Factors Impacting Physical Therapy Utilization for Patients With Nonspecific Low Back Pain: Retrospective Analysis of a Clinical Data Set.

OBJECTIVE: Factors predicting physical therapy utilization for lower back pain (LBP) remain unclear, limiting the development of value-based initiatives. The purpose of this study was to identify important factors that impact the number of physical therapist visits per episode of care for US adults with nonspecific LBP. METHODS: This study was a retrospective observational cohort study of a clinical dataset derived from 80 clinics of a single physical therapy provider organization. Research variables were categorized at the individual (patient) level and the organization (therapist, clinic) level. A hierarchical regression model was designed to identify factors influencing the number of physical therapist visits per episode of care. RESULTS: Higher out-of-pocket payments per visit, receipt of "active" physical therapy, longer average visit length, earlier use of physical therapy, and sex of the therapist (male) were found to predict fewer visits per episode of care. Percent change of function, prior receipt of physical therapy by the same provider organization, self-discharge from physical therapy, level of starting function, and therapist certification were found to predict more visits. Of the variance in number of visits, 8.0% was attributable to the health care organization. CONCLUSIONS: Individual factors, such as higher out-of-pocket payment, have a significant impact on reducing visits per episode of care and should be considered when developing value-based initiatives to optimize clinical and utilization outcomes. IMPACT: Payers use consumer-directed healthcare to reduce costs by discouraging utilization of low value services and encouraging use of low-cost providers. LBP is a costly condition for which physical therapy is a high-value treatment. This study shows that non-need factors predict the number of physical therapy visits per episode of care for patients with nonspecific LBP. Insurance benefit plans with lower out-of-pocket payments for physical therapy and higher reimbursement for active physical therapist interventions may facilitate appropriate utilization of high-value treatment for LBP.

Improved fracture prediction using different fracture risk assessment tool adjustments in HIV-infected women.

OBJECTIVES: A fracture risk assessment tool (FRAX) using clinical risk factors (CRFs) alone underestimates fracture risk in HIV-infected men. Our objective was to determine whether accuracy of FRAX would be improved by considering HIV as a cause of secondary osteoporosis, and further improved with addition of dual-energy X-ray absorptiometry parameters in HIV-infected women. DESIGN: Subgroup analysis of Women's Interagency HIV Study. METHODS: We included 1148 women (900 HIV-infected and 248 uninfected) over age 40 with data to approximate FRAX CRFs and 10-year observational data for incident fragility fractures; 181 (20%) HIV-infected women had dual-energy X-ray absorptiometry data. Accuracy of FRAX was evaluated by the observed/estimated ratios of fracture in four models: CRFs alone; CRFs with HIV included as a cause of secondary osteoporosis; CRFs and femoral neck bone mineral density (FN BMD); and CRFs, FN BMD and trabecular bone score. RESULTS: FRAX using CRFs were less accurate in HIV-infected than uninfected women for major osteoporotic (observed/estimated ratio: 5.05 vs. 3.26, P < 0.001) and hip fractures (observed/estimated ratio: 19.78 vs. 7.94, P < 0.001), but improved when HIV was included as a cause of secondary osteoporosis. Among HIV-infected women, FRAX accuracy improved further with addition of FN BMD (observed/estimated ratio: 4.00) for hip fractures, but no further with trabecular bone score. CONCLUSION: FRAX using CRFs alone underestimated fracture risk more in older HIV-infected women than otherwise similar uninfected women. Accuracy is improved when including HIV as a cause of secondary osteoporosis for both major osteoporotic and hip fractures, whereas addition of FN BMD only improved accuracy for hip fracture.

Exploring the Association between Race and Health among Older Adults Who Are Incarcerated.

One of the little known ironies in the field of prison health is the notion that prison may actually have health-stabilizing effects for some groups. This study contributes to this line of inquiry by examining a variety of physical and mental health indicators among an older cohort of prisoners. Furthermore, this study's focus on race addresses a notable gap in the growing literature on older prisoner health. A cross-section of 625 males who were incarcerated residing in a northeastern state prison system was surveyed and data on self-reported health status and stress and individual demographics characteristics were collected. Univariate and multivariate logistic regressions were used to quantify racial differences with respect to self-reported stress after adjusting for potential confounders. Results suggest that Black men who are older and incarcerated appear to be more resilient than White men who are older. An association was found between race and self-reported stress though not statistically significant. Health status is a significant predictor of self-reported stress in univariate and multivariate analyses. Having ever committed a violent offense and having received mental health services (in and out patient) are statistically associated with self-reported stress. Black men who were older in this study appear to cope better with stress related to incarceration than White men who were older, which may in turn affect other physical and mental health outcomes. Future research is needed to address factors that stabilize health and reduce stress among a racially diverse, aging prison population.

Impact of Out-of-Pocket Expenditure on Physical Therapy Utilization for Nonspecific Low Back Pain: Secondary Analysis of the Medical Expenditure Panel Survey Data.

BACKGROUND: Physical therapy decreases low back pain, improves function, and may lead to decreased use of medical services. However, factors predicting physical therapy utilization for patients with low back pain are not well understood. OBJECTIVES: The purpose of this study was to identify the impact of out-of-pocket expenditure on physical therapy utilization for US adults with nonspecific low back pain. DESIGN: This study was a secondary analysis of retrospective Medical Expenditure Panel Survey data. METHODS: The participants were US adults with nonspecific low back pain. The outcome variable was the number of visits per episode of care. The research variable was out-of-pocket expenditure. Covariate variables were Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) component scores. Descriptive statistics and multiple linear regression analyses were performed. RESULTS: Three hundred fourteen adults met the inclusion criteria and submitted SF-12 scores, representing nearly 4 million adults. Out-of-pocket expenditure, physical component score, and the age-insurance category "18-64 years with public coverage only for all of the year or uninsured all of the year" negatively predicted visits per episode of care in the final regression model. LIMITATIONS: Limitations of the study included use of a nonexperimental design, lack of information about symptom severity and content of physical therapy, and SF-12 scores were not taken coincidental with the episode of care. CONCLUSIONS: Out-of-pocket expenditure negatively predicts physical therapy utilization. More research is needed to identify all factors influencing physical therapy utilization so that effective health policies may be developed.

Over-reported peripheral neuropathy symptoms in a cohort of HIV infected and uninfected Rwandan women: the need for validated locally appropriate questionnaires.

BACKGROUND: Peripheral neuropathy symptoms (PNS) are commonly manifested in HIV-infected (HIV+) individuals, although data are limited on the prevalence and predictors of PNS in HIV+ patients from sub-Saharan Africa. OBJECTIVE: To determine the prevalence and predictors of PNS in HIV+ and HIV-uninfected (HIV-) Rwandan women. METHODS: Data were analysed from 936 (710 HIV+ and 226 HIV-) women from the Rwanda Women Interassociation Study and Assessment (RWISA), an observational prospective cohort study investigating the effectiveness and toxicity of ART in HIV+ women. RESULTS: Of 936 enrolled, 920 (98.3%) were included in this analysis with 44% of HIV- and 52% of the HIV+ women reporting PNS (p=0.06). CD4+ count was not associated with PNS, although there was a non-significant trend towards higher prevalence in those with lower CD4+ counts. For the HIV- women, only alcohol and co-trimoxazole use were independently associated with PNS. WHO HIV stage IV illness and albumin ≤ 3.5 were associated with PNS in HIV+ women. CONCLUSIONS: The rate of peripheral neuropathy symptoms reported in this cohort of HIV-infected African women seems implausible, and rather suggests that the screening tool for peripheral neuropathy in culturally diverse African settings be locally validated.

Food insecurity with hunger is associated with obesity among HIV-infected and at risk women in Bronx, NY.

BACKGROUND: Food insecurity, insufficient quality and quantity of nutritionally adequate food, affects millions of people in the United States (US) yearly, with over 18 million Americans reporting hunger. Food insecurity is associated with obesity in the general population. Due to the increasing prevalence of obesity and risk factors for cardiovascular disease among HIV-infected women, we sought to determine the relationship between food insecurity and obesity in this cohort of urban, HIV-infected and -uninfected but at risk women. METHODS: Using a cross-sectional design, we collected data on food insecurity, body mass index and demographic and clinical data from 231 HIV-infected and 119 HIV-negative women enrolled in Bronx site of the Women's Interagency HIV Study (WIHS). We used multivariate logistic regression to identify factors associated with obesity. RESULTS: Food insecurity was highly prevalent, with almost one third of women (110/350, 31%) reporting food insecurity over the previous six months and over 13% of women reported food insecurity with hunger. Over half the women were obese with a Body Mass Index (BMI) of ≥ 30. In multivariate analyses, women who were food insecure with hunger had higher odds of obesity (Adjusted odds ratio [aOR] =  2.56, 95% Confidence Interval [CI]  =  1.27, 5.20) after adjusting for HIV status, age, race, household status, income, drug and alcohol use. CONCLUSION: Food insecurity with hunger was associated with obesity in this population of HIV-infected and -uninfected, urban women. Both food insecurity and obesity are independent markers for increased mortality; further research is needed to understand this relationship and their role in adverse health outcomes.

Relationship between pain and chronic illness among seriously ill older adults: expanding role for palliative social work.

Confronting the issue of pain among chronically ill older adults merits serious attention in light of mounting evidence that pain in this population is often undertreated or not treated at all (Institute of Medicine, 2011 ). The relationship between pain and chronic illness among adults age 50 and over was examined in this study through the use of longitudinal data from the University of Michigan Health and Retirement Study, sponsored by the National Institute on Aging and the Social Security Administration. Findings suggested positive associations between pain and chronic disease, pain and multimorbidity, as well as an inverse association between pain and education. Policy implications for workforce development and public health are many, and amplification of palliative social work roles to relieve pain and suffering among seriously ill older adults at all stages of the chronic illness trajectory is needed.

Microfinance safety net: back to basics.

Malnutrition among families living in poorer communities has increased in the past two decades. Initiatives advocated by the World Bank include microfinance programs. Research attributing the success of these programs however, has mixed results. In this article we investigate how additional income provided by microfinance is associated with increased consumption of nondurables for households in rural villages in Bangladesh. For our purposes we compare consumption or money expensed on food, medicine, doctor fees, and smoking. Fisher's least significant difference (LSD) procedure was used to address multiple comparison issues among households. Our findings reinforce the importance of microfinance credit as a safety net. Access to additional income for poor villagers improves the consumption of basic needs as expected, regardless of how many loans are taken; consumption of "bads" remains virtually the same.

The impact of HIV status, HIV disease progression, and post-traumatic stress symptoms on the health-related quality of life of Rwandan women genocide survivors.

PURPOSE: We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV-infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression. METHODS: The Rwandan Women's Interassociation Study and Assessment was a longitudinal prospective study of HIV-infected and uninfected women. At study entry, 922 women (705 HIV+ and 217 HIV-) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical, and behavioral characteristics. RESULTS: Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall quality of life (QOL) than did HIV- women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms. CONCLUSIONS: This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long-term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.

Assessment of haematological parameters in HIV-infected and uninfected Rwandan women: a cross-sectional study.

OBJECTIVES: Although haematological abnormalities are common manifestations of HIV infection, few studies on haematological parameters in HIV-infected persons have been undertaken in sub-Saharan Africa. The authors assessed factors associated with haematological parameters in HIV-infected antiretroviral-naïve and HIV-uninfected Rwandan women. STUDY DESIGN: Cross-sectional analysis of a longitudinal cohort. SETTING: Community-based women's associations. PARTICIPANTS: 710 HIV-infected (HIV+) antiretroviral-naïve and 226 HIV-uninfected (HIV-) women from the Rwanda Women's Interassociation Study Assessment. Haematological parameters categorised as (abnormal vs normal) were compared by HIV status and among HIV+ women by CD4 count category using proportions. Multivariate logistic regression models using forward selection were fit. RESULTS: Prevalence of anaemia (haemoglobin (Hb) <12.0 g/dl) was higher in the HIV+ group (20.5% vs 6.3%; p<0.001), and increased with lower CD4 counts: ≥350 (7.6%), 200-349 (16%) and <200 cells/mm(3) (32.2%). Marked anaemia (Hb <10.0 g/dl) was found in 4.2% of HIV+ and none of the HIV- women (p<0.001), and was highest in HIV+ women with CD4 <200 cells/mm(3) (8.4%). The HIV+ were more likely than HIV- women (4.2 vs 0.5%, respectively, p=0.002) to have moderate neutropenia with white blood cells <2.0×10(3) cells/mm(3) and 8.4% of HIV+ women with CD4 <200 cells/mm(3) had moderate neutropenia. In multivariate logistic regression analysis, BMI (OR 0.87/kg/m(2), 95% CI 0.82 to 0.93; p<0.001), CD4 200-350 vs HIV- (OR 3.59, 95% CI 1.89 to 6.83; p<0.001) and CD4 <200 cells/mm(3) vs HIV- (OR 8.09, 95% CI 4.37 to 14.97; <0.001) had large independent associations with anaemia. There were large independent associations of CD4 <200 cells/mm(3) vs HIV- (OR 7.18, 95% CI 0.78 to 65.82; p=0.081) and co-trimoxazole and/or dapsone use (OR 5.69, 95% CI 0.63 to 51.45; p=0.122) with moderate neutropenia. CONCLUSIONS: Anaemia was more common than neutropenia or thrombocytopenia in the HIV-infected Rwandan women. Future comparisons of haematological parameters in HIV-infected patients before and after antiretroviral therapy initiation are warranted.

Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability.

BACKGROUND: Chlorhexidine bathing has been associated with reductions in healthcare-associated bloodstream infection. To determine the impact and sustainability of the effect of chlorhexidine bathing on central venous catheter-associated bloodstream infection, we performed a prospective, 3-phase, multiple-hospital study. METHODS: In the medical intensive care unit and the respiratory care unit of a tertiary care hospital and the medical-surgical intensive care units of 4 community hospitals, rates of central venous catheter-associated bloodstream infection were collected prospectively for each period. Pre-intervention (phase 1) patients were bathed with soap and water or nonmedicated bathing cloths; active intervention (phase 2) patients were bathed with 2% chlorhexidine gluconate cloths with the number of baths administered and skin tolerability assessed; post-intervention (phase 3) chlorhexidine bathing was continued but without oversight by research personnel. Central venous catheter-associated bloodstream infection rates were compared over study periods using Poisson regression. RESULTS: Compared with pre-intervention, during active intervention there were significantly fewer central venous catheter-associated bloodstream infections (6.4/1000 central venous catheter days vs 2.6/1000 central venous catheter days, relative risk, 0.42; 95% confidence interval, 0.25-0.68; P<.001), and this reduction was sustained during post-intervention (2.9/1000 central venous catheter days; relative risk, 0.46; 95% confidence interval, 0.30-0.70; P<.001). During the active intervention period, compliance with chlorhexidine bathing was 82%. Few adverse events were observed. CONCLUSION: In this multiple-hospital study, chlorhexidine bathing was associated with significant reductions in central venous catheter-associated bloodstream infection, and these reductions were sustained post-intervention when chlorhexidine bathing was unmonitored. Chlorhexidine bathing was well tolerated and is a useful adjunct to reduce central venous catheter-associated bloodstream infection.