Influence of visual acuity, manual dexterity and handgrip strength on oral and denture hygiene ability of non-frail older people: Development of the Gerostomatological Assessment Battery.

BACKGROUND: Due to the heterogeneity of older people, it is difficult to identify reliable factors influencing oral health. OBJECTIVE: The aim was to illustrate the influence of visual acuity, manual dexterity, and handgrip strength on the oral and denture hygiene ability of older non-frail people. METHODS: In a cross-sectional study, conducted at a specialized dental clinic, at baseline, all participants received professional prophylaxis and instruction on daily oral and denture hygiene regimes for a 6-week intervention period. Data on the Quigley and Hein modified plaque index (QHI), respectively, the Denture Hygiene Index (DHI), visual acuity, manual dexterity and handgrip strength in non-frail participants (≥ 65 years) were collected. Recruitment was done within the clinic's patient clientele and within the staff (control cohort). RESULTS: Women showed significantly better manual dexterity than men (Mann-Whitney U, p = .01), while women's mean handgrip strength was significantly lower (Mann-Whitney U, p < .01). Manual dexterity (Mann-Whitney U, p = .003) and handgrip strength (Mann-Whitney U, p = .052) were associated with age. However, visual acuity, manual dexterity and handgrip strength had no influence on oral or denture hygiene. CONCLUSION: Visual acuity, manual dexterity and handgrip strength have no influence on oral and denture hygiene ability in older non-frail people. Further studies should investigate whether these factors also have no influence on oral and denture hygiene in vulnerable older patients. Therefore, an assessment tool for the evaluation of potential influencing factors of oral and denture hygiene is proposed in a dental context. This Gerostomatological Assessment Battery (G-AB) can be used as a helpful tool to check the individual cognitive function and comprehension, dental therapy approaches and their individual adaption.

Nanomaterial interfaces designed with different biorecognition elements for biosensing of key foodborne pathogens.

Foodborne diseases caused by pathogen bacteria are a serious problem toward the safety of human life in a worldwide. Conventional methods for pathogen bacteria detection have several handicaps, including trained personnel requirement, low sensitivity, laborious enrichment steps, low selectivity, and long-term experiments. There is a need for precise and rapid identification and detection of foodborne pathogens. Biosensors are a remarkable alternative for the detection of foodborne bacteria compared to conventional methods. In recent years, there are different strategies for the designing of specific and sensitive biosensors. Researchers activated to develop enhanced biosensors with different transducer and recognition elements. Thus, the aim of this study was to provide a topical and detailed review on aptamer, nanofiber, and metal organic framework-based biosensors for the detection of food pathogens. First, the conventional methods, type of biosensors, common transducer, and recognition element were systematically explained. Then, novel signal amplification materials and nanomaterials were introduced. Last, current shortcomings were emphasized, and future alternatives were discussed.

What's Happening at Home: A Claims-based Approach to Better Understand Home Clinical Care Received by Older Adults.

BACKGROUND: Home clinical care (HCC) includes home-based medical care (HBMC-medical visits in the home) and skilled home health care (skilled nursing or therapy visits). Over 7 million older adults would benefit from HCC; however, we know surprisingly little about homebound older adults and HCC. OBJECTIVE: To describe HCC received by older adults using claims data within the OptumLabs Data Warehouse. RESEARCH DESIGN: Using administrative claims data for commercial and Medicare Advantage enrollees, we describe morbidity profiles, health service use, and care coordination (operationalized as care plan oversight [CPO]) for people receiving HCC and the subgroup receiving HBMC. PARTICIPANTS: Three million adults (3,027,247) age ≥65 with 12 months of continuous enrollment 2013-2014. MEASURES: CPT or HCPCS codes delineated HCC, HBMC, and CPO recipients and care site, frequency, and provider type. Other measures included demographic characteristics, clinical characteristics, and health care utilization. RESULTS: Overall, 5% of the study population (n=161,801) received 2+ months of HCC visits; of these, 46% also received 2+ HBMC visits (n=73,638) while 54% received only skilled home health (n=88,163 HCC but no HBMC). HBMC-recipients had high comorbidity burden (Charlson score 4.3), dementia (35%), and ambulance trips (58%), but few nursing facility admissions (4.9%). Evidence of care coordination (CPO claims) occurred in 30% of the HCC population, 46% of HBMC, and 17% of the skilled home health care only. CONCLUSIONS: Approximately 1 of 20 older adults in this study received HCC; 30% or less have a claim for care coordination by their primary care provider.

Intensive remote monitoring versus conventional care in type 1 diabetes: A randomized controlled trial.

OBJECTIVE: While frequent contact with diabetes care providers may improve glycemic control among patients with type 1 diabetes (T1D), in-person visits are labor-intensive and costly. This study was conducted to assess the impact of an intensive remote therapy (IRT) intervention for pediatric patients with T1D. METHODS: Pediatric patients with T1D were randomized to IRT or conventional care (CC) for 6 months. Both cohorts continued routine quarterly clinic visits and uploaded device data; for the IRT cohort, data were reviewed and patients were contacted if regimen adjustments were indicated. Glycated hemoglobin (HbA1c) change from baseline was assessed at 6 and 9 months. Diabetes-related quality of life (QoL), healthcare services utilization, and hypoglycemic events were also tracked. RESULTS: Among 117 enrollees (60 IRT, 57 CC), mean (SD) 6-month %HbA1c change for IRT vs CC was -0.34 (0.85) (-3.7 mmol/mol) vs -0.05 (0.74) (-0.5 mmol/mol) overall (P = .071); -0.15 (0.67) (1.6 mmol/mol) vs -0.02 (0.66) (0.2 mmol/mol) for ages 8 to 12 (P = .541); and -0.50 (0.95) (-5.5 mmol/mol) vs -0.06 (0.80) (-0.7 mmol/mol) for ages 13 to 17 (P = .056). Diabetes-related QoL increased by 6.5 and 1.3 points for IRT and CC, respectively (P = .062). Three months after intervention cessation, %HbA1c changed minimally among treated children aged 8 to 12 but increased by 0.22 (0.89) (2.4 mmol/mol) among those aged 13 to 17. CONCLUSIONS: IRT substantially affected diabetes metrics and improved QoL among pediatric patients with T1D. Adolescents experienced a stronger treatment effect, but had difficulty in sustaining improved control after intervention cessation.

Drivers of Healthcare Costs Among the Costliest Patients With Psoriasis Over Three Years in a United States Health Plan.

OBJECTIVE: To compare patients with psoriasis by cost level over 3 years.

METHODS: Psoriasis patients in a large US health plan in 2011-2013 were identified. Four groups were created by healthcare costs excluding biologics: patients having top 10% of costs in all 3 years (Top), top 10% in 2 of 3 years (High), bottom 90% in 2 of 3 years (Medium), and bottom 90% in all 3 years (Bottom). Comorbidities, utilization, and costs between groups were compared.

RESULTS: The study included 18,653 patients: 514 (3%), 805 (4%), 2,443 (13%), and 14,891 (80%) patients in the Top, High, Medium, and Bottom groups, respectively. Significantly more patients in the Top vs Bottom group had diabetes (31.1% vs 9.4%), cardiovascular disease (26.5% vs 4.3%), psoriatic arthritis (25.7% vs 10.7%), depression (27.8% vs 6.9%), and anxiety (22.0% vs 7.9%) in 2011 (all P less than 0.05). Patients in the Top group had more unique 2011 prescriptions (17.7 vs 6.6; P less than 0.001) than the Bottom group, but similar biologic use (22.4% vs 21.6%). Patients in the Top, High, Medium, and Bottom groups had mean 2011 total costs of $68,913, $40,575, $24,292, and $8,815, and contributed to 14%, 13%, 23%, and 51% of the overall costs, respectively. Mean total costs increased 14-18% over time for all groups. Although mean 2011 total costs for patients in the Top group were 7.8 times of those in the Bottom group, psoriasis-related costs were less disparate ($8,716 vs $4,541). Compared with patients in the Bottom group, those in the Top group were more likely to have any 2011 hospitalization (36.8% vs 2.6%; psoriasis-related: 11.1% vs 0.7%) or emergency visit (50.8% vs 20.8%; psoriasis-related: 3.9% vs 1.0%).

CONCLUSION: The costliest patients with psoriasis had significantly higher prevalence of comorbidities, prescription fills, inpatient and emergency utilization, but not biologic medication use or biologic costs.

J Drugs Dermatol. 2017;16(7):651-658.

A Real-World Study of Switching From Allopurinol to Febuxostat in a Health Plan Database.

OBJECTIVE: The objective of this study was to assess the real-world comparative effectiveness of continuing on allopurinol versus switching to febuxostat. METHODS: In a retrospective claims data study of enrollees in health plans affiliated with Optum, we evaluated patients from February 1, 2009, to May 31, 2012, with a gout diagnosis, a pharmacy claim for allopurinol or febuxostat, and at least 1 serum uric acid (SUA) result available during the follow-up period. Univariate and multivariable-adjusted analyses (controlling for patient demographics and clinical factors) assessed the likelihood of SUA lowering and achievement of target SUA of less than 6.0 mg/dL or less than 5.0 mg/dL in allopurinol continuers versus febuxostat switchers. RESULTS: The final study population included 748 subjects who switched to febuxostat from allopurinol and 4795 continuing users of allopurinol. The most common doses of allopurinol were 300 mg/d or less in 95% of allopurinol continuers and 93% of febuxostat switchers (prior to switching); the most common dose of febuxostat was 40 mg/d, in 77% of febuxostat switchers (after switching). Compared with allopurinol continuers, febuxostat switchers had greater (1) mean preindex SUA, 8.0 mg/dL versus 6.6 mg/dL (P < 0.001); (2) likelihood of postindex SUA of less than 6.0 mg/dL, 62.2% versus 58.7% (P = 0.072); (3) likelihood of postindex SUA of less than 5.0 mg/dL, 38.9% versus 29.6% (P < 0.001); and (4) decrease in SUA, 1.8 (SD, 2.2) mg/dL versus 0.4 (SD, 1.7) mg/dL (P < 0.001). In multivariable-adjusted analyses, compared with allopurinol continuers, febuxostat switchers had significantly higher likelihood of achieving SUA of less than 6.0 mg/dL (40% higher) and SUA of less than 5.0 mg/dL (83% higher). CONCLUSIONS: In this "real-world" setting, many patients with gout not surprisingly were not treated with maximum permitted doses of allopurinol. Patients switched to febuxostat were more likely to achieve target SUA levels than those who continued on generally stable doses of allopurinol.

Effects on quality characteristics of ultrasound-treated gilaburu juice using RSM and ANFIS modeling with machine learning algorithm.

Gilaburu (Viburnum opulus L.) is a red-colored fruit with a sour taste that grows in Anatolia. It is rich in various antioxidant and bioactive compounds. In this study, bioactive compounds and ultrasound parameters of ultrasound-treated gilaburu water were optimized by response surface methodology (RSM) and adaptive neuro-fuzzy inference system (ANFIS). As a result of RSM optimization, the independent ultrasound parameters were determined as an ultrasound duration of 10.7 min and an ultrasound amplitude of 53.3, respectively. The R2 values of the RSM modeling level were 99.93%, 98.54%, and 99.80%, respectively, and the R2 values of the ANFIS modeling level were 99.99%, 98.89%, and 99.87%, respectively. Some quality parameters of gilaburu juice were compared between ultrasound-treated gilaburu juice (UT-GJ), thermal pasteurized gilaburu juice (TP-GJ), and control group (C-GJ). The quality parameters include bioactive compounds, phenolic compounds, minerals, and sensory evaluation. Bioactive compounds in the samples increased after ultrasound application compared to C-GJ and TP-GJ samples. The content of 15 different phenolic compounds was determined in Gilaburu juice samples, and the phenolic compound of UT-GJ samples increased compared to TP-GJ and C-GJ samples, except for gentisic acid. Ultrasound treatment applied to gilaburu juice enabled its bioactive compounds to hold more in the juice.

Physicochemical characteristics and structural changes of fermented faba bean extrudates prepared by twin-screw extrusion.

In this study, fermented faba bean blends with different locust bean gum (LBG) contents were processed in a co-rotating twin-screw extruder. The effects of extrusion process variables and the LBG level on physicochemical, sensory and structural characteristics of expanded extrudates were investigated. The results showed that physical characteristics of extrudates including expansion, apparent density and texture were significantly affected by variation of screw speed and die temperature, but the effect of LBG level was only significant for expansion and density. FTIR-ATR analysis revealed that a significant change occurred in the protein secondary structure as well as in the short-range ordered molecular structure of starch during fermentation and extrusion. The X-ray diffraction patterns of extrudates exhibited V-type pattern. Microstructure of the extrudates analyzed by FE-SEM exhibited variations in cell size and wall thickness depending on extrusion processing conditions and LBG level, which in turn lead to different textural perceptions.

Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017.

Importance: A 2016 Centers for Disease Control and Prevention prescribing guideline cautioned against higher-dose long-term opioid therapy and recommended tapering daily opioid doses by approximately 10% per week if the risks outweigh the benefits. Warnings have since appeared regarding potential hazards of rapid opioid tapering. Objectives: To characterize US trends in opioid dose tapering among patients prescribed long-term opioids from 2008 to 2017 and identify patient-level variables associated with tapering and a more rapid rate of tapering. Design, Setting, and Participants: This retrospective cohort study used deidentified medical and pharmacy claims and enrollment records for 100 031 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races/ethnicities, and geographical regions across the United States. Adults with stable, higher-dosage (mean, ≥50 morphine milligram equivalents [MMEs]/d) opioid prescriptions for a 12-month baseline period and 2 or more months of follow-up from January 1, 2008, to December 31, 2017, were included in the study. Main Outcomes and Measures: Tapering was defined as 15% or more relative reduction in mean daily MME during any of 6 overlapping 60-day windows within a 7-month follow-up period. The rate of tapering was computed as the maximum monthly percentage dose reduction. Results: Among the 100 031 participants (53 452 [53.4%] women; mean [SD] age, 57.6 [11.8] years), from 2008 to 2015, the age- and sex-standardized percentage of patients tapering daily opioid doses increased from 10.5% to 13.7% (adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 16.2% in 2016 and 22.4% in 2017 (aIRR in 2016-2017 vs 2008-2015, 1.20 [95% CI, 1.16-1.25]). Patient-level covariates associated with tapering included female sex (aIRR, 1.13 [95% CI, 1.10-1.15]) and higher baseline dose (aIRR for ≥300 MMEs/d vs 50-89 MMEs/d, 2.57 [95% CI, 2.48-2.65]). Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 27.6% (17.0%) per month, and 18.8% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). More rapid dose reduction was associated with 2016-2017 vs 2008-2015 (adjusted difference, 1.4% [95% CI, 0.8%-2.1%]) and higher baseline dose (adjusted difference, 2.7% [95% CI, 2.2%-3.3%] for 90-149 vs 50-89 MMEs/d). Conclusions and Relevance: Patients using long-term opioid therapy are increasingly undergoing dose tapering, particularly women and those prescribed higher doses; in addition, dose tapering has become more common since 2016. Many patients undergoing tapering reduce daily doses at a rapid maximum rate.

Trends in Health Care Costs and Utilization Associated With Untreated Hearing Loss Over 10 Years.

Importance: Nearly 38 million individuals in the United States have untreated hearing loss, which is associated with cognitive and functional decline. National initiatives to address hearing loss are currently under way. Objective: To determine whether untreated hearing loss is associated with increased health care cost and utilization on the basis of data from a claims database. Design, Setting, and Participants: Retrospective, propensity-matched cohort study of persons with and without untreated hearing loss based on claims for health services rendered between January 1, 1999, and December 31, 2016, from a large health insurance database. There were 154 414, 44 852, and 4728 participants at the 2-, 5-, and 10-year follow-up periods, respectively. The study was conceptualized and data were analyzed between September 2016 and November 2017. Exposures: Untreated hearing loss (ie, hearing loss that has not been treated with hearing devices) was identified via claims measures. Main Outcomes and Measures: Medical costs, inpatient hospitalizations, total days hospitalized, 30-day hospital readmission, emergency department visits, and days with at least 1 outpatient visit. Results: Among 4728 matched adults (mean age at baseline, 61 years; 2280 women and 2448 men), untreated hearing loss was associated with $22 434 (95% CI, $18 219-$26 648) or 46% higher total health care costs over a 10-year period compared with costs for those without hearing loss. Persons with untreated hearing loss experienced more inpatient stays (incidence rate ratio, 1.47; 95% CI, 1.29-1.68) and were at greater risk for 30-day hospital readmission (relative risk, 1.44; 95% CI, 1.14-1.81) at 10 years postindex. Similar trends were observed at 2- and 5-year time points across measures. Conclusions and Relevance: Older adults with untreated hearing loss experience higher health care costs and utilization patterns compared with adults without hearing loss. To further define this association, additional research on mediators, such as treatment adherence, and mitigation strategies is needed.

Incident Hearing Loss and Comorbidity: A Longitudinal Administrative Claims Study.

Importance: Because hearing loss is highly prevalent and treatable, determining its association with morbidity has major public health implications for disease prevention and the maintenance of health in adults with hearing loss. Objective: To investigate the association between the diagnosis of incident hearing loss and medical comorbidities in adults 50 years or older. Design, Setting, and Participants: Retrospective, propensity-matched cohort study using administrative claims data from commercially insured and Medicare Advantage members in a geographically diverse US health plan. Adults 50 years or older with claims for services rendered from January 1, 2000, to December 31, 2016, were observed for 2 (n = 154 414), 5 (n = 44 852), and 10 (n = 4728) years. This research was conceptualized and data were analyzed between September 2016 and November 2017. Exposures: A claim for incident hearing loss is defined as 2 claims for hearing loss within 2 consecutive years without evidence of hearing device use, excluding claims for sudden hearing loss or hearing loss secondary to medical conditions. Main Outcomes and Measures: Incident claims for dementia, depression, accidental falls, nonvertebral fractures, acute myocardial infarction, and stroke. Results: After cohort matching, 48% of participants were women (n = 74 464), 61% were white (n = 93 442), and 31% (n = 48 056) were Medicare Advantage insured, with a mean (SD) age of 64 (10) years. In a multivariate-adjusted modified Poisson regression with robust standard errors, relative associations were strongest for dementia (relative risk at 5 years, 1.50; 95% CI, 1.38-1.64) and depression (relative risk at 5 years, 1.41; 95% CI, 1.26-1.58). The absolute risk of all outcomes was greater in persons with hearing loss than in those without hearing loss at all times, with the greatest risk difference observed at 10 years for all outcomes. The 10-year risk attributable to hearing loss was 3.20 per 100 persons (95% CI, 1.76-4.63) for dementia, 3.57 per 100 persons (95% CI, 1.67-5.47) for falls, and 6.88 per 100 persons (95% CI, 4.62-9.14) for depression. Conclusions and Relevance: In this large observational study using administrative claims data, incident untreated hearing loss was associated with greater incident morbidity than no hearing loss across a range of health conditions. Future studies are needed to elucidate the mechanisms underlying these associations and to determine if treatment for hearing loss could reduce the risk of comorbidity.

Rethinking costs of psoriasis: 10% of patients account for nearly 40% of healthcare expenditures among enrollees with psoriasis in a U.S. health plan.

OBJECTIVE: To examine characteristics, healthcare utilization and costs among patients with psoriasis who have high medical costs. METHODS: This is a retrospective study of patients with psoriasis with continuous enrollment from 1 January 2011 to 31 December 2013 in a large US health plan. Total paid 2012 healthcare costs excluding biologics (to identify costliest not due to biologic costs) were used to create cohorts representing the top 10% (T10) and bottom 90% (B90) of expenditures. Demographics, comorbidities, prescriptions, all-cause and psoriasis-related healthcare utilization and costs were compared between cohorts. Logistic regression identified demographic and clinical characteristics associated with the 2012 T10 cohort status. RESULTS: 18,653 patients (mean age 48 years; 49% female) were included. Patients in the T10 group accounted for 26% (2011), 39% (2012) and 26% (2013) of all-cause costs including biologics and 13% (2011), 18% (2012) and 11% (2013) of psoriasis-related costs. Mean 2012 total costs were $58,030 for T10 vs. $10,295 for B90 (all-cause) and $10,475 vs. $5301 (psoriasis-related). T10 patients in 2012 filled more prescriptions and were more likely to use corticosteroids (57% vs. 31%); however, biologic use and costs were similar (any use: 23% vs. 24%; prescriptions: 1.5 vs. 1.7, biologic costs: $4959 vs. $5095). Compared with B90 patients, T10 patients were more likely to have hospitalizations (all-cause: 45% vs. 3%; psoriasis-related: 14% vs. 1%) and ER visits (all-cause: 53% vs. 21%; psoriasis-related: 3% vs. 1%), and more likely to have renal disease (odds ratio (OR) = 2.05), depression (OR =1.96), cardiovascular disease (OR =1.88), psoriatic arthritis (OR =1.57) and diabetes (OR =1.50) (all p < .05). CONCLUSIONS: The T10 patient cohort in 2012 accounted for nearly 40% of overall healthcare expenditures. However, cost differences between the T10 and B90 patients were not attributable to psoriasis-related biologic treatment utilization and costs. The T10 patients had significantly more inpatient and emergency utilization, and comorbid medical conditions.

Healthcare Costs Among Patients with Heart Failure: A Comparison of Costs between Matched Decedent and Survivor Cohorts.

INTRODUCTION: Prior research suggests increased costs during the final months of life, yet little is known about healthcare cost differences between patients with heart failure (HF) who die or survive. METHODS: A retrospective claims study from a large US health plan [commercial and Medicare Advantage with Part D (MAPD)] was conducted. Patients were ≥18 years old with two non-inpatient or one inpatient claim(s) with HF diagnosis code(s). The earliest HF claim date during 1 January 2010-31 December 2011 was the index date. Cohort assignment was based on evidence of death within 1 year (decedents) or survival for >1 year (survivors) post-index. Per-patient-per-month (PPPM) and 1-year (variable decedent follow-up) costs (all-cause and HF-related) were calculated up to 1 year post-index. Cohorts were matched on demographic and clinical characteristics. Independent samples t tests and Pearson's chi-square tests were used to examine cohort differences. RESULTS: Among patients with HF, 8344 survivors were 1:1 matched to decedents [mean age 75 years, 50% female, 88% MAPD; mean time to decedents' death: 150 (SD 105) days]. Compared to survivors, more decedents had no pharmacy claims for HF-related outpatient pharmacotherapy within 60 days post-index (42.1% vs. 27.1%; p < 0.001). Decedents also incurred higher all-cause medical costs (PPPM: $21,400 vs. $2663; 1 year: $60,048 vs. $32,394; both p < 0.001) and higher HF-related medical costs (PPPM: $16,477 vs. $1358; 1 year: $39,052 vs. $16,519; both p < 0.001). Hospitalizations accounted for more than half of all-cause PPPM medical costs (54.6% for survivors, 84.3% for decedents). CONCLUSION: Patients with HF who died within 1 year after an index HF encounter incurred markedly higher costs within 1 year (despite the much shorter post-index period) and PPPM costs than those who survived, with the majority of costs attributable to hospitalizations for both patient cohorts. There may be opportunities for improving outcomes in HF, considering higher use of pharmacotherapy and lower costs were seen among survivors.

Evaluation of mortality and readmissions following hospitalization with heart failure.

OBJECTIVE: To examine the association of patient/clinical characteristics with mortality and readmission following a heart failure (HF)-related hospitalization. RESEARCH DESIGN AND METHODS: Claims data, linked to laboratory, race/ethnicity, and mortality data, from a large US health plan were utilized to identify individuals with ≥1 inpatient claim with a diagnosis code for HF (1 January 2008-30 September 2012). Study variables were analyzed using descriptive and multivariable approaches to identify patient/clinical characteristics associated with post-discharge outcomes. MAIN OUTCOME MEASURES: Primary outcomes included post-discharge mortality and readmission. RESULTS: A total of 126,214 individuals were identified with a HF-related hospitalization; 19.1% with data to calculate chronic kidney disease (CKD) stage. For the overall sample, mortality probability was 4.9% and 13.4% at 1 and 6 months post-discharge, respectively (4.5% and 12.4% for subset with calculated CKD stage), while readmission (all-cause) probability was 14.8% and 39.6% at 1 and 6 months post-discharge, respectively (18.4% and 44.5% for subset with calculated CKD stage). Within the subset with calculated CKD stage, mortality and readmission probabilities differed by CKD stage (p < 0.001), with decreased renal function corresponding with increased risk of mortality and readmission. After multivariable adjustment, increasing age was associated with increased risk of mortality, while advancing CKD stage, various index hospitalization variables (i.e., pre-admission emergency room visit, intensive care unit during hospitalization), and baseline all-cause hospitalization were associated with both increased risk of mortality and all-cause 1 month readmission. CONCLUSIONS: Calculated CKD, various index hospitalization variables, and baseline all-cause hospitalization were associated with increased risk of mortality and all-cause 1 month readmission among patients hospitalized with HF. Risk of post-discharge readmission and mortality increased with worse renal function, suggesting that improved management of this subset may reduce the burden and cost of this disease. Key study limitations include those related to retrospective claims-based studies and that renal function data were available for a subset of study patients.

Health Care Costs for Patients with Heart Failure Escalate Nearly 3-Fold in Final Months of Life.

BACKGROUND: Heart failure (HF) is a severe chronic disease with growing prevalence and health care burden as well as high mortality. End-of-life cost data for patients with HF may inform disease and medication therapy management. OBJECTIVES: To (a) characterize a real-world sample of patients with HF who died; (b) estimate health care costs for 6 months and semiannually for 24 months, before death; and (c) examine associations between patient characteristics and predeath health care costs. METHODS: This was a retrospective study of commercial and Medicare Advantage with Part D (MAPD) enrollees (aged ≥ 18 years), using data from a large national health plan. Included patients had evidence of HF during January 1, 2009-December 31, 2013, based on ≥ 1 inpatient hospitalization or ≥ 2 noninpatient encounters with diagnosis code for HF and evidence of mortality during July 1, 2009-December 31, 2013. Demographic data, comorbidities, guideline-directed HF-related outpatient pharmacotherapy (HFRx), and predeath health care costs (all-cause and HF-related) were described. A generalized linear model examined associations between all-cause health care costs (months 6 and 1 previous to death) and specific patient characteristics. RESULTS: Of 48,026 identified patients, mean age was 77.9 years; 52.8% were female; 93.0% were MAPD enrolled; 92.5% had Quan-Charlson comor-bidity score ≥ 3; and about one quarter (26.0%) had no evidence of HFRx. Over the last 6 months of life, monthly all-cause total cost increased 3.2-fold for MAPD enrollees and 2.8-fold for commercial enrollees, although pharmacy cost decreased slightly (0.8-fold for both plan types). Cumulative 6-month all-cause medical cost was $37,186 for MAPD enrollees and $143,363 for commercial enrollees (68.8% and 73.2% due to hospitalization, respectively), and cumulative HF-related medical cost was $20,794 for MAPD enrollees and $78,440 for commercial enrollees (88.8% and 95.3% due to hospitaliza-tion, respectively). Over the last 24 months, semiannual all-cause total cost increased 3.2-fold for MAPD enrollees and 4.5-fold for commercial enroll-ees, although pharmacy cost increased only slightly (1.1-fold and 1.3-fold, respectively). Based on multivariable analysis, factors associated with higher risk of incurring a cost increase between month 6 and month 1 before death included older age (75-84 years: cost ratio [CR] = 1.33, P < 0.001; 226585 years: CR = 1.43, P < 0.001), comorbid coronary heart disease (CR = 1.12, P = 0.003), and no evidence of HFRx (CR = 1.48, P < 0.001). CONCLUSIONS: Patients with HF experienced ≥ 2.8-fold increase in monthly all-cause total cost over the last 6 months of life, which was driven by hospitalization. Although MAPD enrollees incurred greater cost increases, cumulative costs were higher for commercial enrollees. After multivariable adjustment, older age, comorbid coronary heart disease, and no evidence of HFRx were among factors associated with higher risk of cost increase over the last 6 months of life. Study findings provide predeath cost information that should be useful in value assessments of innovative HF interventions and highlight impact of HFRx on predeath health care costs.

Flare frequency, healthcare resource utilisation and costs among patients with gout in a managed care setting: a retrospective medical claims-based analysis.

OBJECTIVES: For most gout patients, excruciatingly painful gout attacks are the major clinical burden of the disease. The goal of this study was to assess the association of frequent gout flares with healthcare burden, and to quantify how much lower gout-related costs and resource use are for those with infrequent flares compared to frequent gout flares. DESIGN: Retrospective cohort study. SETTING: Administrative claims data from a large US health plan. PARTICIPANTS: Patients aged 18 years or above, and with evidence of gout based on medical and pharmacy claims between January 2009 and April 2012 were eligible for inclusion. Patient characteristics were assessed during a 12-month baseline period. OUTCOME MEASURES: Frequency of gout flares, healthcare costs and resource utilisation were assessed in the 12 months following the first qualifying gout claim. Generalised linear models were employed to assess the impact of flare frequency on cost outcomes after adjusting for covariates. RESULTS: 102,703 patients with gout met study inclusion criteria; 89,201 had 0-1 gout flares, 9714 had 2 flares, and 3788 had 3+ flares. Average counts of gout-related inpatient stays, emergency room visits and ambulatory visits were higher among patients with 2 or 3+ flares, compared to those with 0-1 flares (all p<0.001). Adjusted annual gout-related costs were $1804, $3014 and $4363 in those with 0-1, 2 and 3+ gout flares, respectively (p<0.001 comparing 0-1 flares to 2 or 3+ flares). CONCLUSIONS: Gout-related costs and resource use were lower for those with infrequent flares, suggesting significant cost benefit to a gout management plan that has a goal of reducing flare frequency.

A simple rule to identify patients with chronic obstructive pulmonary disease who may need treatment reevaluation.

BACKGROUND: A simple rule based on short-acting inhaled ß2-agonist (SABA) use could identify patients with chronic obstructive pulmonary disease (COPD) at increased risk of exacerbations and signal the need for maintenance therapy change, similar to asthma "Rules of Two(®)". METHODS: Associations between SABA use, COPD exacerbations, and health care costs over 1 year were examined retrospectively using de-identified patient data from the Optum Research Database (ORD; N = 56,581) and the Impact National Benchmark Database (IMPACT™; N = 9423). Nebulized and metered-dose inhaler (MDI) SABA doses were normalized to 2.5 mg and 90 mcg albuterol equivalents, respectively. RESULTS: The GOLD initiative establishes ≥2 exacerbations/year as indicative of increased risk in COPD. We identified a correlation (p < 0.0001) between 1.5 SABA doses/day and this frequency of exacerbations. In ORD, patients using ≥1.5 versus <1.5 SABA doses/day experienced significantly more exacerbations: 1.92 (95% confidence interval [CI], 1.89-1.96) versus 1.36 (95% CI, 1.34-1.38) per patient year (PPY). Above-threshold use was associated with higher average annual COPD-related costs (2010 $US): $21,868 (standard deviation [SD], $53,910) versus $11,686 (SD, $32,707) for nebulized SABA only, $9216 (SD, $30,710) versus $7334 (SD, $24,853) for MDI SABA only, and $15,806 (SD, $35,260) versus $11,233 (SD, $27,006) for both nebulized and MDI SABA. IMPACT™ validated these findings. CONCLUSION: Patients with COPD using ≥1.5 SABA doses/day were at increased risk of exacerbations. Our results suggest a "Rule of 3-2": SABA use ≥3 times in 2 days should be considered a clinical marker for needing treatment reevaluation.

Healthcare Resource Utilization and Costs Associated with Autosomal Dominant Polycystic Kidney Disease.

Background: Autosomal dominant polycystic kidney disease (ADPKD), a hereditary nephropathy, eventually leads to end-stage renal disease (ESRD), typically by mid-life. Objectives: The objective of this study was to assess real-world healthcare resource utilization and cost among commercially insured (COM) and Medicare Advantage (MAPD) ADPKD patients in addition to the cost profile by chronic kidney disease (CKD) stage. Methods: Patients diagnosed with ADPKD (two or more claims) with ≥30 days of continuous medical and pharmacy benefits and no evidence of autosomal recessive polycystic kidney disease were selected (Optum Research Database and Impact National Benchmarking Database: 1/1/06-8/31/12). Plan and patient paid healthcare costs and resource utilization per patient per month (PPPM) were described in total and by insurance type. CKD stage was established based on serum creatinine laboratory values or dialysis-related codes. Adjusted, CKD stage-specific costs were predicted for 4 years using regression models. Results: Of the 36,253,096 patients in the databases (1/1/06-8/31/12), 5,051 had evidence of ADPKD. Following exclusion criteria, 4,356 COM and 468 MAPD ADPKD patients remained. Total healthcare resource utilization and costs were high, and costs increased substantially from CKD stage 1-5. PPPM healthcare costs were 37% for ADPKD management and 52% for dialysis services. Predicted 4-year healthcare costs by CKD stage were $40,164 (stage 1), $33,397 (stage 2), $42,686 (stage 3), $148,402 (stage 4), and $207,548 (stage 5). Conclusions: Healthcare resource utilization and costs associated with ADPKD were substantial, irrespective of payer type, and primarily driven by CKD stage. Of the total healthcare costs, 88% were ADPKD- and dialysis-related. Most impactful was the spike in predicted cost when patients progressed from CKD stage 3 to stage 4 (by 348%) after multivariate adjustment. These stage 4-associated costs are primarily due to ultimate progression into stage 5 and ESRD within the 4-year time frame.

Oil migration in chocolate and almond product confectionery systems.

UNLABELLED: Oil migration from high oil content almond confections into adjacent chocolate causes changes in product quality. The objective of this study was to quantify the oil migration from almond products to dark chocolate. Magnetic resonance imaging (MRI) was used to monitor spatial and temporal changes of liquid lipid content. A multislice spin echo pulse (MSSE) sequence was used to acquire images with a 7.8-ms echo time and a 1000-ms repetition time using a 1.03T Aspect AI MRI spectrometer. Samples were prepared as a 2-layer model system of chocolate and almond confection. Six different almond products and 1 type of dark chocolate were used. Samples were stored at 20, 25, and 30°C for a time frame of several months. Rate and extent of migration were quantified by a kinetic expression based on the linear dependence of oil uptake by chocolate and the square root of the time. Samples showed distinctly different rate and extent of oil migration, as evidenced by quantitative differences in the kinetic rate constants and equilibrium uptake for the different sample types. This work will be helpful to design formulations for almond and almond-based products in confections. PRACTICAL APPLICATION: This work will be helpful to design formulations for almond use in confections.

Image analysis of microstructural changes in almond cotyledon as a result of processing.

Release of oil from nuts due to damaged cellular structures can degrade the quality of products incorporating nuts. The aim of this study was to investigate the effects of different processing conditions on microstructure of almond tissue and to quantify these changes using image processing. Spinning disk confocal fluorescence microscopy was used for imaging changes in microstructure of almonds as a function of different thermal processing of almonds. Multiple staining of Nile Red and Calcofluor White was applied to differentiate cell wall structures and oil bodies within individual almond cells without chemical fixation. An algorithm for image processing, included image preprocessing, segmentation, and determination of morphological features of segmented objects, was developed. Oil-roasting processes (140 °C and 150 °C) were found to have a significant impact on microstructure of almonds when compared to the hot air-roasting and blanching processes. Oil-roasted almond at 150 °C had a greater cellular damage due to cell wall and membrane rupture. These changes in microstructure of almonds would make them slightly more susceptible to release oil during storage. The image analysis presented allows quantitative evaluation for the effect of different processing on almond microstructure.