What are the Conditions of Riparian Ecosystems? Identifying Impaired Floodplain Ecosystems across the Western U.S. Using the Riparian Condition Assessment (RCA) Tool.

Environmental stressors associated with human land and water-use activities have degraded many riparian ecosystems across the western United States. These stressors include (i) the widespread expansion of invasive plant species that displace native vegetation and exacerbate streamflow and sediment regime alteration; (ii) agricultural and urban development in valley bottoms that decouple streams and rivers from their floodplains and reduce instream wood recruitment and retention; and (iii) flow modification that reduces water quantity and quality, degrading aquatic habitats. Here we apply a novel drainage network model to assess the impacts of multiple stressors on reach-scale riparian condition across two large U.S. regions. In this application, we performed a riparian condition assessment evaluating three dominant stressors: (1) riparian vegetation departure from historical condition; (2) land-use intensity within valley bottoms; and (3) floodplain fragmentation caused by infrastructure within valley bottoms, combining these stressors in a fuzzy inference system. We used freely available, geospatial data to estimate reach-scale (500 m) riparian condition for 52,800 km of perennial streams and rivers, 25,600 km in Utah, and 27,200 km in 12 watersheds of the interior Columbia River Basin (CRB). Model outputs showed that riparian condition has been at least moderately impaired across ≈70% of the streams and rivers in Utah and ≈49% in the CRB. We found 84% agreement (Cohen's ĸ = 0.79) between modeled reaches and field plots, indicating that modeled riparian condition reasonably approximates on-the-ground conditions. Our approach to assessing riparian condition can be used to prioritize watershed-scale floodplain conservation and restoration by providing network-scale data on the extent and severity of riparian degradation. The approach that we applied here is flexible and can be expanded to run with additional riparian stressor data and/or finer resolution input data.

Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database.

Objective: To validate a risk index that estimates the likelihood of overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids. Subjects and Methods: A case-control analysis of 18,365,497 patients with an opioid prescription from 2009 to 2013 in the IMS PharMetrics Plus commercially insured health plan claims database (CIP). An OIRD event occurred in 7,234 cases. Four controls were selected per case. Validity of the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD), developed previously using Veterans Health Administration (VHA) patient data, was assessed. Multivariable logistic regression was used within the CIP study population to develop a slightly refined RIOSORD. The composition and performance of the CIP-based RIOSORD was evaluated and compared with VHA-based RIOSORD. Results: VHA-RIOSORD performed well in discriminating OIRD events in CIP (C-statistic = 0.85). Additionally, re-estimation of logistic model coefficients in CIP yielded a 0.90 C-statistic. The resulting comorbidity and pharmacotherapy variables most highly associated with OIRD and retained in the CIP-RIOSORD were largely concordant with VHA-RIOSORD. These variables included neuropsychiatric and cardiopulmonary disorders, impaired drug excretion, opioid characteristics, and concurrent psychoactive medications. The average predicted probability of OIRD ranged from 2% to 83%, with excellent agreement between predicted and observed incidence across risk classes. Conclusions: RIOSORD had excellent predictive accuracy in a large population of US medical users of prescription opioids, similar to its performance in VHA. This practical risk index is designed to support clinical decision-making for safer opioid prescribing, and its clinical utility should be evaluated prospectively.

Hispanics' Satisfaction with Free Clinic Providers: An Analysis of Patient-Centered Medical Home Characteristics.

Hispanic Americans are less likely to be insured and they experience cultural and linguistic barriers that may prevent them from obtaining necessary and preventive healthcare. Adoption of Patient Centered Medical Home (PCMH) concepts in healthcare settings utilized by Hispanics could improve Hispanic patients' satisfaction with their healthcare providers. This study examined the association between Spanish-speaking and non-Spanish-speaking patients' perceptions of PCMH characteristics and satisfaction with the provider. Data were collected using a self-administered survey from two unaffiliated free clinics. Logistic regression modeled the associations between patients' perceptions of PCMH and their satisfaction with their provider, and their desire to see the same provider in the future. The sample consisted of 367 adults; 44 % were Spanish-speaking. Spanish-speaking patients were younger, less educated, and had fewer chronic conditions than non-Spanish-speaking patients. In adjusted analyses for each population, better ratings of the provider's communication skills were associated with increased satisfaction with the provider (Spanish-speaking: OR = 8.33, 95 % CI = 2.19-31.76; non-Spanish-speaking: OR = 31.39, 95 % CI = 6.91-142.62), and willingness to see the provider again (Spanish-speaking: OR = 12.54, 95 % CI = 2.80-56.24; non-Spanish-speaking: OR = 8.77, 95 % CI = 2.40-31.96). Among Spanish-speakers, lower perceived discrimination was associated with 137 % increased odds and higher perceived staff helpfulness had 212 % increased odds of seeing the provider again. Relative to other PCMH components, interpersonal skills were the most important factors in patient satisfaction with free clinics. Increased training for clinicians on cultural competence and clinician-patient communication may lead to improved patient satisfaction for both Spanish and non-Spanish speakers seen at free clinics, particularly clinics in states without Medicaid expansion.

Dental dilemmas: Endodontics or dental implants?

UNLABELLED: This narrative review explores treatment planning options in restorative dentistry. The growth of dental implants, as an accessible and predictable treatment option, gives practitioners a useful tool for managing the missing tooth or teeth with a hopeless prognosis. Traditionally, endodontics and fixed prosthodontics have been used to restore teeth and spaces where the outlook for such treatment appears reasonable. Practitioners may, however, question the predictability and cost effectiveness of such an approach where, at times, it might appear that replacement of a compromised tooth with a dental implant could be a more predictable option. The evidence base for these treatment options is explored and discussed, and suggestions are made for future management strategies. CLINICAL RELEVANCE: A clear knowledge and understanding of the scientific literature for implants and endodontic treatment is necessary if practitioners are to make an evidence-based approach when treatment planning these modalities for their patients. This is particularly true in cases where there may appear to be a reasonable choice between the two of these.

Impact of surgical site infections on length of stay and costs in selected colorectal procedures.

BACKGROUND: Length of stay (LOS) and inpatient costs for open-abdomen colorectal procedures have not been examined recently. The aim of this study was to determine LOS and costs for several colorectal procedures in the context of factors potentially associated with surgical site infection (SSI). METHODS: We used a large U.S. hospital database to identify the variables associated with longer LOS and higher costs for colorectal procedures from January 1, 2005, through June 30, 2006. The study population consisted of all patients >18 years, identified via International Classification of Disease, Ninth Revision, procedural codes for elective colorectal surgery. Patient demographics, surgical procedure, and a modified Study of the Efficacy of Nosocomial Infection Control (SENIC) infection risk score were examined using logistic regression as predictors of LOS >or=1 week and cost >or=$15,000. Patients given cefotetan as surgical prophylaxis were compared with patients given cefazolin/metronidazole. Superficial and deep SSIs were considered; intra-abdominal infection was not. RESULTS: The 25,825 patients were of average age 63 years, with 53% being female and 75% being Caucasian. The overall infection rate was 3.7%. The mean LOS was 7.25 days, and the mean +/- standard deviation total cost per patient $13,746 +/- $13,330. Rates of infection, LOS, and mean hospital costs were all greater for patients with a high SENIC score and increasing disease acuity. Values for these outcome variables were highest for procedures involving stoma formation, followed by operations on the small bowel and large bowel. Variables independently predictive of longer LOS were SSI (odds ratio [OR] 11.74; 95% confidence interval [CI] 9.67, 14.26), age >or=65 years (OR 1.90; 95% CI 1.81, 2.01), and high SENIC score (OR 1.79; 95% CI 1.67, 1.92), whereas Caucasian race (OR 0.86; 95% CI 0.81, 0.91) was predictive of a shorter LOS. Cefazolin/metronidazole was not predictive of a shorter LOS compared with cefotetan (OR 1.06; 95% CI 0.96, 1.17) but was associated with significantly more hospitalizations with costs >or=$15,000 (OR 1.39; 95% CI 1.23, 1.56). CONCLUSIONS: Length of stay and cost rise proportionally with SENIC score, disease acuity, and patient characteristics such as age. Surgical site infections are significantly and independently associated with LOS and cost and contribute to inpatient morbidity and expense. Cefotetan has limited availability, and substitutions are utilized increasingly. Although equally efficacious in elective colon procedures, cefotetan used as surgical prophylaxis was associated with lower hospitalization costs than cefazolin plus metronidazole.

Economic burden of postoperative ileus associated with colectomy in the United States.

BACKGROUND: Postoperative ileus, a transient impairment of gastrointestinal motility, is a common cause of delay in return to normal bowel function after abdominal surgery. Colectomy surgery patients who develop postoperative ileus could have greater health care resource utilization, including prolonged hospitalization, compared with those who do not develop postoperative ileus. Very few studies have assessed the impact of postoperative ileus on resource utilization and costs using retrospective analysis of administrative databases. OBJECTIVE: To assess health care utilization and costs in colectomy surgery patients who developed postoperative ileus versus those who did not. METHODS: A retrospective cohort study design was used. Adult patients with a principal procedure code for colectomy (ICD-9-CM procedure codes 45.71-45.79), discharged between January 1, 2004, and December 31, 2004, were identified from the Premier Perspective database of inpatient records from more than 500 hospitals in the United States. The colectomy patients were further classified for the presence of postoperative ileus, identified by the presence, in any diagnosis field on the administrative patient records, of a code for paralytic ileus (ICD-9-CM code 560.1) and/or digestive system complications (ICD-9-CM code 997.4) during the inpatient stay. Code 997.4 was used to account for cases in which postoperative ileus would be reported as a complication of anastomosis, as could be the case in colectomy surgeries. Hospital length of stay (LOS) and hospitalization costs were compared using t-tests. Multivariate analyses were performed with log-transformed LOS and log-transformed cost as the dependent variables. Patient demographics, mortality risk, disease severity, admission source, payment type (retrospective/prospective), and hospital characteristics were used as covariates. RESULTS: A total of 17,876 patients with primary procedure code for colectomy were identified, of whom 3115 (17.4%) patients were classified for presence of postoperative ileus (including paralytic ileus only [n=1216; 6.8%], digestive system complications only [n=383; 2.1%], or both [n=1516; 8.5%]). A majority of the colectomy patients with and without postoperative ileus, respectively, were male (54.1% vs. 50.3%, P < 0.001), Caucasian (70.5% vs. 69.3%, P = 0.170), and aged 51-64 years (51.1% vs. 49.7%, P = 0.143). The mean [SD] hospital LOS was significantly longer in patients with postoperative ileus (13.8 [13.3] days) compared with patients without postoperative ileus (8.9 [9.5] days; P < 0.001). Presence of postoperative ileus was found to be a significant predictor of LOS (P < 0.001) in the regression model, controlling for covariates. Female gender (P = 0.002), greater severity level (P < 0.001), and hospital bed size of more than 500 (P = 0.013) were other significant predictors of hospital LOS. Presence of postoperative ileus was found to be a significant predictor of hospitalization costs (P < 0.001), controlling for covariates. CONCLUSION: Postoperative ileus in colectomy patients is a significant predictor of hospital resource utilization.

Burden of blood transfusion in knee and hip surgery in the US and Belgium.

OBJECTIVE: Transfusion services in orthopaedic surgery can lead to unnecessary complications and increased healthcare costs. The objective of this study was to assess treatments and costs associated with blood and blood product transfusions in a historical cohort of 189,457 inpatients in the US and 34,987 inpatients in Belgium undergoing knee or hip surgery. METHODS: Descriptive analysis, logistic regression and ordinary least squares regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion. RESULTS: Hospitalisation costs for joint replacement surgery totalled $12,718 (SD=6,356) and averaged 4.33 days in the US, while costs in Belgium were $6,526 (SD=3,192) and averaged 17.1 days. The use of low molecular weight heparin and tranexamic acid was much higher in Belgium than the US (36% and 99% compared to 0% and 40%, respectively). Patients in the US spent 12.7 (p<0.0001) fewer days in the hospital, 0.3 (p<0.0001) fewer days in the intensive care unit and were 88% less likely to have allogeneic blood transfusions (OR=0.22, 95% CI 0.22-0.23), but incurred $6,483 (p<0.0001) more costs per hospitalisation than patients in Belgium. CONCLUSIONS: While hospital costs for patients were greater in the US, length of stay was shorter and patients were less likely to have transfusion services than those patients in Belgium. While this study is limited by factors inherent to observational studies, such as omitted variable bias, misclassification, and disease comorbidity, there are substantial differences in the use of blood products between Belgium and the US.

Comparison between spinal surgery blood transfusion services costs and associated treatment practices in the United States and Belgium.

OBJECTIVE: This study assessed utilization and cost of allogeneic blood transfusion (ABT) associated with spinal surgery in the United States (US) and Belgium. METHODS: A retrospective cohort of 292,864 spinal surgery inpatients in US hospitals was pooled with a cohort of 27,952 inpatients who had similar procedures in Belgian hospitals. Utilization and cost data were derived from hospital accounting systems. Costs were converted to US dollars. Descriptive and multivariate statistics were used to describe the factors associated with the use and cost of ABT. Missing data, confounding, and variable measurement error were addressed using standard approaches for observational studies. RESULTS: US hospitalizations cost $12,044 (SD = 15,920) over 3.6 days compared to $4010 (SD = 3586) over 10.3 days in Belgium. Low molecular weight heparin was used by 78% of Belgian patients and 4% of US patients. Red blood cell utilization occurred in approximately 7% of patients from both countries; however US patients received 6 units compared to 3 units by Belgian patients. US patients spent 3.5 (p < 0.0001) less days in hospital, 1.0 (p < 0.0001) more days in an intensive care unit, used 64% more allogeneic blood (OR = 1.64, 95% CI 1.53-1.75), and incurred $13,647 (p < 0.0001) more per hospitalization than Belgian patients. CONCLUSIONS: US patients used more blood products, had shorter hospital stays, and incurred greater costs than Belgian patients. Specialists as attending physicians were associated with lower utilization of ABT; this may be an administrative change that hospitals can implement to reduce utilization and costs.

Cost and utilization of blood transfusion associated with spinal surgeries in the United States.

The purpose of this study was to examine factors associated with the utilization and cost of blood transfusion during and post-spinal fusion surgery. A retrospective, observational study of 42,029 inpatients undergoing spinal fusion surgery in United States hospitals participating in the Perspective( Comparative Database for inpatient use was conducted. Descriptive analysis, logistic regression, and ordinary least squares (OLS) regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion (ABT). Hospitalization costs were $18,690 (SD=14,159) per patient, erythropoietin costs were $85.25 (SD=3,691.66) per patient, and topical sealant costs were $414.34 (SD=1,020.06) per patient. Sub-analysis of ABT restricted to users revealed ABT costs ranged from $312.24 (SD=543.35) per patient with whole blood to $2,520 (SD=3,033.49) per patient with fresh frozen plasma. Patients that received hypotensive anesthesia (OR,1.61; 95% CI, 1.47-1.77), a volume expander (OR,1.95; 95% CI, 1.75-2.18), autologous blood (OR, 2.04; 95% CI, 1.71-2.42), or an erythropoietic agent (OR=1.64; 95% CI, 1.27-2.12) had a higher risk of ABT. Patients that received cell salvage had a lower risk of transfusion (OR=0.40; 95% CI, 0.32-0.50). Most blood avoidance techniques have low utilization or do not reduce the burden of transfusion associated with spinal fusion.

Resource utilization and costs of blood management services associated with knee and hip surgeries in US hospitals.

This article assesses the use and costs of blood transfusion during knee and hip surgery through a retrospective observational study of 92,223 discharged inpatients who had undergone knee or hip surgery from July 1, 2003, through June 30, 2004; a sample of US hospitals that participated in the Perspective Comparative Database (Premier Inc., Charlotte, NC) was used. Descriptive and multivariate analyses were performed to determine the use and costs of allogeneic blood transfusion (ABT). The average cost of ABT per user ranged from $387 (SD=$952) for red blood cells to $6585 (SD=$11,162) for cryoprecipitate. Utilization rates in the sample were as follows: antifibrinolytics, 0.14%; topical sealants, 3.24%; volume expanders, 3.89%; erythropoietin agents, 5.08%; and hypotensive anesthesia, 22.28%. Patients who were given volume expanders ($133.73, SD=$23.00, P<.01) or erythropoietin ($177.72, SD=$34.61, P<.01) had higher costs associated with ABT than did those who did not use volume expanders or erythropoietin. Patients who received hypotensive anesthesia (odds ratio [OR]=1.96; 95% confidence interval [CI], 1.87-2.06), a volume expander (OR=1.71; 95% CI, 1.57- 1.85), a topical sealant (OR=1.61; 95% CI, 1.45-1.79), or an erythropoietic agent (OR=2.30; 95% CI, 2.06-2.57) had a greater likelihood of ABT. Investigators concluded that most transfusion reduction techniques are underused, or they do not reduce the burden of ABT associated with knee or hip surgery.