The Association Between Medicare Eligibility and Gains in Access to Rehabilitative Care: A National Regression Discontinuity Assessment of Patients Ages 64 Versus 65 Years.

OBJECTIVES: The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related "best-practice" factors. SUMMARY BACKGROUND DATA: Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients. METHODS: Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007-2012 National Trauma Data Bank. RESULTS: A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8-7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5-12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 "presumptive diagnosis codes" (inpatient facilities' 60% rule) demonstrated abrupt gains in both SNF and inpatient care. CONCLUSIONS: The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.

Access to post-discharge inpatient care after lower limb trauma.

BACKGROUND: Most hospitals in the United States are required to provide emergency care to all patients, regardless of insurance status. However, uninsured patients might be unable to access non-acute services, such as post-discharge inpatient care (PDIC). This could result in prolonged acute hospitalization. We tested the hypothesis that insurance status would be independently associated with both PDIC and length of stay (LOS). METHODS: An observational study was undertaken using the California State Inpatient Database (2007-2011), which captures 98% of patients admitted to hospital in California. All patients with a diagnosis of orthopedic lower limb trauma were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes 820-828. Multivariable logistic and generalized linear regression models were used to adjust odds of PDIC and LOS for patient and hospital characteristics. RESULTS: There were 278,573 patients with orthopedic lower limb injuries, 160,828 (57.7%) of which received PDIC. Uninsured patients had lower odds of PDIC (adjusted odds ratio 0.20, 95% confidence interval 0.17-0.24) and significantly longer hospital LOS (predicted mean difference 1.06 [95% confidence interval 0.78-1.34] d) than those with private insurance. CONCLUSIONS: Lack of health insurance is associated with reduced access to PDIC and prolonged hospital LOS. This potential barrier to hospital discharge could reduce the number of trauma beds available for acutely injured patients.

Creating a Resident Research Track in Synergy With the Rehabilitation Medicine Scientist Training Program.

ABSTRACT: Physician scientists play an important role in the translation of research findings to patient care; however, their training faces numerous challenges. Residency research track programs represent an opportunity to facilitate the training of future physician scientists in physical medicine and rehabilitation, although optimal program organization and long-term outcomes remain unknown. The Rehabilitation Medicine Scientist Training Program is a National Institutes of Health-funded program aimed at addressing the shortage of physician researchers in the field of physical medicine and rehabilitation by providing instruction, mentorship, and networking opportunities for a successful research career. While the opportunities provided through the Rehabilitation Medicine Scientist Training Program provide critical education and guidance at a national level, trainees are most successful with availability of strong local support and mentorship. The purpose of this article was to present a realistic and easily applicable structure for a physical medicine and rehabilitation residency research track that can be used in concert with the Rehabilitation Medicine Scientist Training Program.

Survival after bronchiolitis obliterans syndrome among bilateral lung transplant recipients.

RATIONALE: Despite the importance of bronchiolitis obliterans syndrome (BOS) in lung transplantation, little is known regarding the factors that influence survival after the onset of this condition, particularly among bilateral transplant recipients. OBJECTIVES: To identify factors that influence survival after the onset of BOS among bilateral lung transplant recipients. METHODS: The effect of demographic or clinical factors, occurring before BOS, upon survival after the onset of BOS was studied in 95 bilateral lung transplant recipient using Cox proportional hazards models. MEASUREMENTS AND MAIN RESULTS: Although many factors, including prior acute rejection or rejection treatments, were not associated with survival after BOS, BOS onset within 2 years of transplantation (early-onset BOS), or BOS onset grade of 2 or 3 (high-grade onset) were predictive of significantly worse survival (early onset P = 0.04; hazard ratio, 1.84; 95% confidence interval, 1.03-3.29; high-grade onset P = 0.003; hazard ratio, 2.40; 95% confidence interval, 1.34-4.32). The effects of both early onset and high-grade onset on survival persisted in multivariable analysis and after adjustment for concurrent treatments. Results suggested an interaction might exist between early onset and high-grade onset. In particular, high-grade onset of BOS, regardless of its timing after transplant, is associated with a very poor prognosis. CONCLUSIONS: The course of BOS after bilateral lung transplantation is variable. Distinct patterns of survival after BOS are evident and related to timing or severity of onset. Further characterization of these subgroups should provide a more rational basis from which to design, stratify, and assess response in future BOS treatment trials.

Factors Associated With Ambulation in Myelomeningocele: A Longitudinal Study From the National Spina Bifida Patient Registry.

OBJECTIVE: Evidence is limited regarding clinical factors associated with ambulation status over the lifespan of individuals with myelomeningocele. We used longitudinal data from the National Spina Bifida Patient Registry to model population-level variation in ambulation over time and hypothesized that effects of clinical factors associated with ambulation would vary by age and motor level. DESIGN: A population-averaged generalized estimating equation was used to estimate the probability of independent ambulation. Model predictors included time (age), race, ethnicity, sex, insurance, and interactions between time, motor level, and the number of orthopedic, noncerebral shunt neurosurgeries, and cerebral shunt neurosurgeries. RESULTS: The study cohort included 5371 participants with myelomeningocele. A change from sacral to low-lumbar motor level initially reduced the odds of independent ambulation (OR = 0.24, 95% CI = 0.15-0.38) but became insignificant with increasing age. Surgery count was associated with decreased odds of independent ambulation (orthopedic: OR = 0.65, 95% CI = 0.50-0.85; noncerebral shunt neurosurgery: OR = 0.65, 95% CI = 0.51-0.84; cerebral shunt: OR = 0.90, 95% CI = 0.83-0.98), with increasing effects seen at lower motor levels. CONCLUSIONS: Our findings suggest that effects of several commonly accepted predictors of ambulation status vary with time. As the myelomeningocele population ages, it becomes increasingly important that study design account for this time-varying nature of clinical reality. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe general trends in ambulation status by age in the myelomeningocele population; (2) Recognize the nuances of cause and effect underlying the relationship between surgical intervention and ambulation status; (3) Explain why variation of clinical effect over time within myelomeningocele population matters. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Operative team communication during simulated emergencies: Too busy to respond?

BACKGROUND: Ineffective communication among members of a multidisciplinary team is associated with operative error and failure to rescue. We sought to measure operative team communication in a simulated emergency using an established communication framework called "closed loop communication." We hypothesized that communication directed at a specific recipient would be more likely to elicit a check back or closed loop response and that this relationship would vary with changes in patients' clinical status. METHODS: We used the closed loop communication framework to code retrospectively the communication behavior of 7 operative teams (each comprising 2 surgeons, anesthesiologists, and nurses) during response to a simulated, postanesthesia care unit "code blue." We identified call outs, check backs, and closed loop episodes and applied descriptive statistics and a mixed-effects negative binomial regression to describe characteristics of communication in individuals and in different specialties. RESULTS: We coded a total of 662 call outs. The frequency and type of initiation and receipt of communication events varied between clinical specialties (P < .001). Surgeons and nurses initiated fewer and received more communication events than anesthesiologists. For the average participant, directed communication increased the likelihood of check back by at least 50% (P = .021) in periods preceding acute changes in the clinical setting, and exerted no significant effect in periods after acute changes in the clinical situation. CONCLUSION: Communication patterns vary by specialty during a simulated operative emergency, and the effect of directed communication in eliciting a response depends on the clinical status of the patient. Operative training programs should emphasize the importance of quality communication in the period immediately after an acute change in the clinical setting of a patient and recognize that communication patterns and needs vary between members of multidisciplinary operative teams.

Race-based differences in duration of stay among universally insured coronary artery bypass graft patients in military versus civilian hospitals.

BACKGROUND: Duration of stay for coronary artery bypass graft operation outcomes differs for black versus white patients, with differences often attributed to insurance. We examined black versus white differences in duration of stay among TRICARE-covered patients undergoing coronary artery bypass graft. METHODS: Patients aged 18-64 years with TRICARE who underwent isolated coronary artery bypass graft (ICD-9CM 36.10-36.20) between 2006-2010 and who identified as black or white race were identified. Negative binomial regression, stratified by sex and military versus civilian facility, examined the duration of stay controlling for patient- and hospital-level factors. RESULTS: Of 3,496 eligible patients, 2,904 underwent coronary artery bypass graft at 682 civilian and 592 at 11 military hospitals. Patients (mean age 56.2 years) were predominantly white (88.9%), male (88.7%), married (88.2%), and retired (87%). Black patients demonstrated longer duration of stay (8.6 vs 7.5 days, P > .001), and overall duration of stay was longer at military facilities (8.1 vs 7.5 days, P = .013). Among the men, mean duration of stay was 14% longer for black patients at civilian hospitals (95% confidence interval 1.07-1.22) with no race-based differences at military facilities. CONCLUSION: Among coronary artery bypass graft patients with TRICARE coverage, black, male patients demonstrated greater duration of stay at civilian facilities. Further work should examine care at military hospitals to elucidate factors that drive the apparent mitigation of race-related variability in duration of stay.

Prioritizing qualitative research in surgery: A synthesis and analysis of publication trends.

BACKGROUND: Over the past 2 decades, researchers have recognized the value of qualitative research. Little has been done to characterize its application to surgery. We describe characteristics and overall prevalence of qualitative surgical research. METHODS: We searched PubMed and CINAHL using "surgery" and 7 qualitative methodology terms. Four researchers extracted information; a fifth researcher reviewed 10% of abstracts for inter-rater reliability. RESULTS: A total of 3,112 articles were reviewed. Removing duplicates, 28% were relevant (N = 878; κ = 0.70). Common qualitative methodologies included phenomenology (34.3%) and grounded theory (30.2%). Interviews were the most common data collection method (81.9%) of patients (64%) within surgical oncology (15.4%). Postdischarge was the most commonly studied topic (30.8%). Overall, 41% of studies were published in nursing journals, while 8% were published in surgical journals. More than half of studies were published since 2011. CONCLUSION: Results suggest qualitative surgical research is gaining popularity. Most is published in nonsurgical journals, however, utilizing only 2 methodologies (phenomenology, grounded theory). The surgical journals that have published qualitative research had study topics restricted to a handful of surgical specialties. Additional surgical qualitative research should take advantage of a greater variety of approaches to provide insight into rare phenomena and social context.

Implications for human leukocyte antigen antibodies after lung transplantation: a 10-year experience in 441 patients.

BACKGROUND: Long-term survival after lung transplant is limited by the development of chronic and progressive airflow obstruction, a condition known as bronchiolitis obliterans syndrome (BOS). While prior studies strongly implicate cellular rejection as a strong risk factor for BOS, less is known about the clinical significance of human leukocyte antigen (HLA) antibodies and donor HLA-specific antibodies in long-term outcomes. METHODS: A single-center cohort of 441 lung transplant recipients, spanning a 10-year period, was prospectively screened for HLA antibodies after transplant using flow cytometry-based methods. The prevalence of and predictors for HLA antibodies were determined. The impact of HLA antibodies on survival after transplant and the development of BOS were determined using Cox models. RESULTS: Of the 441 recipients, 139 (32%) had detectable antibodies to HLA. Of these 139, 54 (39%) developed antibodies specific to donor HLA. The detection of posttransplant HLA antibodies was associated with BOS (HR, 1.54; P=.04) and death (HR, 1.53; P=.02) in multivariable models. The detection of donor-specific HLA antibodies was associated with death (HR, 2.42; P<.0001). The detection of posttransplant HLA antibodies was associated with pretransplant HLA-antibody detection, platelet transfusions, and the development of BOS and cytomegalovirus pneumonitis. CONCLUSIONS: Approximately one-third of lung transplant recipients have detectable HLA antibodies, which are associated with a worse prognosis regarding graft function and patient survival.

Long-term efficacy and safety of 12 months of valganciclovir prophylaxis compared with 3 months after lung transplantation: a single-center, long-term follow-up analysis from a randomized, controlled cytomegalovirus prevention trial.

BACKGROUND: The optimal approach to cytomegalovirus (CMV) prevention after lung transplantation is controversial. We recently completed a prospective, randomized, placebo-controlled study of CMV prevention in lung transplantation that demonstrated the short-term efficacy and safety of extending valganciclovir prophylaxis to 12 months vs 3 months of therapy. In the current analysis, we monitored a single-center subset of patients enrolled in the CMV prevention trial to determine if extended prophylaxis conferred a sustained long-term benefit and to assess its hematologic safety. METHODS: The sub-analysis included 38 randomized patients from Duke University Medical Center. All patients underwent consistent serial serum CMV monitoring and surveillance bronchoscopies. CMV was defined by viremia (≥ 500 CMV DNA copies/ml) or pneumonitis. The safety assessment included a review of all complete blood counts obtained from transplant onward. RESULTS: During a mean follow-up of 3.9 years in each group, extended-course compared with short-course prophylaxis provided a sustained protective benefit with a lifetime CMV incidence of 12% vs 55%, respectively (hazard ratio, 0.13; 95% confidence interval, 0.03-0.61; p = 0.009), an effect that persisted after adjustment for clinical risk factors. Patients in each group underwent a comparable number of peripheral blood draws and bronchoscopies. Post-transplant white blood cell, neutrophil, and platelet counts were similar between each treatment group during the course of follow-up. CONCLUSION: Extending valganciclovir prophylaxis to 12 months provides a durable long-term CMV protective benefit compared with short-course therapy, without increasing adverse hematologic effects.