Limited Health Literacy and Hearing Loss Among Older Adults.

BACKGROUND: Effective communications between health care providers and patients are critical for high-quality health care. OBJECTIVE: This study sampled adults age 65 years and older to explore (1) characteristics associated with limited health literacy (LHL) and (2) medical costs and gaps in care based on health literacy, hearing loss, and hearing aid use status. METHODS: The study included 19,223 adults age 65 years and older who completed a health survey that was linked to his or her medical claims that were generated after medical care provided in the year prior to survey completion. Health literacy, hearing loss, and hearing aid use were assessed through self-reports. Health literacy was coded as limited and adequate. Hearing loss and hearing aid use were coded into five categories: no hearing loss, unaided mild, aided mild, unaided severe, and aided severe hearing loss. KEY RESULTS: Seven percent reported LHL and 41% reported hearing loss. Hearing loss, especially unaided severe, was associated with LHL, as were memory loss, depression, loneliness, older age, and male gender. People with aided severe hearing loss and LHL had higher annual medical costs than those with adequate health literacy. Similarly, those with no hearing loss and LHL had higher annual medical costs than those with adequate health literacy. CONCLUSIONS: Unaided mild, aided severe, and unaided severe hearing loss were positively associated with LHL, although the association was reduced among hearing aid users. Specifically, aided mild or severe hearing loss had lower odds of LHL, compared to unaided mild or severe hearing loss, respectively. We also observed that people with both hearing loss and LHL were more likely to have higher medical costs. Continued focus on solutions to address both LHL and hearing loss remains warranted. [HLRP: Health Literacy Research and Practice. 2020;4(2):e129-e137.] PLAIN LANGUAGE SUMMARY: Health survey and medical claims data were used for this study. Hearing loss, especially unaided severe, was associated with limited health literacy, as were memory loss, depression, loneliness, older age, and male gender. Those with both limited health literacy and hearing loss had the highest medical costs. Health literacy and hearing loss can affect health care communications, warranting further study.

Characteristics and Health Outcomes Associated With Hearing Loss and Hearing Aid Use Among Older Adults.

Background: This study recruited older adults to explore physical and psychosocial conditions and other health outcomes associated with hearing loss (HL) and hearing aid use. Method: Survey data were used to categorize 20,244 participants into five groups: no HL, unaided mild HL, aided mild HL, unaided severe HL, and aided severe HL. Results: Individuals with unaided severe HL were more likely to report poor-fair self-rated health and were less likely to leave the home, or exercise 4 to 7 days per week, while there were no such associations for those with aided mild or severe HL. In addition, those with aided hearing were less likely to report depression, low social support, or mobility limitations. Discussion: In several instances, hearing aid use reduced associations between HL and negative psychosocial and physical characteristics, and health outcomes. More research using longitudinal study designs is needed to better understand the true implications of these findings.

Self-Reported Hearing Loss in Older Adults Is Associated With Higher Emergency Department Visits and Medical Costs.

Hearing loss is common among older adults. Thus, it was of interest to explore differences in health care utilization and costs associated with hearing loss and hearing aid use. Hearing loss and hearing aid use were assessed through self-reports and included 5 categories: no hearing loss, aided mild, unaided mild, aided severe, and unaided severe hearing loss. Health care utilization and costs were obtained from medical claims. Those with aided mild or severe hearing loss were significantly more likely to have an emergency department visit. Conversely, those with aided severe hearing loss were about 15% less likely to be hospitalized. Individuals with unaided severe hearing loss had the highest annual medical costs ($14349) compared with those with no hearing loss ($12118, P < .001). In this study, those with unaided severe hearing loss had the highest medical costs. Further studies should attempt to better understand the relationship between hearing loss, hearing aid use, and medical costs.

Local Disease Control in Ocular Adnexal Lymphoproliferative Disorders: Comparative Outcomes of MALT Versus Non-MALT Histologies.

INTRODUCTION: Ocular adnexal lymphoproliferative disorders (OALDs) are almost exclusively of B-cell origin, with the majority being extra-nodal marginal zone lymphomas of mucosa-associated lymphoid tissue (MALT). The comparative efficacy of involved field radiation therapy (IFRT) in MALT vs. non-MALT OALDs is not known. MATERIALS AND METHODS: We present a single-center, large cohort, retrospective study of the efficacy of IFRT in OALDs. Failure-free survival (FFS), complete remission, and local, regional, and distant failure were determined for 112 patients with MALT OALDs (n = 71) and non-MALT OALDs (n = 41) cohorts. RESULTS: Fifty-six patients with MALT OALD and 26 patients with non-MALT OALD received IFRT only (without any planned concurrent or sequential systemic chemothereapy or chemo-immunotherapies). Among the OALD cohorts treated with only IFRT, complete remission was achieved in 49 (87.5%) patients in the MALT cohort and 23 (88.4%) in the non-MALT cohort (P = .99). Clinically, resolution of symptoms occurred in 83.3% and 93.3% of the patients in the MALT and non-MALT cohorts, respectively. Local failure occurred in 4 (7.1%) patients in the MALT cohort, compared with 4 (15.3%) patients in the non-MALT cohort (P = .24). Regional failure (or extra-orbital failure) occurred in 5 (8.9%) patients in the MALT cohort and in 3 (11.5%) patients in the non-MALT cohort (P = .71). Distant failure was reported in 1 (1.7%) and 2 patients (7.6%) in the MALT and non-MALT cohorts, respectively (P = .18). The median follow-up of survivors was 5.1 years (range, 0.1-22.5 years) in the MALT cohort and 3.9 years (range, 0.1-22.9 years) in the non-MALT cohort. The 5-year and 10-year FFS was 95% (95% confidence interval [CI], 88%-100%) and 83% (95% CI, 70%-98%) for the ocular MALT and 67% (95% CI, 48%-94%) and 56% (95% CI, 34%-91%) for the non-MALT cohorts, respectively (log rank for P = .025). On multivariate analyses, age (hazard ratio [HR], 1.06; 95% CI, 1.10-1.12; P = .03), presence of non-MALT histology (HR, 13.9; 95% CI, 2.05-94.4; P = .007), and radiation dose < 30.6 Gy (HR, 5.27; 95% CI, 1.14-24.3; P = .03) were associated with worse FFS. The 5-year and 10-year overall survival was 92% (95%, CI 83%-100%) and 80% (95% CI, 66%-96%) for the MALT and 78% (95% CI, 61%-100%) and 62% (95% CI, 38%-100%) for the non-MALT cohorts, respectively (P = .80). CONCLUSION: Our results reveal that IFRT provided excellent disease control with superior FFS in the MALT cohort when compared with the non-MALT group.

Incorporating Reporting Efforts to Manage and Improve Health and Wellness Programs.

Wellness programs are designed to help individuals maintain or improve their health. This article describes how a reporting process can be used to help manage and improve a wellness program. Beginning in 2014, a wellness pilot program became available in New Jersey for individuals with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company. The program has since expanded to include Missouri, Texas, Alabama, and Washington. This wellness program includes an online health portal, one-on-one telephonic coaching, gym membership discounts, and local health events. To assure smooth program operations and alignment with program objectives, weekly and monthly reports are produced. The weekly report includes metrics on member engagement and utilization for the aforementioned 4 program offerings and reports on the last 4 weeks, as well as for the current month and the current year to date. The monthly report includes separate worksheets for each state and a summary worksheet that includes all states combined, and provides metrics on overall engagement as well as utilization of the 4 program components. Although the monthly reports were used to better manage the 4 program offerings, the weekly reports help management to gauge response to program marketing. Reporting can be a data-driven management tool to help manage wellness programs. Reports provide rapid feedback regarding program performance. In contrast, in-depth program evaluations serve a different purpose, such as to report program-related savings, return on investment, or to report other longer term program-related outcomes.

Care Coordination Challenges Among High-Needs, High-Costs Older Adults in a Medigap Plan.

PURPOSE OF THE STUDY: Many adults 65 years or older have high health care needs and costs. Here, we describe their care coordination challenges. PRIMARY PRACTICE SETTING: Individuals with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York). METHODOLOGY AND SAMPLE: The three groups included the highest needs, highest costs (the "highest group"), the high needs, high costs (the "high group"), and the "all other group." Eligibility was determined by applying an internally developed algorithm based upon a number of criteria, including hierarchical condition category score, the Optum ImpactPro prospective risk score, as well as diagnoses of coronary artery disease, congestive heart failure, or diabetes. RESULTS: The highest group comprised 2%, although consumed 12% of health care expenditures. The high group comprised 20% and consumed 46% of expenditures, whereas the all other group comprised 78% and consumed 42% of expenditures. On average, the highest group had $102,798 in yearly health care expenditures, compared with $34,610 and $7,634 for the high and all other groups, respectively. Fifty-seven percent of the highest group saw 16 or more different providers annually, compared with 21% and 2% of the high and all other groups, respectively. Finally, 28% of the highest group had prescriptions from at least seven different providers, compared with 20% and 5% of the high and all other groups, respectively. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Individuals with high health care needs and costs have visits to numerous health care providers and receive multiple prescriptions for pharmacotherapy. As a result, these individuals can become overwhelmed trying to manage and coordinate their health care needs. Care coordination programs may help these individuals coordinate their care.

Using Propensity to Succeed Modeling to Increase Utilization and Adherence in a Nurse HealthLine Telephone Triage Program.

Propensity to succeed modeling was used to identify characteristics associated with higher utilization of a telephone triage program and adherence to nurse recommendations among callers. Characteristics significantly associated with calling the telephone triage service and engaging in triage services were being female and having an elevated health risk score. Callers most likely to adhere to nurse recommendations were younger than 85 years of age, had called on a weekday, and had received a recommendation to seek care at an emergency department or a doctor's office visit. Additional analyses suggest the propensity to succeed modeling is stable and valid.

Traumatic orbital encephalocele: Presentation and imaging.

OBJECTIVE: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. METHODS: Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin. RESULTS: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. CONCLUSION: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.

Risk for broad-spectrum neuropsychiatric disorders after mild traumatic brain injury in a cohort of US Air Force personnel.

BACKGROUND: Military personnel are at increased risk for traumatic brain injury (TBI) from combat and non-combat exposures. Sequelae of moderate-to-severe TBI are well described, but the literature remains conflicted regarding whether mild TBI (mTBI) results in lasting brain injury and functional impairments. This study assessed risk for a range of neuropsychiatric disorders presenting after mTBI while adjusting for the potential confounds of depression and post-traumatic stress disorder (PTSD). METHODS: A historical prospective association study was conducted utilising electronic demographic, medical and military-specific data for over 49,000 active duty US Air Force service members (Airmen). This study utilised diagnostic codes considered by an expert panel to be indicative of mTBI to identify cases. Cox proportional hazards modelling calculated HRs for neuropsychiatric outcomes while controlling for varying lengths of follow-up and potentially confounding variables. RESULTS: Airmen with mTBI were at increased risk for specific neuropsychiatric disorders compared with a similarly injured non-mTBI control group. HRs for memory loss/amnesia, cognitive disorders, schizophrenia, PTSD, and depression were significantly elevated and remained so for at least 6 months post-mTBI, even after eliminating those with previous neuropsychiatric diagnoses. CONCLUSIONS: mTBI was positively associated with neuropsychiatric disorders in this population of primarily young adult males; with increased HRs 6 months post-mTBI. The results support that mTBI is distinguished from moderate-to-severe TBI in terms of risk for developing neuropsychiatric disorders. Further, these findings suggest the importance of screening for psychiatric and cognitive disorders post-mTBI in general medical practice.

Post-traumatic stress disorder predicts future weight change in the Millennium Cohort Study.

OBJECTIVE: To prospectively examine the association between post-traumatic stress disorder (PTSD) and weight change. METHODS: Longitudinal analysis techniques were used to examine data (2001-2008) from Millennium Cohort Study participants, consisting of U.S. service members and veterans. Using the PTSD Checklist-Civilian Version, PTSD was assessed as none, resolved, new onset, or persistent. Subsequent weight change was assessed as stable (≤3% loss or gain), >3% weight loss, >3% but <10% weight gain, and ≥10% weight gain. RESULTS: Of the 38,352 participants, 2391 (6.2%) had PTSD (838 resolved, 1024 new onset, and 529 persistent), and 11% of participants subsequently had ≥10% weight gain. In multivariable models, PTSD was associated with higher odds of ≥10% weight gain (new onset OR: 1.44 [95% CI: 1.20-1.73]; persistent OR: 1.51 [CI: 1.17-1.96]; resolved OR: 1.30 [CI: 1.05-1.60]) compared with those without PTSD. New-onset and persistent PTSD were also associated with higher odds of >3% weight loss (OR: 1.41 [CI: 1.17-1.71]; OR: 1.42 [CI: 1.09-1.86], respectively). CONCLUSIONS: PTSD is independently associated with a higher risk of weight gain and loss, the former of which leads to a higher prevalence of overweight and obesity and a higher risk of comorbidities associated with excessive body adiposity.

Propensity to Succeed: Prioritizing Individuals Most Likely to Benefit from Care Coordination.

The objective was to develop a propensity to succeed (PTS) process for prioritizing outreach to individuals with Medicare Supplement (ie, Medigap) plans who qualified for a high-risk case management (HRCM) program. Demographic, socioeconomic, health status, and local health care supply data from previous HRCM program participants and nonparticipants were obtained from Medigap membership and health care claims data and public data sources. Three logistic regression models were estimated to find members with higher probabilities of engaging in the HRCM program, receiving high quality of care once engaged, and incurring enough monetary savings related to program participation to more than offset program costs. The logistic regression model intercepts and coefficients yielded the information required to build predictive models that were then applied to generate predicted probabilities of program engagement, high quality of care, and cost savings a priori for different members who later qualified for the HRCM program. Predicted probabilities from the engagement and cost models were then standardized and combined to obtain an overall PTS score, which was sorted from highest to lowest and used to prioritize outreach efforts to those newly eligible for the HRCM program. The validity of the predictive models also was estimated. The PTS models for engagement and financial savings were statistically valid. The combined PTS score based on those 2 components helped prioritize outreach to individuals who qualified for the HRCM program. Using PTS models may help increase program engagement and financial success of care coordination programs.

Hearing loss associated with US military combat deployment.

The objective of this study was to define the risk of hearing loss among US military members in relation to their deployment experiences. Data were drawn from the Millennium Cohort Study. Self-reported data and objective military service data were used to assess exposures and outcomes. Among all 48,540 participants, 7.5% self-reported new-onset hearing loss. Self-reported hearing loss showed moderate to substantial agreement (k = 0.57-0.69) with objective audiometric measures. New-onset hearing loss was associated with combat deployment (adjusted odds ratio [AOR] = 1.63, 95% confidence interval [CI] = 1.49-1.77), as well as male sex and older age. Among deployers, new-onset hearing loss was also associated with proximity to improvised explosive devices (AOR = 2.10, 95% CI = 1.62-2.73) and with experiencing a combat-related head injury (AOR = 6.88, 95% CI = 3.77-12.54). These findings have implications for health care and disability planning, as well as for prevention programs.

Reconstructive and rehabilitation challenges following a cranio-orbital gunshot wound.

We present a case of a 26-year-old man who sustained a close-range gunshot wound to the head. His injuries included significant left orbital injury resulting in a ruptured, blind eye and severely comminuted fractures of the left orbital roof, superior and inferior orbital rims, and orbital floor. Associated injuries included left frontal lobe injury, anterior and posterior table fractures of the left frontal sinus, and a comminuted left zygomaticomaxillary complex fracture. We employed an interdisciplinary surgical approach with collaboration among the Otolaryngology, Neurosurgery, and Oculoplastic Surgery services performed in two stages. Management of such extensive craniofacial injuries can be challenging and requires a coordinated, interdisciplinary approach.

Big Data, Little Data, and Care Coordination for Medicare Beneficiaries with Medigap Coverage.

Most healthcare data warehouses include big data such as health plan, medical, and pharmacy claims information for many thousands and sometimes millions of insured individuals. This makes it possible to identify those with multiple chronic conditions who may benefit from participation in care coordination programs meant to improve their health. The objective of this article is to describe how large databases, including individual and claims data, and other, smaller types of data from surveys and personal interviews, are used to support a care coordination program. The program described in this study was implemented for adults who are generally 65 years of age or older and have an AARP(®) Medicare Supplement Insurance Plan (i.e., a Medigap plan) insured by UnitedHealthcare Insurance Company (or, for New York residents, UnitedHealthcare Insurance Company of New York). Individual and claims data were used first to calculate risk scores that were then utilized to identify the majority of individuals who were qualified for program participation. For efficient use of time and resources, propensity to succeed modeling was used to prioritize referrals based upon their predicted probabilities of (1) engaging in the care coordination program, (2) saving money once engaged, and (3) receiving higher quality of care. To date, program evaluations have reported positive returns on investment and improved quality of healthcare among program participants. In conclusion, the use of data sources big and small can help guide program operations and determine if care coordination programs are working to help older adults live healthier lives.

Neurologically-related sequelae associated with mild traumatic brain injury.

OBJECTIVE: Mild traumatic brain injury (mTBI) accounts for more than 75% of traumatic brain injuries every year. This study examines the temporal association between non-blast mTBI and the onset of neurologic sequelae to illuminate risks of post-concussive syndrome, epilepsy and chronic pain. METHODS: A large historical prospective study was conducted utilizing electronically-recorded demographic, medical and military-specific data for over half a million active duty US Air Force Airmen. This study utilized diagnostic codes to identify mTBI exposures, two control groups and three post-mTBI time periods. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards modelling. RESULTS: HRs were higher when mTBI exposed Airmen were compared with the full cohort and lower when compared with the other injured group. When compared to the other injured group, mTBI was positively associated with epilepsy/recurrent seizure outcomes, post-concussive syndrome and pain disorders. HRs tended to be highest within the first 30 days and decreased over time. CONCLUSIONS: Findings support that mTBI may have a prolonged neurological impact. Findings are also likely generalizable to young adult populations with exposure to non-blast related mTBI, including civilians, as those included in this study were young adults with a high prevalence of recreational/sports and motor vehicle injuries.

Surgical timing and postoperative ocular motility in type B orbital blowout fractures.

PURPOSE: To determine whether patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) repaired within 7 days of injury have statistically greater postoperative vertical binocular fusion than similar patients who undergo later surgery. METHODS: Prospective and retrospective surgical case series. Inclusion criteria were orbital floor (with or without medial wall) blowout fracture repair, preoperative coronal orbital CT scans, and patient age of at least 12 years at time of postoperative binocular visual field. RESULTS: Twenty-five patients met inclusion criteria. Ten patients (group 1) had surgery within 7 days of injury, and 15 patients (group 2) had surgery more than 7 days after injury. The total cohort had a median postoperative vertical binocular fusion of 90°. Group 1 had postoperative vertical binocular fusion averaging 100°. Nine of 10 patients (90%) were above and 1 of 10 (10%) were below the median for the entire cohort. Group 2 had postoperative vertical binocular fusion averaging 70°. Three of 15 patients (20%) were above and 12 of 15 patients (80%) were below the median for the entire cohort. The difference between the average postoperative vertical binocular fusion of the 2 groups was statistically significant by two-tailed unpaired t test with p value 0.0022. CONCLUSIONS: Patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) have statistically greater average postoperative vertical binocular fusion if repaired within 7 days of injury than similar patients who undergo later surgery.

Evaluation of a high-risk case management pilot program for Medicare beneficiaries with Medigap coverage.

The objective was to evaluate the 3-year experience of a high-risk case management (HRCM) pilot program for adults with an AARP Medicare Supplement (Medigap) Insurance Plan. Participants were provided in-person visits as well as telephonic and mailed services to improve care coordination from December 1, 2008, to December 31, 2011. Included were adults who had an AARP Medigap Insurance Plan, resided in 1 of 5 pilot states, and had a Hierarchical Condition Category score>3.74, or were referred into the program. Propensity score weighting was used to adjust for case-mix differences among 2015 participants and 7626 qualified but nonparticipating individuals. Participants were in the program an average of 15.4 months. After weighting, multiple regression analyses were used to estimate differences in quality of care and health care expenditures between participants and nonparticipants. Increased duration in the program was associated with fewer hospital readmissions. Additionally, participants were significantly more likely to have recurring office visits and recommended laboratory tests. The program demonstrated $7.7 million in savings over the 3 years, resulting in a return on investment of $1.40 saved for every dollar spent on the program. Savings increased each year from 2009 to 2011 and with longer length of engagement. The majority of savings were realized by the federal Medicare program. This study focused on quality of care and savings for an HRCM program designed solely for Medicare members with Medicare Supplement coverage. This program had a favorable impact on quality of care and demonstrated savings over a 3-year period.

Deployment-related depression screening, 2001-2008: comparing clinical versus research surveys.

BACKGROUND: Potential adverse mental health effects of deployment, including depression, are an ongoing concern. Although a previous study assessed under-reporting of depression on post-deployment health assessments compared to anonymous surveys, those results were not examined at the individual level to identify demographic or military factors that may be associated with unwillingness to report depression symptoms. PURPOSE: To compare self-reported depression symptoms on post-deployment health assessments with responses to the same depression questions on a research survey. METHODS: This cross-sectional study analyzed depression screening responses from 2001 to 2008 from participants of the Millennium Cohort Study, a longitudinal military cohort study, who completed a post-deployment health assessment within 30 days of a research survey. Kappa statistics and percent positive and negative agreement were calculated. Demographic and military characteristics associated with discordant screening results were examined. Initial analyses were performed in 2011, with additional analyses in 2013. RESULTS: Moderate agreement (κ=0.464) was observed between paired survey responses. A higher proportion of active duty members, the unmarried, and new accessions into military service endorsed depression symptoms on the research survey but not the military-linked survey. In stratified analyses, agreement was higher in Reserve/National Guard members than active duty (κ=0.561 vs 0.409). New active duty accessions showed lower agreement (κ=0.388), as did unmarried active duty participants (κ=0.304). CONCLUSIONS: Deployment health surveys are important tools for identifying returning service members experiencing depression symptoms. However, these findings suggest that ongoing stigma and barriers to appropriate follow-up mental health care remain to be addressed in the military setting.