Community Participation Transition After Stroke (COMPASS) Randomized Controlled Trial: Effect on Adverse Health Events.

OBJECTIVE: To compare adverse health events in intervention versus control group participants in the Community Participation Transition After Stroke trial to reduce barriers to independent living for community-dwelling stroke survivors. DESIGN: Randomized controlled trial. SETTING: Inpatient rehabilitation (IR) to home and community transition. PARTICIPANTS: Stroke survivors aged ≥50 years being discharged from IR who had been independent in activities of daily living prestroke (N=183). INTERVENTIONS: Participants randomized to intervention group (n=85) received home modifications and self-management training from an occupational therapist over 4 visits in the home. Participants randomized to control group (n=98) received the same number of visits consisting of stroke education. MAIN OUTCOME MEASURES: Death, skilled nursing facility (SNF) admission, 30-day rehospitalization, and fall rates after discharge from IR. RESULTS: Time-to-event analysis revealed that the intervention reduced SNF admission (cumulative survival, 87.8%; 95% confidence interval [CI], 78.6%-96.6%) and death (cumulative survival, 100%) compared with the control group (SNF cumulative survival, 78.9%; 95% CI, 70.4%-87.4%; P=.039; death cumulative survival, 87.3%; 95% CI, 79.9%-94.7%; P=.001). Thirty-day rehospitalization also appeared to be lower among intervention participants (cumulative survival, 95.1%; 95% CI, 90.5%-99.8%) than among control participants (cumulative survival, 86.3%; 95% CI, 79.4%-93.2%; P=.050) but was not statistically significant. Fall rates did not significantly differ between the intervention group (5.6 falls per 1000 participant-days; 95% CI, 4.7-6.5) and the control group (7.2 falls per 1000 participant-days; 95% CI, 6.2-8.3; incidence rate ratio, 0.78; 95% CI, 0.46-1.33; P=.361). CONCLUSIONS: A home-based occupational therapist-led intervention that helps stroke survivors transition to home by reducing barriers in the home and improving self-management could decrease the risk of mortality and SNF admission after discharge from rehabilitation.

Deaths of Despair and Population Aging in Missouri.

Recent declines in life expectancy in the US, especially for middle-aged White persons, have called attention to mortality from deaths of despair - deaths due to alcohol, drugs, and suicide. Using data from the Centers for Disease Control and the U.S. Census Bureau, this paper examined deaths of despair by race/ethnicity, age, cause of death, birth cohort, and sex in Missouri. We focused on Area Agencies on Aging as geographic units of interest to increase usefulness of our findings to public administrators. Deaths of despair began trending up for all age groups beginning in 2007-2009, with the sharpest increases occurring for Black or African American non-Hispanics beginning in 2013-2015. The most dramatic increases occurred for the population age 50-59 in St. Louis City and Area Agency on Aging regions in southern Missouri. For older adults, considerable variation in rates, trends, and cause of deaths of despair is evident across the state.

Improving Cancer Patients' Insurance Choices (I Can PIC): A Randomized Trial of a Personalized Health Insurance Decision Aid.

BACKGROUND: Many cancer survivors struggle to choose a health insurance plan that meets their needs because of high costs, limited health insurance literacy, and lack of decision support. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. MATERIALS AND METHODS: Eligible individuals (18-64 years, diagnosed with cancer for ≤5 years, English-speaking, not Medicaid or Medicare eligible) were randomized to I Can PIC or an attention control health insurance worksheet. Primary outcomes included health insurance knowledge, decisional conflict, and decision self-efficacy after completing I Can PIC or the control. Secondary outcomes included knowledge, decisional conflict, decision self-efficacy, health insurance literacy, financial toxicity, and delayed care at a 3-6-month follow-up. RESULTS: A total of 263 of 335 eligible participants (79%) consented and were randomized; 206 (73%) completed the initial survey (106 in I Can PIC; 100 in the control), and 180 (87%) completed a 3-6 month follow-up. After viewing I Can PIC or the control, health insurance knowledge and a health insurance literacy item assessing confidence understanding health insurance were higher in the I Can PIC group. At follow-up, the I Can PIC group retained higher knowledge than the control; confidence understanding health insurance was not reassessed. There were no significant differences between groups in other outcomes. Results did not change when controlling for health literacy and employment. Both groups reported having limited health insurance options. CONCLUSION: I Can PIC can improve cancer survivors' health insurance knowledge and confidence using health insurance. System-level interventions are needed to lower financial toxicity and help patients manage care costs. IMPLICATIONS FOR PRACTICE: Inadequate health insurance compromises cancer treatment and impacts overall and cancer-specific mortality. Uninsured or underinsured survivors report fewer recommended cancer screenings and may delay or avoid needed follow-up cancer care because of costs. Even those with adequate insurance report difficulty managing care costs. Health insurance decision support and resources to help manage care costs are thus paramount to cancer survivors' health and care management. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. I Can PIC provides health insurance information, supports patients through managing care costs, offers a list of financial and emotional support resources, and provides a personalized cost estimate of annual health care expenses across plan types.

Medicaid savings from the Contraceptive CHOICE Project: a cost-savings analysis.

BACKGROUND: Forty-five percent of births in the United States are unintended, and the costs of unintended pregnancy and birth are substantial. Clinical and policy interventions that increase access to the most effective reversible contraceptive methods (intrauterine devices and contraceptive implants) have potential to generate significant cost savings. Evidence of cost savings for these interventions is needed. OBJECTIVE: The purpose of this study was to conduct a cost-savings analysis of the Contraceptive CHOICE Project, which provided counseling and no-cost contraception, to demonstrate the value of investment in enhanced contraceptive care to the Missouri Medicaid program. STUDY DESIGN: The Contraceptive CHOICE Project was a prospective cohort study of 9256 reproductive-age women who were enrolled between 2007 and 2011. Study follow-up was completed October 2013. This analysis includes 5061 Contraceptive CHOICE Project participants who were current Missouri Medicaid beneficiaries or were uninsured and reported household incomes <201% of the federal poverty line. We created a simulated comparison group of women who were receiving care through the Missouri Title X program and modeled the contraception and pregnancy outcomes that would have occurred in the absence of the Contraceptive CHOICE Project. Data about contraceptive use for the comparison group (N=5061) were obtained from the Missouri Title X program and adjusted based on age, race, ethnicity, and income. To make an accurate comparison that would account for the difference in the 2 populations, we used our simulation model to estimate total Contraceptive CHOICE Project costs and total comparison group costs. We reported all costs in 2013 dollars to account for inflation. RESULTS: Among the Contraceptive CHOICE Project participants who were included, the uptake of intrauterine devices and implants was 76.1% compared with 4.8% among the comparison group. The estimated contraceptive cost for the simulated Contraceptive CHOICE Project group was $4.0 million vs $2.3 million for the comparison group. The estimated numbers of unintended pregnancies and births averted among the simulated Contraceptive CHOICE Project group compared with the comparison group were 927 and 483, respectively, which represented a savings in pregnancy and maternity care of $6.7 million. We estimated that the total cost savings for the state of Missouri attributable to the Contraceptive CHOICE Project was $5.0 million (40.7%) over the project duration. CONCLUSION: A program providing counseling and no-cost contraception yields substantial cost savings because of the increased uptake of highly effective contraception and consequent averted unintended pregnancy and birth.

Show Me My Health Plans: a study protocol of a randomized trial testing a decision support tool for the federal health insurance marketplace in Missouri.

BACKGROUND: The implementation of the ACA has improved access to quality health insurance, a necessary first step to improving health outcomes. However, access must be supplemented by education to help individuals make informed choices for plans that meet their individual financial and health needs. METHODS/DESIGN: Drawing on a model of information processing and on prior research, we developed a health insurance decision support tool called Show Me My Health Plans. Developed with extensive stakeholder input, the current tool (1) simplifies information through plain language and graphics in an educational component; (2) assesses and reviews knowledge interactively to ensure comprehension of key material; (3) incorporates individual and/or family health status to personalize out-of-pocket cost estimates; (4) assesses preferences for plan features; and (5) helps individuals weigh information appropriate to their interests and needs through a summary page with "good fit" plans generated from a tailored algorithm. The current study will evaluate whether the online decision support tool improves health insurance decisions compared to a usual care condition (the healthcare.gov marketplace website). The trial will include 362 individuals (181 in each group) from rural, suburban, and urban settings within a 90 mile radius around St. Louis. Eligibility criteria includes English-speaking individuals 18-64 years old who are eligible for the ACA marketplace plans. They will be computer randomized to view the intervention or usual care condition. DISCUSSION: Presenting individuals with options that they can understand tailored to their needs and preferences could help improve decision quality. By helping individuals narrow down the complexity of health insurance plan options, decision support tools such as this one could prepare individuals to better navigate enrollment in a plan that meets their individual needs. The randomized trial was registered in clinicaltrials.gov (NCT02522624) on August 6, 2015.

Methodological innovations in public health education: transdisciplinary problem solving.

In 2008, the faculty of the Brown School at Washington University in St. Louis designed a Master of Public Health program centered on transdisciplinary problem solving in public health. We have described the rationale for our approach, guiding principles and pedagogy for the program, and specific transdisciplinary competencies students acquire. We have explained how transdisciplinary content has been organized and delivered, how the program is being evaluated, and how we have demonstrated the feasibility of this approach for a Master of Public Health degree.

Impact of the Affordable Care Act on access to care for US adults with diabetes, 2011-2012.

INTRODUCTION: Lack of health insurance is a barrier to medical care, which may increase the risk of diabetes complications and costs. The objective of this study was to assess the potential of the Affordable Care Act (ACA) of 2010 to improve diabetes care through increased health care access by comparing health care and health outcomes of insured and uninsured people with diabetes. METHODS: We examined demographics, access to care, health care use, and health care expenditures of adults aged 19 to 64 years with diabetes by using the 2011 and 2012 Medical Expenditure Panel Survey. Bivariate descriptive statistics comparing insured and uninsured persons were evaluated separately by income above and below 138% of the federal poverty level (FPL), (a threshold for expanded Medicaid eligibility in select states under the ACA) using the t test and proportion and median tests. RESULTS: Uninsured adults reported poorer access to care than insured adults, such as having a usual source of health care (69.0% vs 89.5% [≤138% FPL], 77.1% vs 94.6% [>138% FPL], both P < .001) and having lower rates of 6 key diabetes preventive care services (P ≤ .05). Insured adults with diabetes had significantly higher health care expenditures than uninsured adults ($13,706 vs $4,367, $10,838 vs $4,419, respectively, both P < .001). CONCLUSION: Uninsured adults with diabetes had less access to health care and lower levels of preventive care, health care use, and expenditures than insured adults. To the extent that the ACA increases access and coverage, uninsured people with diabetes are likely to significantly increase their health care use, which may lead to reduced incidence of diabetes complications and improved health.

Behavioral economics: "nudging" underserved populations to be screened for cancer.

Persistent disparities in cancer screening by race/ethnicity and socioeconomic status require innovative prevention tools and techniques. Behavioral economics provides tools to potentially reduce disparities by informing strategies and systems to increase prevention of breast, cervical, and colorectal cancers. With an emphasis on the predictable, but sometimes flawed, mental shortcuts (heuristics) people use to make decisions, behavioral economics offers insights that practitioners can use to enhance evidence-based cancer screening interventions that rely on judgments about the probability of developing and detecting cancer, decisions about competing screening options, and the optimal presentation of complex choices (choice architecture). In the area of judgment, we describe ways practitioners can use the availability and representativeness of heuristics and the tendency toward unrealistic optimism to increase perceptions of risk and highlight benefits of screening. We describe how several behavioral economic principles involved in decision-making can influence screening attitudes, including how framing and context effects can be manipulated to highlight personally salient features of cancer screening tests. Finally, we offer suggestions about ways practitioners can apply principles related to choice architecture to health care systems in which cancer screening takes place. These recommendations include the use of incentives to increase screening, introduction of default options, appropriate feedback throughout the decision-making and behavior completion process, and clear presentation of complex choices, particularly in the context of colorectal cancer screening. We conclude by noting gaps in knowledge and propose future research questions to guide this promising area of research and practice.

What can health communication science offer for ACA implementation? Five evidence-informed strategies for expanding Medicaid enrollment.

CONTEXT: Implementing the Affordable Care Act (ACA) in 2014 will require effective enrollment and outreach efforts to previously uninsured individuals now eligible for coverage. METHODS: From 1996 to 2013, the Health Communication Research Laboratory conducted more than 40 original studies with more than 30,000 participants to learn how to improve the reach to and effectiveness of health information for low-income and racial/ethnic minority populations. We synthesized the findings from this body of research and used them to inform current challenges in implementing the ACA. FINDINGS: We found empirical support for 5 recommendations regarding partnerships, outreach, messages and messengers, life priorities of low-income individuals and families, and the information environment. We translated these into 12 action steps. CONCLUSIONS: Health communication science can inform the development and execution of strategies to increase the public's understanding of the ACA and to support the enrollment of eligible individuals into Medicaid or the Health Insurance Marketplace.

Health care system collaboration to address chronic diseases: a nationwide snapshot from state public health practitioners.

INTRODUCTION: Until recently, health care systems in the United States often lacked a unified approach to prevent and manage chronic disease. Recent efforts have been made to close this gap through various calls for increased collaboration between public health and health care systems to better coordinate provision of services and programs. Currently, the extent to which the public health workforce has responded is relatively unknown. The objective of this study is to explore health care system collaboration efforts and activities among a population-based sample of state public health practitioners. METHODS: During spring 2013, a national survey was administered to state-level chronic disease public health practitioners. Respondents were asked to indicate whether or not they collaborate with health care systems. Those who reported "yes" were asked to indicate all topic areas in which they collaborate and provide qualitative examples of their collaborative work. RESULTS: A total of 759 respondents (84%) reported collaboration. Common topics of collaboration activities were tobacco, cardiovascular health, and cancer screening. More client-oriented interventions than system-wide interventions were found in the qualitative examples provided. Respondents who collaborated were also more likely to use the Community Guide, use evidence-based decision making, and work in program areas that involved secondary, rather than primary, prevention. CONCLUSION: The study findings indicate a need for greater guidance on collaboration efforts that involve system-wide and cross-system interventions. Tools such as the Community Guide and evidence-based training courses may be useful in providing such guidance.

State legislators' work on public health-related issues: what influences priorities?

CONTEXT: Policies are an effective way to influence population health and prevent disease. Unfortunately, public health research is often not well translated for policy audiences. Furthermore, researchers seeking to influence policy face an incomplete understanding of what influences legislators' decisions regarding which issues will receive their limited time and focus. OBJECTIVE: The objective of this analysis was to examine various factors that may influence state legislators' decisions about which health issues they address. DESIGN: Cross-sectional analysis of data collected from a randomized trial. SETTING: State legislatures. PARTICIPANTS: State-level legislators. MAIN OUTCOME MEASURE(S): Measures included a rating of the influence of various factors on health policy priorities. A 7-point scale was used to measure political ideology on social and fiscal issues. Standard demographic questions were included on age, gender, and level of education. RESULTS: Seventy-five legislators completed surveys. Sixty-three percent were aged 55 years or older, and 76% male. When they were asked to rate factors according to importance in determining what health issues to work on, the top-rated factor was constituents' needs or opinions followed by evidence of scientific effectiveness. Ratings were also examined by subgroups. CONCLUSIONS: These findings point to several important applications for public health practitioners and researchers. Because legislators value constituents' opinions, it is critical to inform and educate constituents about public health issues as well as policy options that may be effective in addressing problems. The results also highlight the importance of public health researchers and practitioners improving dissemination efforts to ensure that evidence-based scientific information is shared with policymakers in an effective and timely manner.

Policy implications of fixed-to-total-cost ratio variation across rural and urban hospitals.

PURPOSE: Hospitals with lower fixed-to-total-cost ratios may be better positioned to remain financially viable when reducing service volumes required by many value-based payment systems. We assessed whether hospitals in rural areas have higher fixed-to-total-cost ratios, which would tend to create a systematic disadvantage in such an environment. METHODS: Our observational study used a mixed-effects, repeated-measures model to analyze Medicare Hospital Cost Report Information System data for 2011-2020. We included all 4,953 nonfederal, short-term acute hospitals in the United States that are present in these years. After estimating the relationship between volume (measured in adjusted patient days) and patient-care costs in a model that controlled for a small number of hospital characteristics, we calculated fixed-to-total-cost ratios based on our model's estimates. FINDINGS: We found that nonmetropolitan hospitals tend to have higher average fixed-to-total-cost ratios (0.85-0.95) than metropolitan hospitals (0.73-0.78). Moreover, the degree of rurality matters; hospitals in micropolitan counties have lower ratios (0.85-0.87) than hospitals in noncore counties (0.91-0.95). While the Critical Access Hospital (CAH) designation is associated with higher average fixed-to-total-cost ratios, high fixed-to-total-cost ratios are not exclusive to CAHs. CONCLUSIONS: Overall, these results suggest that hospital payment policy and payment model development should consider hospital fixed-to-total-cost ratios particularly in settings where economies of scale are unattainable, and where the hospital provides a sense of security to the community it serves.

Exempting casinos from the Smoke-free Illinois Act will not bring patrons back: they never left.

OBJECTIVE: The Smoke-free Illinois Act was implemented in January 2008, one month after the beginning of a national recession. In December 2010, the Illinois legislature proposed new legislation that would provide an exemption for casinos from the act until neighbouring states also implement smoke-free casino policies. Lobbyists and gaming commission representatives argued that Illinois casinos were losing patrons to casinos in neighbouring states that allow smoking. This study examined the influence of the act on casino admissions in Illinois and neighbouring states in light of the economy. METHODS: A multilevel model was developed to examine monthly casino admissions from January 2007 to December 2008. RESULTS: There was no difference in changes in admissions across the four states over time after accounting for the economic downturn. CONCLUSIONS: The Smoke-Free Illinois Act did not have a detectable effect on Illinois casino admissions.

Understanding contributors to racial and ethnic inequities in COVID-19 incidence and mortality rates.

BACKGROUND: Racial inequities in Coronavirus 2019 (COVID-19) have been reported over the course of the pandemic, with Black, Hispanic/Latinx, and Native American individuals suffering higher case rates and more fatalities than their White counterparts. METHODS: We used a unique statewide dataset of confirmed COVID-19 cases across Missouri, linked with historical statewide hospital data. We examined differences by race and ethnicity in raw population-based case and mortality rates. We used patient-level regression analyses to calculate the odds of mortality based on race and ethnicity, controlling for comorbidities and other risk factors. RESULTS: As of September 10, 2020 there were 73,635 confirmed COVID-19 cases in the State of Missouri. Among the 64,526 case records (87.7% of all cases) that merged with prior demographic and health care utilization data, 12,946 (20.1%) were Non-Hispanic (NH) Black, 44,550 (69.0%) were NH White, 3,822 (5.9%) were NH Other/Unknown race, and 3,208 (5.0%) were Hispanic. Raw cumulative case rates for NH Black individuals were 1,713 per 100,000 population, compared with 2,095 for NH Other/Unknown, 903 for NH White, and 1,218 for Hispanic. Cumulative COVID-19-related death rates for NH Black individuals were 58.3 per 100,000 population, compared with 38.9 for NH Other/Unknown, 19.4 for NH White, and 14.8 for Hispanic. In a model that included insurance source, history of a social determinant billing code in the patient's claims, census block travel change, population density, Area Deprivation Index, and clinical comorbidities, NH Black race (OR 1.75, 1.51-2.04, p<0.001) and NH Other/Unknown race (OR 1.83, 1.36-2.46, p<0.001) remained strongly associated with mortality. CONCLUSIONS: In Missouri, COVID-19 case rates and mortality rates were markedly higher among NH Black and NH Other/Unknown race than among NH White residents, even after accounting for social and clinical risk, population density, and travel patterns during COVID-19.

Impact of Sugar-Sweetened Beverage Warning Labels on Consumer Behaviors: A Systematic Review and Meta-Analysis.

CONTEXT: As a primary source of added sugars, sugar-sweetened beverage consumption contributes to obesity. This study systematically synthesizes the scientific evidence regarding the impact of sugar-sweetened beverage warning labels on consumer behaviors and intentions. EVIDENCE ACQUISITION: A keyword/reference search was performed in 2019 in Cochrane Library, PubMed, Web of Science, CINAHL, Scopus, and Google Scholar. Meta-analysis was conducted in 2020 to estimate the effect of sugar-sweetened beverage warning labels on consumers' purchase decisions. EVIDENCE SYNTHESIS: A total of 23 studies (13 RCTs, 9 nonrandomized experiments, and 1 computer simulation study) met the eligibility criteria and were included. Labels were classified into 6 categories: (1) symbol with nutrient profile, (2) symbol with health effect, (3) text of nutrient profile, (4) text of health effect, (5) graphic with health effect, and (6) graphic with nutrient profile. Compared with the no-label control group, sugar-sweetened beverage warning label use was associated with reduced odds of choosing sugar-sweetened beverages (OR=0.49, 95% CI=0.41, 0.56) and a reduced sugar-sweetened beverage purchase intention (Cohen's d= -0.18, 95% CI= -0.31, -0.06). Across alternative label categories, the graphic with health effect (OR=0.34, 95% CI=0.08, 0.61), text of health effect (OR=0.47, 95% CI=0.39, 0.55), graphic with nutrient profile (OR=0.58, 95% CI=0.36, 0.81), and symbol with health effect (OR=0.67, 95% CI=0.39, 0.95) were associated with reduced odds of choosing sugar-sweetened beverages. CONCLUSIONS: Sugar-sweetened beverage warning labels were effective in dissuading consumers from choosing them. Graphic with health effect labels showed the largest impact. Future studies should delineate the psychosocial pathways linking sugar-sweetened beverage warning labels to purchase decisions, recruit socioeconomically diverse participants, and design experiments in naturalistic settings.

Trends in Hospital Mortality for Uninsured Rural and Urban Populations, 2012-2016.

PURPOSE: Rural-urban health disparities have received increasing scrutiny as rural individuals continue to have worse health outcomes. However, little is known about how insurance status contributes to urban-rural disparities. This study characterizes how rural uninsured patients compare to the urban uninsured, determines whether rurality among the uninsured is associated with worse clinical outcomes, and examines how clinical outcomes based on rurality have changed over time. METHODS: We conducted a retrospective cohort study of the 2012-2016 National Inpatient Sample hospital discharge data including 1,478,613 uninsured patients, of which 233,816 were rural. Admissions were broken into 6 rurality categories. Logistic regression models were used to determine the independent association between rurality and hospital mortality. FINDINGS: Demographic and clinical characteristics differed significantly between rural and urban uninsured patients: rural patients were more often white, lived in places with lower median household income, and were more often admitted electively and transferred. Rurality was associated with significantly higher in-hospital mortality rates (1.44% vs 1.89%, OR 1.32, P < .001). This association strengthened after adjusting for medical comorbidities and hospital characteristics. Further, disparities between urban and rural mortality were found to be growing, with the gap almost doubling between 2012 and 2016. CONCLUSIONS: Rural and urban uninsured patients differed significantly, specifically in terms of race and median income. Among the uninsured, rurality was associated with higher in-hospital mortality, and the gap between urban and rural in-hospital mortality was widening. Our findings suggest the rural uninsured are a vulnerable population in need of informed, tailored policies to reduce these disparities.

Chronic Pain Treatment Strategies in Parkinson's Disease.

Neurological disorders, including Parkinson's disease (PD), have increased in prevalence and are expected to further increase in the coming decades. In this regard, PD affects around 3% of the population by age 65 and up to 5% of people over the age of 85. PD is a widely described, physically and mentally disabling neurodegenerative disorder. One symptom often poorly recognized and under-treated by health care providers despite being reported as the most common non-motor symptom is the finding of chronic pain. Compared to the general population of similar age, PD patients suffer from a significantly higher level and prevalence of pain. The most common form of pain reported by Parkinson's patients is of musculoskeletal origin. One of the most used combination drugs for PD is Levodopa-Carbidopa, a dopamine precursor that is converted to dopamine by the action of a naturally occurring enzyme called DOPA decarboxylase. Pramipexole, a D2 dopamine agonist, and apomorphine, a dopamine agonist, and Rotigotine, a dopamine receptor agonist, have showed efficacy on PD-associated pain. Other treatments that have shown efficacy in treating pain of diverse etiologies are acetaminophen, Nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors. Opioids and opioid-like medications such as oxycodone, morphine, tramadol, and codeine are also commonly employed in treatment of chronic pain in PD. Other opioid related medications such as Tapentadol, a central-acting oral analgesic with combined opioid and noradrenergic properties, and Targinact, a combination of the opioid agonist oxycodone and the opioid antagonist naloxone have shown improvement in pain. Anticonvulsants such as gabapentin, pregabalin, lamotrigine, carbamazepine and tricyclic antidepressants (TCAs) can be trialed when attempting to manage chronic pain in PD. The selective serotonin and noradrenaline reuptake inhibitors (SNRIs) also possess pain relieving and antidepressant properties, but carry less of the risk of anticholinergic side effects seen in TCAs. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been shown in multiple studies to be effective against various types of PD associated pain symptoms. Massage therapy (MT) is one of the most common forms of complementary and alternative medicine. Studies have shown that pressure applied during MT may stimulate vagal activity, promoting reduced anxiety and pain, as well as increasing levels of serotonin. In a survey study of PD patients, rehabilitative therapy and physical therapy were rated as the most effective for pain reduction, though with only temporary relief but these studies were uncontrolled. Yoga has been studied for patients with a wide array of neurological disorders. In summary, PD pathology is thought to have a modulating effect on pain sensation, which could amplify pain. This could help explain a portion of the higher incidence of chronic pain felt by PD patients. A treatment plan can be devised that may include dopaminergic agents, acetaminophen, NSAIDs, opioids, antidepressants, physical therapies, DBS and other options discussed in this review. A thorough assessment of patient history and physical examination should be made in patients with PD so chronic pain may be managed effectively.

Reliability and validity of the SF-12v2 in the medical expenditure panel survey.

OBJECTIVE: Evaluate the reliability and validity of the Medical Outcomes Study Short-Form version 2 (SF-12v2) in the 2003-2004 Medical Expenditure Panel Survey (MEPS). RESEARCH DESIGN: Data were collected in the self-administered mail-out questionnaire and face-to-face interviews of the MEPS (n = 20,661). Internal consistency and test-retest reliability and construct, discriminate, predictive and concurrent validity were tested. The EQ-5D, perceived health and mental health questions were used to test construct and discriminate validity. Self-reported work, physical and cognitive limits tested predictive validity and number of chronic conditions assessed concurrent validity. RESULTS: Both Mental Component Summary Scores (MCS) and Physical Component Summary Scores (PCS) were shown to have high internal consistency reliability (alpha > .80). PCS showed high test-retest reliability (ICC = .78) while MCS demonstrated moderate reliability (ICC = .60). PCS had high convergent validity for EQ-5D items (except self-care) and physical health status (r > .56). MCS demonstrated moderate convergent validity on EQ-5D and mental health items (r > .38). PCS distinguish between groups with different physical and work limitations. Similarly, MCS distinguished between groups with and without cognitive limitations. The MCS and PCS showed perfect dose response when variations in scores were examined by participant's chronic condition status. CONCLUSIONS: Both component scores showed adequate reliability and validity with the 2003-2004 MEPS and should be suitable for use in a variety of proposes within this database.

Comparing Rural and Urban Medicare Advantage Beneficiary Characteristics.

Purpose: The Medicare Advantage (MA) program allows Medicare beneficiaries to receive benefits from private plans rather than from traditional fee-for-service (FFS) Medicare. Little is known about the rural and urban differences in the populations that enroll in the MA program, and these differences may be important for setting policy. This brief uses data from the 2012-13 Medicare Current Beneficiary Survey (MCBS) to describe these differences, and combined with county-level data on MA issuer participation, this dataset also allows us to assess the degree to which issuers may engage in selective MA market entry on the basis of demographic characteristics. Key Findings: (1) Rural and urban MA and FFS populations did not differ much on average by any characteristics reported in the data, including age, self-reported health status, cancer diagnosis, smoking status, Medicaid status, or by other variables assessing frailty and presence of chronic conditions. (2) Most measures of access were similar across rural and urban respondents. However, in terms of cost, urban enrollees were less likely to pay an additional premium (beyond Medicare Part A and B) to obtain MA coverage: 42 percent reported doing so in urban places, while 54 percent did so in rural places. (3) While rurality on its own was often a significant predictor of lower issuer participation in a county's MA market, the addition of other demographic characteristics did not influence the prediction. In other words, we found no evidence, based upon MCBS data, that issuers exclude rural counties due to other demographics.

Repeat reports among cases reported for child neglect: A scoping review.

BACKGROUND: In the United States (US), child welfare policy prioritizes prevention of future harm (e.g., repeat reports) after a report of maltreatment. The majority of reports include some form of child neglect, but no prior review of the recurrence literature has focused on neglect. OBJECTIVE: This review sought to help guide future research, policy and practice by summarizing recurrence findings related to child neglect with attention to the broader ecological context in which maltreatment occurs. PARTICIPANTS: The final review included 34 US studies of maltreatment recurrence. Twenty-eight studies compared child neglect with at least one other form of maltreatment and six studies examined recurrence among neglect cases. METHODS: Eleven online databases were searched to locate relevant empirical studies. This review attended specifically to contextualizing findings according to other modifiable factors as well as methodological variation. A scoping review approach was used to summarize findings. RESULTS: Of the 28 studies comparing neglect to other types of maltreatment, 14 found increased risk for neglect, 12 found no association, and two reported a lower risk. When significant, the effect size ranged from 10% to over three times higher risk for neglect. Poverty or material need was the most commonly included control (15 studies), with two thirds finding that lower resource families had higher risk. CONCLUSION: Methodological variability across studies confounds current ability to guide practice or policy. More research is needed that can replicate and extend findings with comparable samples and model specifications that take into account the regional and policy context.