION: Although patients express concern over and desire disclosure of surgeon ownership of orthopedic-related businesses, the majority believes that it is an ethical practice and feel comfortable receiving care at such a facility.

Are Financial Conflicts of Interest for the Surgeon A Source of Concern for the Patient?

We surveyed 269 consecutive patients (81% response rate) with an anonymous questionnaire to assess their attitudes toward conflicts-of-interest (COIs) resulting from three financial relationships between orthopedic surgeons and orthopedic industry: (1) being paid as a consultant; (2) receiving research funding; (3) receiving product design royalties. The majority perceived these relationships favorably, with 75% agreeing that surgeons in such relationships are top experts in the field and two-thirds agreeing that surgeons engage in such relationships to serve patients better. Patients viewed surgeons who designed products more favorably than those who are consultants (P=0.03). The majority (74%) agreed that these COIs should be disclosed to patients. Given patients' desires for disclosure and their favorable perceptions of these relationships, open discussions about financial COIs is appropriate.

"Righteous minds" in health care: measurement and explanatory value of social intuitionism in accounting for the moral judgments in a sample of U.S. physicians.

The broad diversity in physicians' judgments on controversial health care topics may reflect differences in religious characteristics, political ideologies, and moral intuitions. We tested an existing measure of moral intuitions in a new population (U.S. physicians) to assess its validity and to determine whether physicians' moral intuitions correlate with their views on controversial health care topics as well as other known predictors of these intuitions such as political affiliation and religiosity. In 2009, we mailed an 8-page questionnaire to a random sample of 2000 practicing U.S. physicians from all specialties. The survey included the Moral Foundations Questionnaire (MFQ30), along with questions on physicians' judgments about controversial health care topics including abortion and euthanasia (no moral objection, some moral objection, strong moral objection). A total of 1032 of 1895 (54%) physicians responded. Physicians' overall mean moral foundations scores were 3.5 for harm, 3.3 for fairness, 2.8 for loyalty, 3.2 for authority, and 2.7 for sanctity on a 0-5 scale. Increasing levels of religious service attendance, having a more conservative political ideology, and higher sanctity scores remained the greatest positive predictors of respondents objecting to abortion (ß = 0.12, 0.23, 0.14, respectively, each p<0.001) as well as euthanasia (ß = 0.08, 0.17, and 0.17, respectively, each p<0.001), even after adjusting for demographics. Higher authority scores were also significantly negatively associated with objection to abortion (ß = -0.12, p<0.01), but not euthanasia. These data suggest that the relative importance physicians place on the different categories of moral intuitions may predict differences in physicians' judgments about morally controversial topics and may interrelate with ideology and religiosity. Further examination of the diversity in physicians' moral intuitions may prove illustrative in describing and addressing moral differences that arise in medical practice.

Substituted judgment in principle and practice: a national physician survey.

OBJECTIVE: To describe the extent to which US physicians endorse substituted judgments in principle or accommodate them in practice. PATIENTS AND METHODS: We surveyed a stratified, random sample of 2016 physicians by mail from June 25, 2010, to September 3, 2010. Primary outcome measures were agreement with 2 in-principle statements about substituted judgment and, after an experimental vignette that varied the basis used by a patient's surrogate to refuse life-saving treatment, responses indicating how appropriate it would be to overrule the surrogate's decision. RESULTS: Our response rate was 62% (1156 of 1875 respondents). When there is a conflict between what a surrogate believes a patient would have wanted (substituted judgment) and what the surrogate believes is in the patient's best interest, 4 of 5 physicians (78%) agreed that the surrogate should base their decision on substituted judgment. Yet we also found that 2 of 5 physicians (40%) agree that surrogates should make decisions they believe are in the patient's best interest, even if those seem to contradict the patient's prior wishes. In the experimental vignette, physicians were much more likely to oppose overruling a surrogate's refusal of life-sustaining medical treatment when that refusal was made on the basis of substituted judgment compared with when the refusal was made on the basis of the patient's best interest (50% vs 20%; odds ratio, 4.2; 95% CI, 2.7-6.3). Responses to the in-principle items about substituted judgment were not consistently associated with responses to the experimental vignette. CONCLUSION: US physicians largely agree, in principle, that surrogates should prioritize what the patient would have wanted over what they believe is in the patient's best interest, although many physicians are ambivalent in cases in which the 2 norms conflict. Even physicians who reject the principle of substituted judgment tend to treat substituted judgment as the preferred norm for surrogate decision making when responding to a clinical vignette.

An assessment of US physicians' training in religion, spirituality, and medicine.

This study examined US physicians' training in religion and medicine and its association with addressing religious and spiritual issues in clinical encounters. Reports of receiving training were higher for highly spiritual physicians, psychiatrists, and physicians with high numbers of critically ill patients. Discussing religion or spirituality with patients was associated with having received training through a book or CME literature or during Grand Rounds, through one's religious tradition and from other unspecified sources but not with having received such training in medical school.

Obstetrician-gynecologist physicians' beliefs about emergency contraception: a national survey.

BACKGROUND: Although emergency contraception (EC) is available without a prescription, women still rely on doctors' advice about its safety and effectiveness. Yet little is known about doctors' beliefs and practices in this area. STUDY DESIGN: We surveyed 1800 US obstetrician-gynecologists. Criterion variables were doctors' beliefs about EC's effects on pregnancy rates, and patients' sexual practices. We also asked which women are offered EC. Predictors were demographic, clinical and religious characteristics. RESULTS: Response rate was 66% (1154/1760). Most (89%) believe EC access lowers unintended pregnancy rates. Some believe women use other contraceptives less (27%), initiate sex at younger ages (12%) and have more sexual partners (15%). Half of physicians offer EC to all women (51%), while others offer it never (6%) or only after sexual assault (6%). Physicians critical of EC, males and religious physicians were more likely to offer it never or only after sexual assault (odds ratios 2.1-12). CONCLUSION: Gender, religion and divergent beliefs about EC's effects shape physicians' beliefs and practices.

Effect of a sudden infant death syndrome risk reduction education program on risk factor compliance and information sources in primarily black urban communities.

BACKGROUND: In the US, a higher incidence of sudden infant death syndrome (SIDS) and a slower decline in the incidence of SIDS has been found among blacks when compared with white infants. The continued racial disparity in SIDS is thought to be attributable to lack of compliance with SIDS risk reduction recommendations. OBJECTIVES: To better understand the disparities in SIDS risk reduction behaviors, we sought to study compliance and information sources related to SIDS among primarily black communities in a city with a high SIDS incidence rate before and after a targeted educational campaign. DESIGN: Pre- and post-SIDS Risk Reduction Education Program telephone surveys were performed in targeted Chicago communities with at least 86% blacks. Data collection for Survey 1 was from September 22 to November 4, 1999. Data collection for Survey 2 was from November 17, 2001, to January 12, 2002, 24 months after the aggressive implementation of a comprehensive, ethnically sensitive risk reduction program. RESULTS: Survey 1 analyzed data from 480 mothers with an infant <12 months of age (327 black, 66 white, and 87 Hispanic) and Survey 2 had 472 mothers (305 black, 77 white, and 90 Hispanic). The incidence of nighttime prone sleeping at Survey 1 was 25% among black respondents, 17% in whites, and 12% in Hispanics and decreased (but not significantly) among all groups by Survey 2. Overall, in Survey 2 compared with Survey 1, fewer mothers reported putting their infants on an adult bed, sofa, or cot both during the day and at night, with the biggest change seen in black mothers for daytime naps. Despite the same educational initiative, blacks increased the use of pillows, stuffed toys, and soft bedding in the sleep environment as compared with whites. More mothers in Survey 2 than in Survey 1 said that they noticed their infants sleeping on their back during the newborn hospitalization. Significantly more black and white mothers in Survey 2 compared with Survey 1 reported that a doctor or nurse had told them what the best position was for putting their infants to sleep, and all 3 groups said that the health care providers indicated that placing the infant on its back was the best sleep position. In examining the relationship between information sources and SIDS risk behaviors, among all groups observation of sleep position in hospital had no effect on behavior after newborn discharge; however, specific instruction by a nurse or doctor in the hospital about how to properly place the infant for sleep influenced behavior after the mother left the hospital. CONCLUSIONS: The Surveys indicate the greatest impact of the SIDS risk factor educational initiative targeted at black communities was changing behaviors regarding safe sleep locations by reducing the incidence of infants placed for nighttime and daytime sleep in adult beds, sofas, or cots. Although these data indicate considerable progress as a result of the targeted educational initiative, our findings suggest that cultural explanations for specific infant care practices must be more clearly understood to close the gap between SIDS risk factor compliance and apparent knowledge about SIDS risk factors.