We Know Health Is Not Elective: Impacts of COVID-19.

Several months into the impact of the global COVID-19 pandemic, the authors use the framework of "radical uncertainty" and specific regional health care data to understand current and future health and economic impacts. Four key areas of discussion included are: (1) How did structural health care inequality manifest itself during the closure of all elective surgeries and visits?; (2) How can we really calculate the so-called untold burden that resulted from the closure, with a special emphasis on primary care?; (3) The Pennsylvania experience - using observations from the population of one major delivery ecosystem (Jefferson Health), a major accountable care organization (Delaware Valley ACO), and statewide data from Pennsylvania; and (4) What should be the priorities and focus of the delivery system of the future given the dramatic financial and clinical disruption of COVID-19?

Linking Survey and Administrative Data to Measure Income, Inequality, and Mobility.

BACKGROUND: Income is one of the most important measures of well-being, but it is notoriously difficult to measure accurately. In the United States, income data are available from surveys, tax records, and government programs, but each of these sources has important strengths and major limitations when used alone. OBJECTIVES: We link multiple data sources to develop the Comprehensive Income Dataset (CID), a prototype for a restricted micro-level dataset that combines the demographic detail of survey data with the accuracy of administrative measures. METHODS: By incorporating information on nearly all taxable income, tax credits, and cash and in-kind government transfers, the CID surpasses previous efforts to provide an accurate and comprehensive measure of income for the population of United States individuals, families, and households. We also evaluate the accuracy of different income sources and imputation methods. CONCLUSIONS: While still in development, we envision the CID enhancing Census Bureau surveys and statistics by investigating measurement error, improving imputation methods, and augmenting surveys with the best possible estimates of income. It can also be used for policy related research, such as forecasting and simulating changes in programs and taxes. Finally, the CID has substantial advantages over other sources to analyze numerous research topics, including poverty, inequality, mobility, and the distributional consequences of government transfers and taxes.

Childhood Medicaid Coverage and Later-Life Health Care Utilization.

Exploiting a discontinuity in childhood Medicaid eligibility based on date of birth, we find that more years of childhood eligibility are associated with fewer hospitalizations in adulthood. For blacks, we find a 7-15% decrease in hospitalizations and a suggestive 2-5% decrease in emergency department visits, but no similar effect for non-blacks. The effects are pronounced for utilization related to chronic illnesses and for patients living in low-income zip codes. Calculations suggest that lower rates of hospitalizations during one year in adulthood for blacks offset between 2 and 4 percent of the initial costs of expanding Medicaid for all children.

Viewing Prevention of Catheter-Associated Urinary Tract Infection as a System: Using Systems Engineering and Human Factors Engineering in a Quality Improvement Project in an Academic Medical Center.

BACKGROUND: Urinary tract infections (UTIs) are the most commonly reported health care-associated infection (HAI) in the United States. Among UTIs acquired in the hospital, approximately 75% are associated with urinary catheters, with an estimated 15%-25% of all hospitalized patients receiving urinary catheters during their hospitalization. Despite ambitious national goals to reduce these infections, catheter-associated urinary tract infection (CAUTI) has not decreased in the United States. METHODS: Systems engineering (SE) and human factors engi- neering (HFE) methods were used to reduce urinary catheter utilization and CAUTIs in a three-year (June 1, 2012-May 31, 2015) quality improvement project in a 610-bed academic medical center. These methods were used to define the factors leading to CAUTI and promote standardization of urinary catheter utilization, insertion, and maintenance. RESULTS: The total systemwide CAUTI count decreased from 135 cases at baseline to 74 cases at the end of the project's Year 1, to 59 cases at the end of Year 2, and 25 cases at the end of Year 3-alone, an 81.5% reduction from baseline. The control chart showed a steady decline in the CAUTI count within a few months after the project's start. By the end of Year 3, on the basis of an average attributable-per-patient cost of CAUTI ($1,007 per case), the estimated annual avoidable CAUTI costs decreased from approximately $135,945 to $25,175 per year. Urinary catheter utilization decreased by 27.3% during the same three-year period, and the systemwide CAUTI standardized infection ratio (SIR) decreased from 3.2 to 0.51 (84.1% from baseline). CONCLUSION: SE and HFE methods and principles can effectively decrease urinary catheter utilization and CAUTI incidence in an academic medical center hospital environment.

What the VA can teach us about geriatric care.

The innovation now being demanded by Medicare is creating new opportunities for health care organizations to redesign how they deliver care for elderly people. For many years, the VA Health System has experimented with ways to deliver care more effectively and efficiently. Hospital-based postacute and palliative care and home-based primary care are two examples of successful approaches that non-VA providers should be looking at as they move away from fee-for-service reimbursement and invent new care-delivery models.

ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001.

Soluble endoglin for the prediction of preeclampsia in a high risk cohort.

OBJECTIVES: To evaluate soluble endoglin (sEng) and the soluble fms-like tyrosine kinase 1 (sFlt1) to placental growth factor (PlGF) ratio for the prediction of preeclampsia in high-risk women, and to evaluate differences in sEng between women with high-risk singleton and multiple gestation pregnancies. STUDY DESIGN: We collected serial serum specimens from 119 women at high preeclampsia risk. sEng, sFlt1 and PlGF were measured by ELISA. RESULTS: Among subjects who did not develop preeclampsia, mean serum sEng was significantly higher in those with multiple gestation pregnancies vs. high-risk singletons. Among women with singleton gestations, mean serum sEng was higher in subjects who developed early-onset (<34 weeks) and late-onset (>or= 34 weeks) preeclampsia, as compared with subjects without preeclampsia, from 22 weeks and 28 weeks gestation onward, respectively. The within-woman rate of change of sEng was also higher in women who later developed preeclampsia. CONCLUSIONS: sEng is higher in women with multiple gestations vs. high-risk singleton pregnancies. In high-risk women, serum sEng is increased prior to preeclampsia onset.

Pregnancy-specific stress, prenatal health behaviors, and birth outcomes.

OBJECTIVE: Stress in pregnancy predicts earlier birth and lower birth weight. The authors investigated whether pregnancy-specific stress contributes uniquely to birth outcomes compared with general stress, and whether prenatal health behaviors explain this association. DESIGN: Three structured prenatal interviews (N = 279) assessing state anxiety, perceived stress, life events, pregnancy-specific stress, and health behaviors. MAIN OUTCOME MEASURES: Gestational age at delivery, birth weight, preterm delivery (<37 weeks), and low birth weight (<2,500 g). RESULTS: A latent pregnancy-specific stress factor predicted birth outcomes better than latent factors representing state anxiety, perceived stress, or life event stress, and than a latent factor constructed from all stress measures. Controlling for obstetric risk, pregnancy-specific stress was associated with smoking, caffeine consumption, and unhealthy eating, and inversely associated with healthy eating, vitamin use, exercise, and gestational age at delivery. Cigarette smoking predicted lower birth weight. Clinically-defined birth outcomes were predicted by cigarette smoking and pregnancy-specific stress. CONCLUSION: Pregnancy-specific stress contributed directly to preterm delivery and indirectly to low birth weight through its association with smoking. Pregnancy-specific stress may be a more powerful contributor to birth outcomes than general stress.

Circulating angiogenic factors in singleton vs multiple-gestation pregnancies.

OBJECTIVE: Placental soluble fms-like tyrosine kinase-1 may contribute to the pathogenesis of preeclampsia. Here we describe alterations in serum angiogenic factor levels in women with multiple gestation pregnancies, a major preeclampsia risk factor. STUDY DESIGN: We collected serial serum specimens from 101 pregnant women at high preeclampsia risk between 22 and 36 weeks' gestation. Soluble fms-like tyrosine kinase-1 and placental growth factor were measured by enzyme-linked immunosorbent assay. Women who had preeclampsia or gestational hypertension develop were excluded. RESULTS: Maternal soluble fms-like tyrosine kinase-1 was higher in multiple gestation (n = 20) compared with high-risk singleton (n = 81) pregnancies for each gestational age range examined. Maternal placental growth factor was significantly higher in multiple vs high-risk singletons before 31 weeks' gestation, whereas the soluble fms-like tyrosine kinase-1/placental growth factor ratio was higher in multiple vs high-risk singletons after 27 weeks. CONCLUSION: Alterations in circulating angiogenic factors are present in women with multiple gestations and may contribute to higher preeclampsia risk in this population.

Angiogenic factors for the prediction of preeclampsia in high-risk women.

OBJECTIVE: The objective of the study was to evaluate angiogenic factors for the prediction of preeclampsia in high-risk women. STUDY DESIGN: We collected serial serum specimens from 94 women at high preeclampsia risk between 22 and 36 weeks' gestation. Soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) were measured by enzyme-linked immunosorbent assay. RESULTS: Mean serum sFlt1 and the sFlt1/PlGF ratio were higher in subjects who developed early-onset (less than 34 weeks) preeclampsia, as compared with subjects without preeclampsia, from 22 weeks gestation onward. In subjects who developed late-onset (34 weeks or later) preeclampsia, sFlt1 was significantly increased after 31 weeks' gestation. The sFlt1/PlGF ratio at 22-26 weeks was highly predictive of early-onset preeclampsia. The within-woman rate of change of the sFlt1/PlGF ratio was predictive of overall preeclampsia risk. CONCLUSIONS: In high-risk women, serum sFlt1 and the sFlt1:PlGF ratio are altered prior to preeclampsia onset and may be predictive of preeclampsia. Larger studies are needed to confirm these findings.

Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial.

OBJECTIVE: The purpose of this study was to determine whether oral analgesia with oxycodone-acetaminophen or a patient-controlled analgesia device with morphine provides superior analgesia after cesarean delivery. STUDY DESIGN: Ninety-three patients with scheduled cesarean delivery were assigned randomly to receive either oral analgesia with oxycodone-acetaminophen or a morphine patient-controlled analgesia device. At 6 and 24 hours after the procedure, pain was assessed on a visual analog pain scale of 0 to 10. Nausea, sedation, pruritus, ambulation, emesis, and oral fluid intake were also assessed. RESULTS: Patients who used oral analgesia without a patient-controlled analgesia device experienced less pain at 6 and 24 hours after cesarean delivery. They also had less nausea and drowsiness at 6 hours but slightly more nausea at 24 hours. CONCLUSION: Oral analgesia with oxycodone-acetaminophen may offer superior pain control after cesarean delivery with fewer side-effects as compared with morphine patient-controlled analgesia. Consideration should be given to expanding the use of oral analgesia in patients immediately after cesarean delivery.

Verrucous carcinoma of the endometrium: case history, pathologic findings, brief review of literature and discussion.

BACKGROUND: Verrucous carcinoma is a rare condition. A defined disease of the oral cavity, larynx, esophagus, skin, vulva, vagina and cervix. But a verrucous carcinoma arising from the endometrium without evidence of cervical malignancy or endometrial adenocarcinoma is extremely rare. CASE: A 67-year-old G2P2 menopausal patient that was referred for consultation 1 year after presenting with vaginal bleeding to her gynecologist who subsequently underwent several endometrial biopsies where the pathological findings were repetitively similar: papillary squamous proliferation, cytologically bland with low mitotic activity but extensive proliferation. A hysterectomy with bilateral salpingo-oophorectomy was performed. The final histologic examination revealed a squamous cell carcinoma of endometrium, verrucous and well differentiated, and there was no cervical invasion identified. CONCLUSION: This is a rare form of endometrial cancer with apparent favorable prognosis that must be considered when squamous cells are identified on endometrial samplings.

Prenatal maternal stress is associated with delivery analgesia and unplanned cesareans.

We tested the hypothesis that women with greater prenatal maternal stress (PNMS) would be more likely to receive intravenous opiates and epidural for delivery, and thereby increase the likelihood of unplanned cesarean delivery. PNMS was assessed during early, mid, and late pregnancy using psychometrically sound instruments in structured interviews with women receiving prenatal care at a public university clinic. Medical records were abstracted for analgesia during delivery, fetal heart tracing (FHT) abnormalities, and method of delivery. Only subjects attempting vaginal delivery (N = 298) were included. Using structural equation modeling, a PNMS variable was constructed from five indicators: pregnancy-specific distress, number of prenatal stressful life events, distress from life events, state anxiety, and perceived stress. After controlling for medical predictors of analgesia receipt and surgical delivery, women with higher PNMS were more likely to receive analgesia, and those who received analgesia were more likely to deliver surgically. Analgesia was also associated with FHT abnormalities, which in turn was associated with surgical delivery (all p's < 0.05). Women who received both an epidural and meperidine were most likely to have a cesarean delivery; 29% of this group delivered surgically. Results indicate that PNMS contributes to higher likelihood of unplanned cesarean delivery through its association with delivery analgesia.

Distress associated with prenatal screening for fetal abnormality.

A theoretically-based, multivariate approach was used to identify factors associated with emotional distress for pregnant women undergoing maternal serum alpha fetoprotein (MSAFP or AFP) testing, used to detect abnormalities of the fetal brain and spinal cord. Participants were those who received normal results (N = 87). Study results supported the hypothesis that different factors would predict distress before and after testing. Satisfaction with information about testing predicted lower emotional distress early in the testing process; concerns about the child having other medical conditions and low-dispositional optimism predicted distress later. Study findings indicate that even in women who receive normal test results, AFP testing is associated with a modest degree of emotional disturbance which declines, but does not completely abate, after testing.

Obtaining patient permission for student participation in obstetric-gynecologic outpatient visits: a randomized controlled trial.

OBJECTIVES: Our purpose was to compare a scripted verbal query with a detailed written permission slip in obtaining patient satisfaction and permission for student involvement in outpatient obstetrics-gynecologic visits. STUDY DESIGN: A prospective, randomized, controlled study was performed using a questionnaire to compare current practice to the study groups. The chi(2) test was used to calculate P values; P<.05 was considered significant. RESULTS: Patient demographics and satisfaction were similar among the three groups: 86% of controls and 79% of study groups agreed to student participation (P=.056). All preferred having the nurse ask permission (86% vs 86%) versus the physician (34% vs 25%) or the student (6% vs 3%). Permission was independent of student gender, visit purpose, or previous exposure to students. CONCLUSION: Patients want a nonphysician to ask permission for student participation independent of method of request, visit purpose, student gender, or previous experience with students. Physician or student requests for consent may unduly influence participation.