Buprenorphine After Nonfatal Opioid Overdose: Reduced Mortality Risk in Medicare Disability Beneficiaries.

INTRODUCTION: Opioid-involved overdose mortality is a persistent public health challenge, yet limited evidence exists on the relationship between opioid use disorder treatment after a nonfatal overdose and subsequent overdose death. METHODS: National Medicare data were used to identify adult (aged 18-64 years) disability beneficiaries who received inpatient or emergency treatment for nonfatal opioid-involved overdose in 2008-2016. Opioid use disorder treatment was defined as (1) buprenorphine, measured using medication days' supply, and (2) psychosocial services, measured as 30-day exposures from and including each service date. Opioid-involved overdose fatalities were identified in the year after nonfatal overdose using linked National Death Index data. Cox proportional hazards models estimated the associations between time-varying treatment exposures and overdose death. Analyses were conducted in 2022. RESULTS: The sample (N=81,616) was mostly female (57.3%), aged ≥50 years (58.8%), and White (80.9%), with a significantly elevated overdose mortality rate, compared with the general U.S. population (standardized mortality ratio=132.4, 95% CI=129.9, 135.0). Only 6.5% of the sample (n=5,329) had opioid use disorder treatment after the index overdose. Buprenorphine (n=3,774, 4.6%) was associated with a significantly lower risk of opioid-involved overdose death (adjusted hazard ratio=0.38, 95% CI=0.23, 0.64), but opioid use disorder-related psychosocial treatment (n=2,405, 2.9%) was not associated with risk of death (adjusted hazard ratio=1.18, 95% CI=0.71, 1.95). CONCLUSIONS: Buprenorphine treatment after nonfatal opioid-involved overdose was associated with a 62% reduction in the risk of opioid-involved overdose death. However, fewer than 1 in 20 individuals received buprenorphine in the subsequent year, highlighting a need to strengthen care connections after critical opioid-related events, particularly for vulnerable groups.

Stepped-wedge randomized controlled trial of a novel opioid court to improve identification of need and linkage to medications for opioid use disorder treatment for court-involved adults.

In response to the opioid crisis in New York State (NYS), the Unified Court System developed a new treatment court model-the opioid intervention court-designed around 10 Essential Elements of practice to address the flaws of existing drug courts in handling those with opioid addiction via broader inclusion criteria, rapid screening, and linkage to medications to treat opioid use disorder (MOUD). The new court model is now being rolled out statewide yet, given the innovation of the opioid court, the exact barriers to implementation in different counties with a range of resources are largely unknown. We describe a study protocol for the development and efficacy-test of a new implementation intervention (Opioid Court REACH; Research on Evidence-Based Approaches to Court Health) that will allow the opioid court, as framed by the 10 Essential Elements, to be scaled-up across 10 counties in NYS. Using a cluster-randomized stepped-wedge type-2 hybrid effectiveness-implementation design, we will test: (a) the implementation impact of Opioid Court REACH in improving implementation outcomes along the opioid cascade of care (screening, referral, treatment enrollment, MOUD initiation), and (b) the clinical and cost effectiveness of Opioid Court REACH in improving public health (treatment retention/court graduation) and public safety (recidivism) outcomes. Opioid Court REACH has the potential to improve management of individuals with opioid addiction in the court system via widespread scale-up of the opioid court model across the U.S., should this study find it to be effective.

Budget Impact Analysis of Veterans Affairs Medical Foster Homes versus Community Living Centers.

The objectives were to determine whether and by what amounts the US Department of Veterans Affairs (VA) use of Medical Foster Homes (MFH) rather than Community Living Centers (CLC) reduced budget impacts to the VA. This was a retrospective, matched, case-control study of veterans residing in MFH or CLC in the VA health care system from 2008 to 2012. Administrative data sets, nearest neighbor matching, generalized linear models, and a secondary analysis were used to capture and analyze budget impacts by veterans who used MFH or CLC exclusively in 2008-2012. Controls of 1483 veterans in CLC were matched to 203 cases of veterans in MFH. Use of MFH instead of CLC reduced budget impacts to the VA by at least $2645 per veteran per month. A secondary analysis of the data using different matching criteria and statistical methods produced similar results, demonstrating the robustness of the estimates of budget impact. When the average out-of-pocket payments made by MFH residents, not made by CLC residents, were included in the analysis, the net reduction of budget impact ranged from $145 to $2814 per veteran per month or a savings of $1740 to $33,768 per veteran per year. Even though outpatient costs of MFH are higher, much of the reduced budget impact of MFH use arises from lower inpatient or hospital costs. Reduced budget impacts on the VA system indicate that expansion of the MFH program may be cost-effective. Implications for further research are suggested.

Factors associated with lumbar fusion surgery: a case-control study.

PURPOSE: The objective of this study is to identify the demographic and payer factors that are associated with lumbar fusion surgery. METHODS: A case-control study was conducted utilizing a population of 38,092 patients from the 2010 Florida Agency for Health Care Administration (AHCA), USA hospital discharge data. The case population included 16,236 records with any of five ICD-9-CM principal procedure codes for initial lumbar fusion. The control group was comprised of 21,856 patients who were admitted for the same principal diagnoses as the cases, but who did not have initial fusion surgery. Logistic regression was used to analyze the association of age, gender, race and principal payer type with initial lumbar fusions. The interaction between age and payer was also examined, as payer type may moderate the association between age and lumbar fusion surgery. RESULTS: Gender, race, principal payer and age were all found to be significantly associated with lumbar fusion surgery. The interaction of payer and age was also found to be significant. Being female was significantly associated with having a fusion (OR = 1.11, 95 % CI 1.07-1.16). The association between age and receiving surgery was greatest for the less than 20 age group (OR = 10.43, 95 % CI 8.74-12.45). Employees and dependents of Federal government agencies (Tricare, etc.) and patients with commercial insurance were significantly associated with surgery (OR = 1.48, 95 % CI 1.29-1.70 and OR = 1.12, 95 % CI 1.04-1.20, respectively). Patients insured through Medicaid (a social health care program for those with low incomes and limited resources), and the uninsured were negatively associated with surgery (OR = 0.53, 95 % CI 0.47-0.60 and OR = 0.52, 95 % CI 0.46-0.58, respectively). CONCLUSIONS: Lumbar fusion surgery is not recommended in clinical practice guidelines for the top four principal diagnoses in this study. Yet, patients covered by certain types of insurance were found to be significantly associated with fusion surgery.

The symptom experiences of Puerto Rican children undergoing cancer treatments and alleviation practices as reported by their mothers.

Although symptoms during cancer treatments are prevalent and are important clinical outcomes of childhood cancer, the symptom experiences of Puerto Rican children along with the symptom alleviation/care practices that parents provide during cancer treatments have received limited attention. To examine the occurrence/severity of symptoms on the Therapy-Related Symptom Checklist-Children (TRSC-C), reported by mothers of Puerto Rican children undergoing cancer treatments and identifying mothers' symptom alleviation/management strategies. Descriptive study conducted between January and May 2012. Mothers of 65 Puerto Rican children/adolescents undergoing cancer treatments responded to the Spanish versions of the TRSC-C, Symptom Alleviation: Self-Care Methods, and a Demographic and Health form. The children/adolescents' mean age was 9.2 (1-17) years; 62% were boys; 56 had chemotherapy; 9 had chemoradiotherapy. Children diagnoses were 35.4% leukemia, 24.6% solid tumors, 24.6% nervous system tumors, and 15.4% other. On the TRSC-C, the symptoms experienced by 70% or more of the children were: irritability (77%), nausea (75%), and hair loss (72%). On the Symptom Alleviation: Self-Care Methods, the most commonly reported symptom alleviation category was "taking prescribed medicines." Puerto Rican mothers reported the use of alleviation practices to treat their children experiencing symptoms during pediatric cancer treatments. Patients and caregivers need to be educated about treatment-induced side effects, and the life-threatening consequences of underreporting and undermanagement. Symptoms should always be addressed at the time of initiation of primary or adjuvant cancer therapy because pretreatment symptoms may persist or get worse across the trajectory of treatment. A continuous assessment and management of symptoms during the childhood cancer trajectory can optimize clinical care and improve quality of life of patients and families.

Improving Prognostic Web Calculators: Violation of Preferential Risk Independence.

BACKGROUND: Web-based applications are available for prognostication of individual patients. These prognostic models were developed for groups of patients. No one is the average patient, and using these calculators to inform individual patients could provide misleading results. OBJECTIVE: This article gives an example of paradoxical results that may emerge when indices used for prognosis of the average person are used for care of an individual patient. METHODS: We calculated the expected mortality risks of stomach cancer and its associated comorbidities. Mortality risks were calculated using data from 140,699 Veterans Administration nursing home residents. RESULTS: On average, a patient with hypertension has a higher risk of mortality than one without hypertension. Surprisingly, among patients with lung cancer, hypertension is protective and reduces risk of mortality. This paradoxical result is explained by how group-level, average prognosis could mislead individual patients. In particular, average prognosis of lung cancer patients reflects the impact of various comorbidities that co-occur in lung cancer patients. The presence of hypertension, a relatively mild comorbidity of lung cancer, indicates that more serious comorbidities have not occurred. It is not that hypertension is protective; it is the absence of more serious comorbidities that is protective. The article shows how the presence of these anomalies can be checked through the mathematical concept of preferential risk independence. CONCLUSION: Instead of reporting average risk scores, web-based calculators may improve accuracy of predictions by reporting the unconfounded risks.

Assessing health disparities in children using a modified housing-related socioeconomic status measure: a cross-sectional study.

OBJECTIVES: Socioeconomic status (SES) is a well-established risk factor for many health outcomes. Recently, we developed an SES measure based on 4 housing-related characteristics (termed HOUSES) and demonstrated its ability to assess health disparities. In this study, we aimed to evaluate whether fewer housing-related characteristics could be used to provide a similar representation of SES. STUDY SETTING AND PARTICIPANTS: We performed a cross-sectional study using parents/guardians of children aged 1-17 years from 2 US Midwestern counties (n=728 in Olmsted County, Minnesota, and n=701 in Jackson County, Missouri). PRIMARY AND SECONDARY OUTCOME MEASURES: For each participant, housing-related characteristics used in the formulation of HOUSES (assessed housing value, square footage, number of bedrooms and number of bathrooms) were obtained from the local government assessor's offices, and additional SES measures and health outcomes with known associations to SES (obesity, low birth weight and smoking exposure) were collected from a telephone survey. Housing characteristics with the greatest contribution for predicting the health outcomes were added to formulate a modified HOUSES index. RESULTS: Among the 4 housing characteristics used in the original HOUSES, the strongest contributions for predicting health outcomes were observed from assessed housing value and square footage (combined contribution ranged between 89% and 96%). Based on this observation, these 2 were used to calculate a modified HOUSES index. Correlation between modified HOUSES and other SES measures was comparable to the original HOUSES for both locations. Consistent with the original HOUSES formula, the strongest association with modified HOUSES was observed with smoking exposure (OR=0.24 with 95% CI 0.11 to 0.49 for comparing participants in highest HOUSES vs lowest group; overall p<0.001). CONCLUSIONS: The modified HOUSES requires only 2 readily available housing characteristics thereby improving the feasibility of using this index as a proxy for SES in multiple communities, especially in the US Midwestern region.

Sequence of Functional Loss and Recovery in Nursing Homes.

PURPOSE OF THE STUDY: This study provides benchmarks for likelihood, number of days until, and sequence of functional decline and recovery. DESIGN AND METHODS: We analyzed activities of daily living (ADLs) of 296,051 residents in Veteran Affairs nursing homes between January 1, 2000 and October 9, 2012. ADLs were extracted from standard minimum data set assessments. Because of significant overlap between short- and long-stay residents, we did not distinguish between these populations. Twenty-five combinations of ADL deficits described the experience of 84.3% of all residents. A network model described transitions among these 25 combinations. The network was used to calculate the shortest, longest, and maximum likelihood paths using backward induction methodology. Longitudinal data were used to derive a Bayesian network that preserved the sequence of occurrence of 9 ADL deficits. RESULTS: The majority of residents (57%) followed 4 pathways in loss of function. The most likely sequence, in order of occurrence, was bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. The other three paths occurred with reversals in the order of dressing/toileting and bowel/urinary continence. ADL impairments persisted without any change for an average of 164 days (SD = 62). Residents recovered partially or completely from a single impairment in 57% of cases over an average of 119 days (SD = 41). Recovery rates declined as residents developed more than 4 impairments. IMPLICATIONS: Recovery of deficits among those studied followed a relatively predictable path, and although more than half recovered from a single functional deficit, recovery exceeded 100 days suggesting time to recover often occurs over many months.

Shared Homes as an Alternative to Nursing Home Care: Impact of VA's Medical Foster Home Program on Hospitalization.

PURPOSE OF THE STUDY: This study compares hospitalization rates for common conditions in the Veteran Affairs (VA) Medical Foster Home (MFH) program to VA nursing homes, known as Community Living Centers (CLCs). DESIGN AND METHODS: We used a nested, matched, case control design. We examined 817 MFH residents and matched each to 3 CLC residents selected from a pool of 325,031. CLC and MFH cases were matched on (a) baseline time period, (b) follow-up time period, (c) age, (d) gender, (e) race, (f) risk of mortality calculated from comorbidities, and (g) history of hospitalization for the selected condition during the baseline period. Odds ratio (OR) and related confidence interval (CI) were calculated to contrast MFH cases and matched CLC controls. RESULTS: Compared with matched CLC cases, MFH residents were less likely to be hospitalized for adverse care events, (OR = 0.13, 95% CI = 0.03-0.53), anxiety disorders (OR = 0.52, 95% CI = 0.33-0.80), mood disorders (OR = 0.57, 95% CI = 0.42-0.79), skin infections (OR = 0.22, 95% CI = 0.10-0.51), pressure ulcers (OR = 0.22, 95% CI = 0.09-0.50) and bacterial infections other than tuberculosis or septicemia (OR = 0.54, 95% CI = 0.31-0.92). MFH cases and matched CLC controls did not differ in rates of urinary tract infections, pneumonia, septicemia, suicide/self-injury, falls, other injury besides falls, history of injury, delirium/dementia/cognitive impairments, or adverse drug events. Hospitalization rates were not higher for any conditions studied in the MFH cohort compared with the CLC cohort. IMPLICATIONS: MFH participants had the same or lower rates of hospitalizations for conditions examined compared with CLC controls suggesting that noninstitutional care by a nonfamilial caregiver does not increase hospitalization rates for common medical conditions.

Concordance between Individual vs. Area-Level Socioeconomic Measures in an Urban Setting.

Area-level socioeconomic status (SES) measures have been used as a proxy in child health research when individual SES measures are lacking, yet little is known about their validity in an urban setting. We assessed agreement between census block-group and individual-level SES measures obtained from a caregiver telephone survey in Jackson County, Missouri. Associations with prevalence of childhood overweight (OW), low birth weight (LBW), and household smoking exposure were examined using logistic regression models. Seven hundred eighty-one households were surveyed: 49% male, 76% White, mean child age 9.4 years. We found misclassification rates of 20-35% between individual vs. area-level measures of education and income; Kappa indices ranged from 0.26-0.36 indicating poor agreement. Both SES measures showed an inverse association with LBW and smoking exposure. Area-level SES measures may reflect a construct inclusive of neighborhood resources; routine substitution of these measures should be interpreted with caution, despite similar correlations with health outcomes.

The development and application of an oncology Therapy-Related Symptom Checklist for Adults (TRSC) and Children (TRSC-C) and e-health applications.

BACKGROUND: Studies found that treatment symptoms of concern to oncology/hematology patients were greatly under-identified in medical records. On average, 11.0 symptoms were reported of concern to patients compared to 1.5 symptoms identified in their medical records. A solution to this problem is use of an electronic symptom checklist that can be easily accessed by patients prior to clinical consultations. PURPOSE: Describe the oncology Therapy-Related Symptom Checklists for Adults (TRSC) and Children (TRSC-C), which are validated bases for e-Health symptom documentation and management. The TRSC has 25 items/symptoms; the TRSC-C has 30 items/symptoms. These items capture up to 80% of the variance of patient symptoms. Measurement properties and applications with outpatients are presented. E-Health applications are indicated. METHODS: The TRSC was developed for adults (N = 282) then modified for children (N = 385). Statistical analyses have been done using correlational, epidemiologic, and qualitative methods. Extensive validation of measurement properties has been reported. RESULTS: Research has found high levels of patient/clinician satisfaction, no increase in clinic costs, and strong correlations of TRSC/TRSC-C with medical outcomes. A recently published sequential cohort trial with adult outpatients at a Mayo Clinic community cancer center found TRSC use produced a 7.2% higher patient quality of life, 116% more symptoms identified/managed, and higher functional status. DISCUSSION, IMPLICATIONS, AND FOLLOW-UP: An electronic system has been built to collect TRSC symptoms, reassure patients, and enhance patient-clinician communications. This report discusses system design and efforts made to provide an electronic system comfortable to patients. Methods used by clinicians to promote comfort and patient engagement were examined and incorporated into system design. These methods included (a) conversational data collection as opposed to survey style or standardized questionnaires, (b) short response phrases indicating understanding of the reported symptom, (c) use of open-ended questions to reduce long lists of symptoms, (d) directed questions that ask for confirmation of expected symptoms, (e) review of symptoms at designated stages, and (d) alerting patients when the computer has informed clinicians about patient-reported symptoms. CONCLUSIONS: An e-Health symptom checklist (TRSC/TRSC-C) can facilitate identification, monitoring, and management of symptoms; enhance patient-clinician communications; and contribute to improved patient outcomes.

Self-reported assessment of symptoms and self-care within a cohort of U.S. veterans during outpatient care for cancer.

BACKGROUND: This study was undertaken as part of a feasibility study of the use of a symptom checklist and self-care assessment of veterans receiving oncology outpatient treatment within the U.S. Department of Veterans Affairs system. OBJECTIVES: The study aimed to examine (a) symptom occurrence and severity as self-reported on the Therapy-Related Symptom Checklist (TRSC) by veterans at a cancer clinic, (b) symptom alleviation strategies and use of self-care, and (c) the relationship between symptom occurrence and severity and functional status and quality of life. METHODS: Veterans (N = 100) undergoing chemotherapy and/or radiation therapy participated in a cross-sectional study. Tools used, including TRSC, Symptom Alleviation. FINDINGS: Thirteen symptoms were reported by more than 35% of patients. Top-ranked symptoms by percentage occurrence and severity were feeling sluggish, taste changes, nausea, pain, constipation, loss of appetite, numbness of fingers and toes, difficulty sleeping, weight loss, hair loss, difficulty concentrating, shortness of breath, and decreased interest in sexual activity. Occurrence and severity of symptoms had significant negative correlations with functional status and with overall quality of life. Self-care (symptom alleviation) strategies that helped were medicines, diet and nutrition, and lifestyle change. Checklist use (TRSC) facilitated patient-report of symptoms during cancer treatments; self-care strategies helped relieve symptoms.

The talking card: Randomized controlled trial of a novel audio-recording tool for asthma control.

BACKGROUND: Asthma care plans typically include complicated written instructions. Customized, audio-recorded instructions may bridge health literacy gaps and improve treatment plan understanding. OBJECTIVE: To measure the effects of a recordable greeting card-style tool (Talking Card) on asthma control and parental care of children with asthma. METHODS: Multisite randomized trial in two primary care clinics, including children 4-11 years old with uncontrolled asthma and their parents. Parent-child dyads were randomized to usual care of asthma or usual care plus the Talking Card. Dyads completed three asthma-focused visits over 3 months. At the visit, card recipients received customized instructions recorded by the pediatrician onto an audio chip in the card. Asthma control was measured by using the Childhood Asthma Control Test. Card use and parental satisfaction were measured by parental survey (card arm only). Outcomes were analyzed by using generalized estimating equations and frequency distributions. RESULTS: Sixty-four dyads participated and attended 166 clinic visits. Card use was associated with a 1.6-point increase in Childhood Asthma Control Test score (p = 0.02) and a clinic visit regardless of card use with a three-point increase (p < 0.001). Satisfaction and self-efficacy were high among the card users. The mean satisfaction score was 8.9 of 10, with 96% agreeing or strongly agreeing that the card helped them take better care of asthma. CONCLUSIONS: The Talking Card, a novel audio communication tool, was associated with improved asthma control and deemed highly desirable by parents and children struggling to control asthma. This inexpensive portable tool may be useful in other chronic disorders and in locales with low literacy and poor access to digital technology.

Monitoring and Alleviation of Symptom Occurrence and Severity Among Thai Children and Adolescents During Cancer Treatments.

BACKGROUND: Symptom monitoring and alleviation are important during pediatric cancer treatments. AIMS: To examine the use of the Therapy-Related Symptom Checklist for Children (TRSC-C; Thai version) for reported occurrence, severity, and management of treatment-related symptoms within a cohort of Thai pediatric oncology patients/parents METHOD: Cross-sectional study; convenience sample: 100 parents of 71 male children/29 females, 63% with leukemia, 37%, other diagnoses; age-groups: <5 years, n = 33; 5 to 11 years, n = 44; 12 to 17 years, n = 25. Parents reported children's symptom occurrence/severity on the TRSC-C; and complementary care methods on the Symptom Alleviation: Self-Care Methods and their symptom alleviation methods. All tools had good psychometric properties. RESULTS: 18 symptoms on the 30-item TRSC-C occurred in 42% to 95% of children. Mean severity of symptoms was between 1.0 ("a bit") and 2.0 ("quite a bit"); 5-month to 11-year-old children had higher (worse) TRSC-C total scores. Complementary care was used and reported. CONCLUSIONS: Monitoring of multiple symptoms with the TRSC-C and parental symptom alleviation helped children. CLINICAL IMPLICATIONS: Thai parents/patients need and accept assistance in monitoring/managing side effects of pediatric cancer therapy.

Predictors of six-month mortality among nursing home residents: diagnoses may be more predictive than functional disability.

OBJECTIVE: Loss of daily living functions can be a marker for end of life and possible hospice eligibility. Unfortunately, data on patient's functional abilities is not available in all settings. In this study we compare predictive accuracy of two indices designed to predict 6-month mortality among nursing home residents. One is based on traditional measures of functional deterioration and the other on patients' diagnoses and demography. METHODS: We created the Hospice ELigibility Prediction (HELP) Index by examining mortality of 140,699 Veterans Administration (VA) nursing home residents. For these nursing home residents, the available data on history of hospital admissions were divided into training (112,897 cases) and validation (27,832 cases) sets. The training data were used to estimate the parameters of the HELP Index based on (1) diagnoses, (2) age on admission, and (3) number of diagnoses at admission. The validation data were used to assess the accuracy of predictions of the HELP Index. The cross-validated accuracy of the HELP Index was compared with the Barthel Index (BI) of functional ability obtained from 296,052 VA nursing home residents. A receiver operating characteristic curve was used to examine sensitivity and specificity of the predicted odds of mortality. RESULTS: The area under the curve (AUC) for the HELP Index was 0.838. This was significantly (α <0.01) higher than the AUC for the BI of 0.692. CONCLUSIONS: For nursing home residents, comorbid diagnoses predict 6-month mortality more accurately than functional status. The HELP Index can be used to estimate 6-month mortality from hospital data and can guide prognostic discussions prior to and following nursing home admission.

Predictors of the charges for lumbar fusion surgery in Florida hospitals.

STUDY DESIGN: A mixed-effects model was used to evaluate the effects specific surgical procedure by International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code, patient age, sex, ethnic group, payers for the inpatient hospital stay, and number of additional diagnoses beyond the principal diagnosis that led to the procedure (as a proxy for severity of illness) on the charges for lumbar fusion surgery. OBJECTIVE: The present research examined the charges and the predictors of the charges for lumbar fusion surgery in Florida hospitals in 2010. SUMMARY OF BACKGROUND DATA: The number of spinal fusion surgical procedures in the United States has grown exponentially in recent years despite the procedure's high costs and questionable efficacy for many of the principal diagnoses associated with it. METHODS: All records with any of the 5 International Classification of Diseases, Ninth Revision, Clinical Modification, principal procedure codes for lumbar fusion were extracted (cases) from the Florida Agency for Health Care Administration (AHCA) hospital discharge data for the year 2010. A control group was obtained by taking all patients who had the same principal diagnoses as the cases, but who did not have fusion surgery. This produced 16,236 cases and 21,856 controls. RESULTS: The total hospital charges for lumbar fusion surgery in Florida in 2010 were $2,095,413,584. Despite having the same principal diagnoses and a similar number of additional diagnoses, patients who underwent a fusion surgery had 3 times the charges as those incurred by the controls. The number of additional diagnoses, sex, age, payer, and principal procedure, were all found to be statistically significant predictors of charges. Ethnicity was not significant. Of all the predictors, the number of additional diagnoses was the most significant in the model (F=2577, P<0.0001). CONCLUSION: The high incidence and charges for fusion surgical procedures shown in this study emphasize the need for a better understanding of when these surgical procedures are justified and for which patients. LEVEL OF EVIDENCE: N/A.

Application of a novel socioeconomic measure using individual housing data in asthma research: an exploratory study.

BACKGROUND: A housing-based socioeconomic index (HOUSES) was previously developed to overcome an absence of socioeconomic status (SES) measures in common databases. HOUSES is associated with child health outcomes in Olmsted County, Minnesota, USA, but generalisability to other geographic areas is unclear. AIM: To assess whether HOUSES is associated with asthma outcomes outside Olmsted County, Minnesota, USA. METHODS: Using a random sample of children with asthma from Sanford Children's Hospital, Sioux Falls, SD, USA, asthma status was determined. The primary outcome was asthma control status using Asthma Control Test and a secondary outcome was risk of persistent asthma. Home address information and property data were merged to formulate HOUSES. Other SES measures were examined: income, parental education (PE), Hollingshead and Nakao-Treas index. RESULTS: Of a random sample of 200 children, 80 (40%) participated in the study. Of those, 13% had poorly controlled asthma. Addresses of 94% were matched with property data. HOUSES had moderate-good correlation with other SES measures except PE. Poor asthma control rates were 31.6%, 4.8% and 5.6% for patients in the lowest, intermediate and highest tertiles of HOUSES, respectively (P=0.023). HOUSES as a continuous variable was inversely associated with poorly controlled asthma (adjusted odds ratio (OR)=0.21 per 1 unit increase of HOUSES, 95% confidence interval (CI), 0.05-0.89, P=0.035). HOUSES as a continuous variable was inversely related to risk of persistent asthma (OR: 0.36 per 1 unit increase of HOUSES, 95% CI, 0.12-1.04, P=0.06). CONCLUSIONS: HOUSES appears to be generalisable and available as a measure of SES in asthma research in the absence of conventional SES measures.

Psychiatric comorbidity, red flag behaviors, and associated outcomes among office-based buprenorphine patients following Hurricane Sandy.

In October 2012, Bellevue Hospital Center (Bellevue) in New York City was temporarily closed as a result of Hurricane Sandy, the largest hurricane in US history. Bellevue's primary care office-based buprenorphine program was temporarily closed and later relocated to an affiliate public hospital. Previous research indicates that the relationships between disaster exposure, substance use patterns, psychiatric symptoms, and mental health services utilization is complex, with often conflicting findings regarding post-event outcomes (on the individual and community level) and antecedent risk factors. In general, increased use of tobacco, alcohol, and illicit drugs is associated with both greater disaster exposure and the development or exacerbation of other psychiatric symptoms and need for treatment. To date, there is limited published information regarding post-disaster outcomes among patients enrolled in office-based buprenorphine treatment, as the treatment modality has only been relatively approved recently. Patients enrolled in the buprenorphine program at the time of the storm were surveyed for self-reported buprenorphine adherence and illicit substance and alcohol use, as well as disaster-related personal consequences and psychiatric sequelae post-storm. Baseline demographic characteristics and insurance status were available from the medical record. Analysis was descriptive (counts and proportions) and qualitative, coding open-ended responses for emergent themes. There were 132 patients enrolled in the program at the time of the storm; of those, 91 were contacted and 89 completed the survey. Almost half of respondents reported disruption of their buprenorphine supply. Unexpectedly, patients with psychiatric comorbidity were no more likely to report increased use/relapse as a result. Rather, major risk factors associated with increased use or relapse post-storm were: (1) shorter length of time in treatment, (2) exposure to storm losses such as buprenorphine supply disruption, (3) a pre-storm history of red flag behaviors (in particular, repeat opioid-positive urines), and (4) new-onset post-storm psychiatric symptoms. Our findings highlight the relative resilience of buprenorphine as an office-based treatment modality for patients encountering a disaster with associated unanticipated service disruption. In responding to future disasters, triaging patient contact and priority based on a history of red-flag behaviors, rather than a history of psychiatric comorbidity, will likely optimize resource allocation, especially among recently enrolled patients. Additionally, patients endorsing new-onset psychiatric manifestations following disasters may be an especially high-risk group for poor outcomes, warranting further study.