Impact of the COVID-19 pandemic on pediatric Medicaid dental claims in Arizona.

OBJECTIVES: To examine the role COVID-19 had on access to dental services among children in Arizona by comparing paid pediatric dental claims made before and during the pandemic. METHODS: In a retrospective descriptive study, we examined Medicaid paid claims for dental services among pediatric patients from March through December 2019 and during the outbreak in 2020. Using dental claims data obtained from the Centers for Health Information and Research at Arizona State University (ASU), we analyzed Medicaid (Arizona Health Care Cost Containment System [AHCCCS]) reimbursed dental services. RESULTS: During the COVID-19 pandemic, paid preventive dental claims for children aged birth to 21 years decreased in 2020 compared to the same time period in 2019. Pediatric patients in Arizona utilized fewer dental services and had less access to credentialed Medicaid dental providers during the pandemic. Further, rural counties had statistically significant fewer preventive, minor restorative, major restorative, and endodontic claims compared to urban counties. Arizona rural counties also had fewer providers who were paid $10,000 or more per year during 2020 than in 2019. CONCLUSIONS: COVID-19 has had a detrimental impact on pediatric dental service utilization. While dental services were provided during the COVID-19 pandemic, preventive and restorative dental claims dropped for rural Arizona children aged birth to 21 years. This reveals potential negative impacts on oral health. Further research should examine the direct and indirect impact the COVID-19 pandemic has had on dental service utilization and oral health for the general pediatric population.

Telerehabilitation for Lung Transplant Candidates and Recipients During the COVID-19 Pandemic: Program Evaluation.

BACKGROUND: The COVID-19 pandemic resulted in a rapid shift from center-based rehabilitation to telerehabilitation for chronic respiratory disease and lung transplantation due to infection control precautions. Clinical experience with this delivery model on a large scale has not been described. OBJECTIVE: The aim of this study is to describe usage and satisfaction of providers and lung transplant (LTx) candidates and recipients and functional outcomes following the broad implementation of telerehabilitation with remote patient monitoring during the first wave of the COVID-19 pandemic. METHODS: This study was a program evaluation of providers, LTx candidates, and early LTx recipients who used a web-based, remote monitoring app for at least four weeks between March 16 and September 1, 2020, to participate in telerehabilitation. Within-subjects analysis was performed for physical activity, Self-efficacy For Exercise (SEE) scale score, aerobic and resistance exercise volumes, 6-minute walk test results, and Short Physical Performance Battery (SPPB) results. RESULTS: In total, 78 LTx candidates and 33 recipients were included (57 [51%] males, mean age 58 [SD 12] years, 58 [52%] with interstitial lung disease, 34 [31%] with chronic obstructive pulmonary disease). A total of 50 (64%) LTx candidates and 17 (51%) LTx recipients entered ≥10 prescribed exercise sessions into the app during the study time frame. In addition, 35/42 (83%) candidates agreed the app helped prepare them for surgery and 18/21 (85%) recipients found the app helpful in their self-recovery. The strongest barrier perceived by physiotherapists delivering the telerehabilitation was patient access to home exercise and monitoring equipment. Between the time of app registration and ≥4 weeks on the waiting list, 26 LTx candidates used a treadmill, with sessions increasing in mean duration (from 16 to 22 minutes, P=.002) but not speed (from 1.7 to 1.75 mph, P=.31). Quadriceps weight (pounds) for leg extension did not change (median 3.5, IQR 2.4-5 versus median 4.3, IQR 3-5; P=.08; n=37). On the Rapid Assessment of Physical Activity questionnaire (RAPA), 57% of LTx candidates scored as active, which improved to 87% (P=.02; n=23). There was a decrease in pretransplant 6-minute walk distance (6MWD) from 346 (SD 84) meters to 307 (SD 85) meters (P=.002; n=45) and no change in the SPPB result (12 [IQR 9.5-12] versus 12 [IQR 10-12]; P=.90; n=42). A total of 9 LTx recipients used a treadmill that increased in speed (from 1.9 to 2.7 mph; P=.003) between hospital discharge and three months posttransplant. Quadriceps weight increased (3 [IQR 0-3] pounds versus 5 [IQR 3.8-6.5] pounds; P<.001; n=15). At three months posttransplant, 76% of LTx recipients scored as active (n=17), with a high total SEE score of 74 (SD 11; n=12). In addition, three months posttransplant, 6MWD was 62% (SD 18%) predicted (n=8). CONCLUSIONS: We were able to provide telerehabilitation despite challenges around exercise equipment. This early experience will inform the development of a robust and equitable telerehabilitation model beyond the COVID-19 pandemic.

Pre-transplant short physical performance battery: Response to pre-habilitation and relationship to pre- and early post-lung-transplant outcomes.

PURPOSE: To evaluate whether the short physical performance battery (SPPB) pre-lung transplant (LTx) was responsive to pre-habilitation and predicted pre- and early post-transplant outcomes. METHODS: A retrospective study of LTx candidates accepted for transplant between 2016 and 2017. SPPB was categorized as frail/pre-frail (≤9/12) and non-frail (≥10/12). RESULTS: 150 patients had LTx assessment SPPB data (53% male, 61 [52-67] years, 59% had interstitial lung disease (ILD), 26% frail/pre-frail). 131 (87%) underwent transplant by December 31, 2018. Adjusting for age, sex, diagnosis and Canadian transplant listing urgency, and frailty/pre-frailty at LTx assessment was associated with a lower 6MWD pre-transplant [-89 meters 95%CI (-125 to -53), P < .0001]. 62 patients underwent six weeks of pre-habilitation. SPPB increased (11 [10-12) vs. 12 [11-12], P = .01) reflected in the chair stand component (11.4 ± 4.4 vs. 9.8 ± 2.8 seconds, P = .007), with larger improvements in the frail/pre-frail group. A frail/pre-frail SPPB closest to the time of transplant was associated with a lower 6MWD [-77 m 95%CI (-128 to -25), P = .004] but not with hospital length of stay or gait aid use three months post-transplant. CONCLUSIONS: Frailty/pre-frailty was associated with a decreased 6MWD pre- and post-transplant. The SPPB increased following pre-habilitation, which may reflect increased lower extremity strength.

Impaired cardiac autonomic response in lung transplant patients: A retrospective cohort study.

BACKGROUND: Cardiac autonomic dysfunction (AD) is associated with adverse prognosis in lung disease; however, its implications in lung transplantation have not been previously described. This study evaluated the prevalence of AD in lung transplant (LTx) candidates, its determinants, prognostic implications, and prevalence post-transplant. METHODS: Retrospective one-year study of 103 LTx candidates with AD assessed using heart rate (HR) from the six-minute walk test (6MWT). Impaired chronotropic response index (CRI) was defined as <80% age-adjusted HR during 6MWT. Abnormal HR recovery (HRR) was categorized as reduction in HR ≤ 12 beats/minute after the first minute of 6MWT cessation. RESULTS: Abnormal CRI and HRR were observed in 94% and 76% of patients, respectively. A lower CRI was associated with obstructive lung disease and lower estimated aerobic capacity. CRI was independently associated with 6MW distance [12 m per 10% CRI, P = 0.03], but not with post-transplant cardiovascular events, hospital stay, or one-year mortality. At 3 months post-transplant, no improvement was observed in CRI (99%, n = 66/67, P = 0.25) or HRR (88%, n = 36/41, P = 0.12). CONCLUSION: Cardiac AD was prevalent in LTx candidates and recipients, with chronotropic incompetence a modest contributor to exercise intolerance pretransplant. Further study may help determine whether direct autonomic measures such as HR variability may be more prognostic of LTx outcomes.

Physical rehabilitation for lung transplant candidates and recipients: An evidence-informed clinical approach.

Physical rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. As medical and surgical interventions in lung transplantation have evolved over time, there has been a demographic shift of individuals undergoing lung transplantation including older individuals, those with multiple co-morbidites, and candidates with respiratory failure requiring bridging to transplantation. These changes have an impact on the rehabilitation needs of lung transplant candidates and recipients. This review provides a practical approach to rehabilitation based on research and clinical practice at our transplant centre. It focuses on functional assessment and exercise prescription during an uncomplicated and complicated clinical course in the pre-transplant, early and late post-transplant periods. The target audience includes clinicians involved in pre- and post-transplant patient care and rehabilitation researchers.

Skeletal muscle atrophy in advanced interstitial lung disease.

BACKGROUND AND OBJECTIVE: A limited number of studies examine skeletal muscle dysfunction in individuals with interstitial lung disease (ILD). We compared upper and lower limb muscle size and strength in individuals with advanced ILD with healthy controls. Second, the relationships of muscle size to muscle strength and function were explored. METHODS: Individuals with advanced ILD listed for lung transplant and healthy control subjects were studied. B-mode ultrasound was performed to assess cross-sectional area (CSA) of rectus femoris and thickness of gastrocnemius and soleus and biceps brachii. Subjects performed isometric muscle strength testing, Short Physical Performance Battery, Timed Up and Go, and Unsupported Upper Limb Exercise Test. RESULTS: Twenty-six individuals with advanced ILD (61 ± 8 years; 73% males; forced vital capacity: 2 ± 0.8 L, 49 ± 13% predicted; diffusing capacity of carbon monoxide: 9.3 ± 4 mL/min/mm Hg, 51 ± 20% predicted) and 12 healthy age and gender-matched controls (56 ± 9.5 years; 50% males) were included. Compared with controls, people with ILD had a smaller CSA of rectus femoris (7.6 ± 2.1 vs 9.4 ± 2.4 cm(2) ; P = 0.03) and lower strength of knee extensors (119 ± 35 vs 147 ± 39 Nm; P = 0.02) and plantarflexors (37 ± 19 vs 50 ± 15 Nm; P = 0.02), but not of biceps. Individuals with ILD also had impaired performance on all functional tests (P < 0.02). Moderate correlations were found between rectus femoris CSA and knee extensor strength (r = 0.63; P < 0.01) and biceps thickness and elbow flexor strength (r = 0.78; P < 0.01) in the ILD group. CONCLUSIONS: Individuals with advanced ILD presented with lower limb muscle atrophy and weakness. Future studies should evaluate the effectiveness of exercise training on muscle function in advanced ILD.

Pulmonary rehabilitation in lung transplant candidates.

BACKGROUND: While awaiting lung transplantation, candidates may participate in pulmonary rehabilitation to improve their fitness for surgery. However, pulmonary rehabilitation outcomes have not been systematically evaluated in lung transplant candidates. METHODS: This investigation was a retrospective cohort study of 345 pre-transplant pulmonary rehabilitation participants who received a lung transplant between January 2004 and June 2009 and had available pre-transplant exercise data. Data extracted included: 6-minute walk tests at standard intervals; exercise training details; health-related quality-of-life (HRQL) measures; and early post-transplant outcomes. Paired t-tests were used to examine changes in the 6MW distance (6MWD), exercise training volume and HRQL during the pre-transplant period. We evaluated the association between pre-transplant 6MWD and transplant hospitalization outcomes. RESULTS: The final 6MWD prior to transplantation was only 15 m less than the listing 6MWD (n = 200; p = 0.002). Exercise training volumes increased slightly from the start of the pulmonary rehabilitation program until transplant: treadmill, increase 0.69 ml/kg/min (n = 238; p < 0.0001); biceps resistance training, 18 lbs. × reps (n = 286; p < 0.0001); and quadriceps resistance training, 15 lbs. × reps (n = 278; p < 0.0001). HRQL measures declined. A greater final 6MWD prior to transplant correlated with a shorter length of stay in the hospital (n = 207; p = 0.003). CONCLUSIONS: Exercise capacity and training volumes are well preserved among lung transplant candidates participating in pulmonary rehabilitation, even in the setting of severe, progressive lung disease. Participants with greater exercise capacity prior to transplantation have more favorable early post-transplant outcomes.

Physical activity profile of lung transplant candidates with interstitial lung disease.

PURPOSE: Little is known about physical activity in individuals with interstitial lung disease (ILD). The objectives of this study were (1) to objectively measure physical activity in lung transplant candidates with ILD, (2) to compare levels of physical activity on rehabilitation and nonrehabilitation days, and (3) to explore the relationships between physical activity and functional measures. METHODS: Twenty-four (14 men) lung transplant candidates with ILD on long-term oxygen therapy, who were enrolled in an exercise-based rehabilitation program, underwent measurements of physical activity using accelerometry (daily steps and time spent in moderate-intensity physical activity per day), functional exercise capacity (6-minute walk distance), and muscle strength (isometric quadriceps torque). RESULTS: Lung transplant candidates with ILD had reduced levels of physical activity compared to the general population but were more active on rehabilitation versus nonrehabilitation days (M ± SD) (daily steps, 3780 ± 2196 vs 2138 ± 1353; P < .001; and time spent in moderate-intensity activity per day, 4.5 [interquartile range, 1.5-17] minutes vs 2 [interquartile range, 1-3.5] minutes). The 6-minute walk distance showed the strongest correlation to daily steps (r = 0.59, P < .01) and time spent in moderate-intensity physical activity per day (r = 0.56, P < .01). CONCLUSIONS: Individuals with advanced ILD are markedly inactive; however, physical activity levels were significantly higher on rehabilitation days. The importance of physical activity as a rehabilitation outcome in ILD warrants further investigation.

Mentors matter: relationships that increase the number of oral health professionals serving the underserved.

Access to oral healthcare is a persistent problem in the United States. One barrier to this multifaceted issue is the shortage of oral healthcare providers who are willing to provide care for underserved populations. Mentoring relationships with oral health professionals is one solution that will increase the number of public oral health professionals. Using narrative inquiry, this interpretive study explored the relationships that public health dental hygienists had with mentors who leveraged their capital to empower those they mentored. The stories of six dental hygienists practicing in public health and four of their mentors were gathered through one or two 60- to 90-minute interviews. Qualitative data analysis was used to untangle and make meaning of their narrations. The findings are reported in the words of dental hygienists and their mentors, wherever possible, to embrace the voice of the participants. The Iroquois legend of The Three Sisters is used as a metaphor to illustrate the mentoring relationship. These mentor relationships, in which there was mutual growth, were built on a symbiotic, natural bond. The dental hygienists recalled relationships with multiple mentors who leveraged their social and political capital to empower and thereby encouraged a career path in public health.

A model minority faculty fellowship program: enhancing minority faculty in health professions and reducing inequity in health services.

Northern Arizona University (NAU), College of Health and Human Services model Minority Faculty Fellowship Program (MFFP) supports a minority faculty member and strengthens the College without adding to the workload or placing additional strain on an already limited budget. In 2003, the College was awarded a MFFP through the U.S. Department of Health, Health Resources and Services Administration. The College received a second Fellowship in 2008, the only one funded in the country. This three-year Fellowship is aimed at providing minority individuals with the training and skills necessary to flourish in a tenure-track position. There is a shortage of minority faculty in the health professions. Northern Arizona University and the surrounding communities have diverse populations nonetheless, only a very small percentage of faculty at the University are from diverse backgrounds. Success of the NAU, MFFP is largely due to our ability to draw upon existing structures including the University mission and institutional commitment to serving Native Americans, as well as the promotion and tenure process, faculty support programs, and a long-term relationship with the John and Sophie Ottens Foundation. The progress of the current NAU fellowship can also be attributed to the first Fellow's engagement with her contemporary.

Standardized test scores as acceptance criteria for dental hygiene programs.

The principal goal of acceptance criteria is to select candi-dates who will graduate and transition into professional practice. However, in an attempt to increase the diversity of their student populations, educators are anxious to make changes to the traditional acceptance criteria, such as standardized test scores. Yet data indicate that standardized testing biases against certain populations of students (i.e., female, culturally diverse, and those from lower socioeconomic backgrounds). Fairer assessment measures should continue to be sought.

Increasing dental hygiene student diversity: life-performance questions as alternative admissions criteria.

The goal of this study was to create a race/ethnic-neutral admission process. An increase in student diversity in the Northern Arizona University Dental Hygiene Program (NAU DH) was accomplished through modification of its acceptance process. Sixty students, 22% underrepresented minority (URM), were selected using alternative criteria compared with 6.7% URM that would have been accepted using traditional criteria. For the purpose of this study, URM are defined as African American, Hispanic, Native American, or bicultural, groups that are underrepresented in dental hygiene. Six life-performance questions were added on the written application and were designed to assess the candidates' personal characteristics, including (1) leadership, (2) community service, (3) realistic self-appraisal, (4) personal support system, (5) ability to deal with racism, (6) ability to set goals and self-responsibility. Scores from the response to these questions were used as part of the total selection criteria. Data analysis revealed that white candidates scored higher than URM candidates on grade point average (GPA), science GPA, and total points, yet both groups scored the same on life-performance questions. On the basis of these findings, we conclude that alternative criteria in the acceptance process more fairly assesses candidates' qualifications and increases the diversity of the NAU DH student population. These alternative acceptance criteria may serve as a model for dental hygiene and other allied health programs.