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1.
Plast Reconstr Surg ; 145(2): 333-339, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985616

RESUMEN

BACKGROUND: Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS: The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS: Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS: Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Asunto(s)
Reembolso de Seguro de Salud/economía , Mamoplastia/economía , Microcirugia/economía , Adulto , Implantación de Mama/economía , Implantación de Mama/estadística & datos numéricos , Implantes de Mama/economía , Implantes de Mama/estadística & datos numéricos , Neoplasias de la Mama/economía , Neoplasias de la Mama/cirugía , Femenino , Colgajos Tisulares Libres/economía , Humanos , Mamoplastia/estadística & datos numéricos , Massachusetts , Mastectomía/economía , Mastectomía/métodos , Medicaid/economía , Medicaid/estadística & datos numéricos , Microcirugia/estadística & datos numéricos , Microvasos , Persona de Mediana Edad , Reoperación/economía , Reoperación/estadística & datos numéricos , Trasplante Autólogo/economía , Estados Unidos
2.
J Nurs Adm ; 50(1): 40-44, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31809455

RESUMEN

The purpose of the Aging Well Nursing-Interprofessional Salon was to explore current local community healthcare issues for older adults and to develop innovative strategies that support and enhance their health. An initiative emerged from the salon that focuses on identifying caregivers to ensure their awareness of available support resources. We are in the process of developing a pilot plan that includes collaboration of PhD and doctorate of nursing practice students, nursing faculty, and community agencies that support older adults.


Asunto(s)
Cuidadores , Servicios de Salud Comunitaria , Servicios de Salud para Ancianos , Enfermeras Practicantes , Anciano , Femenino , Humanos , Masculino , Massachusetts
3.
J Environ Public Health ; 2019: 1823636, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31641360

RESUMEN

Objective: This study documents the extent of tobacco ads in retail stores and evaluates its association with the comprehensiveness of local tobacco control policies in the state of Massachusetts, US. Methods: Using a two-stage cluster sampling method, we sampled 419 retail stores across 42 municipalities to assess the presence and count of nine mutually exclusive tobacco ad categories. Tobacco ads by store type and municipality were analyzed using summary statistics and contingency tables. Regression models tested the association between the extent of tobacco ads and local tobacco control policy comprehensiveness. Results: Overall, 86.6% (n = 363) of all the retail stores had tobacco ads. On average, there were 6.7 ads per retail store (SD = 6.61) and 2804 ads across all the retail stores (range = 0 : 32). Retail stores had an average of three different categories of tobacco ads (mean = 2.98, SD = 1.84). Across all retail stores, the most frequent ad categories were power walls (80.0%) and e-cigarette ads (55.8%). Retail stores in municipalities with more comprehensive local tobacco control policies were more likely to have fewer tobacco ads (IRR = 0.92, p < 0.01) and a lower number of tobacco ad categories (OR = 0.88, p < 0.05). Conclusion: Municipalities can adopt more comprehensive tobacco control policies to help limit the extent of tobacco retail advertising. This can ultimately reduce smoking in their jurisdiction.


Asunto(s)
/estadística & datos numéricos , Productos de Tabaco/economía , Productos de Tabaco/legislación & jurisprudencia , Ciudades , Humanos , Massachusetts , Fumar/legislación & jurisprudencia
4.
Environ Entomol ; 48(6): 1277-1285, 2019 12 02.
Artículo en Inglés | MEDLINE | ID: mdl-31603500

RESUMEN

The recently described oak gall wasp Zapatella davisae Buffington & Melika (Hymenoptera: Cynipidae) has caused extensive damage and mortality to black oak trees, Quercus velutina L. (Fagales: Fagaceae), in coastal parts of New England, United States. Like many newly described and/or newly introduced species, it is unclear how long populations of Z. davisae have existed in this region. However, as this species forms galls on the woody-tissue of its host, it may be possible to obtain historical information about changes in its population size by examining the presence of galls in relation to annual growth nodes. Here, we explore the utility of this approach to determine population size changes in Z. davisae densities on Nantucket, Martha's Vineyard, and Cape Cod, Massachusetts, through dissection of black oak branches. In addition, we calculated parasitism rates during the years of study and obtained morphological and molecular identifications for the parasitoids associated with Z. davisae. Our results show significant changes in population sizes, with higher levels of parasitism at sites on Martha's Vineyard and Cape Cod compared to sites on Nantucket. In addition, morphological examinations, in combination with DNA sequencing, identified the associated parasitoids as five species in the genus Sycophila Walker (Hymenoptera: Eurytomidae). We comment that considerable morphological variation within several of these recovered species was observed, present the first record of males for a species from which only females have been described, and suggest that future work is required to clarify the species boundaries for this important parasitoid group.


Asunto(s)
Himenópteros , Quercus , Avispas , Animales , Brotes de Enfermedades , Femenino , Massachusetts
5.
Water Res ; 167: 115134, 2019 Dec 15.
Artículo en Inglés | MEDLINE | ID: mdl-31581037

RESUMEN

Development of sustainable and resilient water infrastructure is an urgent challenge for urban areas to secure long-term water availability and mitigate negative impacts of water consumption and urban development. A hybrid system that combines centralized water infrastructure and household decentralized water facilities, including rainwater harvesting and greywater recycling, may be a solution to more sustainable and resilient water management in urban areas. Understanding household and community preferences for decentralized water facilities is important to inform the design and ultimately the promotion and adoption of such systems. In this study, we conducted a discrete choice experiment, via Amazon Mechanical Turk, to collect data on household choices of different decentralized water facility designs in two U.S. cities, Atlanta, Georgia and Boston, Massachusetts. Based on the responses to the choice experiment, we then developed a latent-class choice model to predict households' preferences of decentralized system design features and examine the influence of socioeconomic and personal characteristics on heterogeneous class membership. We identified six major classes of preferences in Atlanta and Boston, respectively, and evaluated how readily each class is likely to choose a decentralized water facility. Atlanta and Boston have some classes sharing similar preferences for decentralized water systems, but the socioeconomic and personal characteristics of these classes in the two cities are different. We found that the early adoption of decentralized water facilities is positively related to neighbors' adoptions and pressure of water scarcity increases households' willingness to share a decentralized facility. The visualization of spatial distribution of the classes highlighted early demand of decentralized water facilities is likely to emerge in low-property-value communities, which creates a unique opportunity for introducing decentralized water facilities during water infrastructure renovations. Our study provides a framework through citizen engagement to understand social demand and to inform the promotion of decentralized water facilities.


Asunto(s)
Abastecimiento de Agua , Agua , Boston , Ciudades , Georgia , Massachusetts
6.
Mar Pollut Bull ; 145: 390-395, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31590801

RESUMEN

Anthropogenic micro debris in the marine environment is a growing concern worldwide, affecting multiple trophic levels, from primary consumers such as zooplankton, to meso- and apex predators like marine mammals and marine birds. In 2016-2017, during the processing of harbor seal (Phoca vitulina vitulina) and gray seal (Halichoerus grypus atlantica) fecal samples for fish otoliths and organic hard parts as part of a prey study, anthropogenic micro debris (>500 µm) was detected in 6% (n = 2/32) of harbor seal and 1% (n = 2/129) of gray seal samples. Spectral analysis identified the fragments as cellophane, alkyd resin and poly(ethylene:propylene:diene) (EPDM) rubber. These results show the potential indirect ingestion of micro debris, which can impact the health and welfare of marine wildlife. This is the first report of micro debris presence in wild populations of phocid seals for the northwestern Atlantic.


Asunto(s)
Phoca , Contaminantes del Agua/análisis , Animales , Animales Salvajes , Heces/química , Massachusetts , Phocidae
7.
Dis Colon Rectum ; 62(11): 1283-1293, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31567917

RESUMEN

BACKGROUND: Extramammary Paget's disease is an uncommon intraepidermal adenocarcinoma with poorly defined clinical implications. OBJECTIVE: The purpose of this research was to estimate the risk of second primary neoplasms in patients with extramammary Paget's disease. DESIGN: This was a retrospective analysis of the Surveillance, Epidemiology, and End Results Registry (1973-2014). SETTINGS: The study included population-based cancer registries from the United States. PATIENTS: Patients who were diagnosed with anogenital Paget's disease were included. MAIN OUTCOME MEASURES: Risk of second primary development was measured. RESULTS: We identified 108 patients with anal Paget's disease, 421 patients with male genital (scrotum or penis) Paget's, and 1677 patients with female genital (vagina or vulva) Paget's. Median follow-up time was 5.9 years. The risk of developing colorectal adenocarcinoma was 18.5% for patients with anal Paget's disease. Eighty percent of colorectal adenocarcinoma diagnoses were synchronous (within 2 mo) to anal Paget's diagnoses, whereas metachronous tumors occurred at a median time of 2.4 years. Of patients with anal Paget's disease, 8.3% developed an anal adenocarcinoma or nonsmall cell cancer. In male patients with genital Paget's, the risk of proximal genitourinary malignancy was 9.7%, scrotal or testicular adenocarcinoma was 0.4%, and penile or scrotal squamous carcinoma was 1.7%. In female patients with genital Paget's, the risk of proximal genitourinary malignancy was 3.0%, vaginal or vulvar adenocarcinoma was 1.4%, and vaginal or vulvar squamous neoplasm was 1.0%. Five-year overall survival was 59.7%, 73.5%, and 80.7% in patients with anal, male genital, and female genital Paget's (p < 0.001). LIMITATIONS: The registry did not record surveillance schedule, provider specialty, or nonprocedural therapies for extramammary Paget's disease. CONCLUSIONS: In the largest published cohort of patients with extramammary Paget's disease, patients with anal Paget's had a much higher risk of both proximal and local neoplasms as compared with patients with genital Paget's. Patients with anal Paget's also experienced worse survival as compared with those with purely genital Paget's. See Video Abstract at http://links.lww.com/DCR/B20. ALTO RIESGO DE NEOPLASIAS PROXIMALES Y LOCALES EN 2206 PACIENTES CON ENFERMEDAD DE PAGET EXTRAMAMARIA ANOGENITAL:: La enfermedad de Paget extramamaria es un adenocarcinoma intraepidérmico poco frecuente con implicaciones clínicas poco definidas.Estimar el riesgo de segundas neoplasias primarias en pacientes con enfermedad de Paget extramamaria.Análisis retrospectivo del Registro de Vigilancia, Epidemiología y Resultados Finales (1973-2014).Registros de base poblacional en cáncer de los Estados Unidos.Pacientes que fueron diagnosticados con enfermedad de Paget anogenital.Riesgo de desarrollo un cáncer primario adicional.Se identificaron 108 pacientes con Paget anal, 421 pacientes con Paget genital masculino (escroto o pene) y 1677 pacientes con Paget genital femenino (vagina o vulva). Tiempo mediano de seguimiento fue de 5,9 años. El riesgo de desarrollar adenocarcinoma colorrectal fue del 18,5% para los pacientes con Paget anal. El ochenta por ciento de los diagnósticos de adenocarcinoma colorrectal fueron sincrónicos (dentro de los 2 meses) a los diagnósticos de Paget anal, mientras que los tumores metacrónicos ocurrieron en un tiempo promedio de 2,4 años. De los pacientes con Paget anal, el 8.3% desarrolló un adenocarcinoma anal o cáncer de células no pequeñas. En los pacientes masculinos con Paget genital, el riesgo de malignidad genitourinaria proximal fue del 9,7%, el adenocarcinoma escrotal o testicular fue del 0,4% y el carcinoma escamoso del pene o escroto fue del 1,7%. En pacientes femeninas con Paget genital, el riesgo de malignidad genitourinaria proximal fue de 3.0%, el adenocarcinoma vaginal o vulvar fue de 1.4% y la neoplasia escamosa vaginal o vulvar fue de 1.0%. La supervivencia general a cinco años fue del 59.7%, 73.5% y 80.7% en pacientes con anal, genital masculino y genital femenino, respectivamente (p <0.001).El registro no señalo el cronograma de vigilancia, la especialidad del proveedor o las terapias sin procedimiento para la enfermedad de Paget extramamaria.En la cohorte más grande publicada de pacientes con enfermedad de Paget extramamaria, los pacientes con Paget anal demostraron un riesgo mucho mayor de neoplasias proximales y locales en comparación con los pacientes con Paget genital. Los pacientes con Paget anal además demostraron una peor supervivencia en comparación con aquellos con Paget aislada genital. Vea el Resumen del Video en http://links.lww.com/DCR/B20.


Asunto(s)
Adenocarcinoma , Neoplasias del Ano , Neoplasias de los Genitales Femeninos , Neoplasias de los Genitales Masculinos , Neoplasias Primarias Secundarias , Enfermedad de Paget Extramamaria , Adenocarcinoma/epidemiología , Adenocarcinoma/patología , Cuidados Posteriores/estadística & datos numéricos , Anciano de 80 o más Años , Neoplasias del Ano/epidemiología , Neoplasias del Ano/patología , Epidermis/patología , Femenino , Neoplasias de los Genitales Femeninos/epidemiología , Neoplasias de los Genitales Femeninos/patología , Neoplasias de los Genitales Masculinos/epidemiología , Neoplasias de los Genitales Masculinos/patología , Humanos , Masculino , Massachusetts/epidemiología , Estadificación de Neoplasias , Neoplasias Primarias Secundarias/epidemiología , Neoplasias Primarias Secundarias/patología , Enfermedad de Paget Extramamaria/epidemiología , Enfermedad de Paget Extramamaria/patología , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia
8.
Pediatrics ; 144(4)2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31554667

RESUMEN

BACKGROUND AND OBJECTIVES: Asthma is responsible for ∼1.7 million emergency department (ED) visits annually in the United States. Studies in adults have shown that anxiety and depression are associated with increased asthma-related ED use. Our objective was to assess this association in pediatric patients with asthma. METHODS: We identified patients aged 6 to 21 years with asthma in the Massachusetts All-Payer Claims Database for 2014 to 2015 using International Classification of Diseases, Ninth and 10th Revision codes. We examined the association between the presence of anxiety, depression, or comorbid anxiety and depression and the rate of asthma-related ED visits per 100 child-years using bivariate and multivariable analyses with negative binomial regression. RESULTS: Of 65 342 patients with asthma, 24.7% had a diagnosis of anxiety, depression, or both (11.2% anxiety only, 5.8% depression only, and 7.7% both). The overall rate of asthma-related ED use was 17.1 ED visits per 100 child-years (95% confidence interval [CI]: 16.7-17.5). Controlling for age, sex, insurance type, and other chronic illness, patients with anxiety had a rate of 18.9 (95% CI: 17.0-20.8) ED visits per 100 child-years, patients with depression had a rate of 21.7 (95% CI: 18.3-25.0), and patients with both depression and anxiety had a rate of 27.6 (95% CI: 24.8-30.3). These rates were higher than those of patients who had no diagnosis of anxiety or depression (15.5 visits per 100 child-years; 95% CI: 14.5-16.4; P < .001). CONCLUSIONS: Children with asthma and anxiety or depression alone, or comorbid anxiety and depression, have higher rates of asthma-related ED use compared with those without either diagnosis.


Asunto(s)
Ansiedad/epidemiología , Asma/epidemiología , Depresión/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adolescente , Algoritmos , Niño , Comorbilidad , Intervalos de Confianza , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Cobertura del Seguro/estadística & datos numéricos , Masculino , Massachusetts/epidemiología , Prevalencia , Análisis de Regresión , Adulto Joven
9.
J Leg Med ; 39(2): 121-136, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31503528

RESUMEN

Empowered to play a larger role in the delivery and administration of health care, a number of states are attempting to solve the pharmaceutical pricing crisis in creative and varied ways. This essay summarizes three particular states' more activist approaches, including states that have sought to empower their Medicaid programs to limit coverage of certain drugs based on price, attempted to use leverage to impose cost-efficiency requirements, and, in the most dramatic example, relied on new usage of "gouging" laws to bring down the costs of prescription drugs. Although all three approaches have met substantial resistance, they illustrate a new era of state experimentation in an effort to bring down the cost of prescription drugs.


Asunto(s)
Control de Costos , Costos de los Medicamentos/legislación & jurisprudencia , Honorarios Farmacéuticos/legislación & jurisprudencia , Medicamentos bajo Prescripción/economía , Gobierno Estatal , Costos y Análisis de Costo/legislación & jurisprudencia , Política de Salud/economía , Política de Salud/legislación & jurisprudencia , Legislación como Asunto , Maryland , Massachusetts , Medicaid/legislación & jurisprudencia , New York , Activismo Político , Estados Unidos
10.
Forensic Sci Int ; 302: 109903, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31400618

RESUMEN

First used over 50 years ago, forensic palynology is an important tool for law enforcement agencies. In most countries that use forensic palynology, microscopic pollen grains and spores are traditionally used in criminal investigations to link suspects to crime scenes or items. While still underutilized in many parts of the world, forensic palynology is increasingly being used to determine the region of origin, or geolocation, for persons and items of interest. Drawing upon the experience of the authors using trace pollen and spores to geolocate forensic samples, the types, methods, and variables of this type of analysis are discussed and demonstrated using the Baby Doe case from Massachusetts, USA as a case study. This is not an exhaustive list and every forensic sample is unique so the methods and experience presented here are intended to be a guide for future forensic and anti-terrorism investigations as forensic palynology becomes more commonplace in law enforcement agencies around the world.


Asunto(s)
Botánica , Víctimas de Crimen , Ciencias Forenses/métodos , Homicidio , Polen , Esporas , Preescolar , Vestuario , Ecosistema , Cabello , Humanos , Massachusetts , Manejo de Especímenes
11.
J Environ Manage ; 249: 109380, 2019 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-31434050

RESUMEN

This article aims to understand decision making under uncertainty and risk, with a case study on Cape Cod, Massachusetts. Decision makers need to consider imperfect information on the cost and effectiveness of advanced nitrogen-removing on-site wastewater treatment systems as options to mitigate water quality degradation. Research included modeling nitrogen load reduction to impaired coastal waters from seven treatment system technologies and eliciting expert knowledge on their costs. Predictions of nitrogen load removal and cost for each technology incorporated variation in effectiveness and uncertainty in household water use, costs, and expert confidence in costs. The predictions were evaluated using the Pareto efficiency concept to reveal tradeoffs between cost and effectiveness. The stochastic dominance index was used to identify preferred technologies for risk-averse decision making, assuming no further learning is possible. Lastly, the predictions were combined into a cost-effectiveness metric to estimate the expected payoff of implementing the best treatment system in the face of uncertainty and the expected payoff of learning which treatment systems are most cost-effective over time. The expected value of perfect information was calculated as the difference between the expected payoffs. Three technologies revealed Pareto efficient tradeoffs between cost and effectiveness, whereas one technology was the preferred risk-averse option in the absence of future learning. There was a high expected value of perfect information, which could motivate adaptive management on Cape Cod. This research demonstrated decision analysis methods to guide future research and decision making toward meeting water quality objectives and reducing uncertainty.


Asunto(s)
Toma de Decisiones , Nitrógeno , Análisis Costo-Beneficio , Massachusetts , Incertidumbre
12.
Rev Fac Cien Med Univ Nac Cordoba ; 76(3): 142-147, 2019 08 29.
Artículo en Español | MEDLINE | ID: mdl-31465180

RESUMEN

Introduction: The analysis of injuries caused by traffic from a physical and mathematical perspective can help improve road safety strategies. Objective: Predict the dynamics of traffic fatalities in the states of Maryland and Massachusetts for the years 2004 and 2014 in the context of probabilistic random walk. Methods: An analysis was made of the number of total fatalities caused by traffic per year, in the states of Maryland and Massachusetts between the years 1994-2003 and 1994-2013. The behavior of these values was analyzed as a probabilistic random walk; for this, the probabilistic lengths were found for each year, during the period studied and four probability spaces were analyzed, with which it was possible to analyze their behavior, to establish a prediction of the number of total fatalities caused by traffic for the years 2004 and 2014. Results: The predictions for the years 2014 and 2004 for Maryland and Massachusetts when compared with the real values, the percentage of success was 98%. Main conclusion: The predictions for the years 2014 and 2004 for Maryland and Massachusetts when compared with the real values, the percentage of success was 98%. Conclusions: the behavior of traffic fatalities in Maryland and Massachusetts presented a predictable self-organization from the context of probabilistic random walk, constituting a useful tool for analyzing the operation of road safety strategies.


Asunto(s)
Accidentes de Tránsito/mortalidad , Accidentes de Tránsito/tendencias , Humanos , Maryland/epidemiología , Massachusetts/epidemiología , Teoría de la Probabilidad
13.
Sr Care Pharm ; 34(8): 514-519, 2019 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-31462355

RESUMEN

OBJECTIVE: The aim of this study was to evaluate prescribing practices for elderly patients started on apixaban in multiple practice settings.
DESIGN: Retrospective, chart review.
SETTING: One outpatient and three inpatient settings in Arizona and Massachusetts.
PATIENT, PARTICIPANTS: Patients who received a new order for apixaban between July 1, 2015, and December 31, 2016. Inclusion criteria included adults 65 years of age and older who were receiving apixaban for atrial fibrillation or venous thromboembolism (VTE) at a current treatment dose.
There were 1,045 patients included, the average age was 78 years, 52% were male, and 90% had atrial fibrillation.
MAIN OUTCOME MEASURE: Appropriate prescribing of apixaban based on Food and Drug Administration (FDA)-labeling (age, weight, serum creatinine).
RESULTS: Six patients who were on hemodialysis were excluded from the analysis, leaving 1,039 patients to be analyzed. 16.2% (168/1,039) of patients had an incorrect dose of apixaban prescribed based on their indication. Of those, 75% (126/168) were taking the medication for atrial fibrillation and 25% (42/168) for VTE. For those with atrial fibrillation (n = 126), the majority of inappropriate orders resulted from doses that were lower than indicated (113/126).
CONCLUSION: This research suggests that elderly patients may receive inappropriately lower doses of apixaban than indicated, which may decrease the effectiveness of the medication. This research supports the fact that pharmacists can play a vital role in anticoagulation stewardship by verifying apixaban doses for accuracy.


Asunto(s)
Pirazoles/efectos adversos , Piridonas/efectos adversos , Anciano , Anticoagulantes , Arizona , Femenino , Humanos , Masculino , Massachusetts , Estudios Retrospectivos
15.
J Opioid Manag ; 15(3): 183-191, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31343720

RESUMEN

OBJECTIVE: To characterize primary care physicians' (PCPs') perceptions of the reasons patients receive opioid medications from both VA and non-VA healthcare systems. DESIGN: Qualitative. SETTING: Department of Veterans Affairs (VA). PARTICIPANTS: Forty-two VA PCPs who prescribed opioids to at least 15 patients and who practiced in Massachusetts, Illinois, or Pennsylvania. METHODS: Thirty-minute, semistructured telephone interviews were conducted in 2016, addressing topics regarding PCPs' experiences and perspectives on patients who use both VA and non-VA healthcare systems to obtain prescription opioids. The analysis focused on two questions: attributes that PCPs believe characterize dual-use patients and reasons that PCPs believe patients obtain opioids from both VA and non-VA sources. RESULTS: PCPs identified multiple attributes of, and reasons for, patients obtaining opioid medications from both VA and non-VA healthcare systems, including pain issues, opioid misuse, having healthcare managed through multiple healthcare systems, and transferring care between systems. More than half of the PCPs identified addiction and diversion as key attributes and reasons why patients obtain prescription opioids from multiple sources. PCPs also identified several behavioral and psychological factors as attributes of these patients. CONCLUSIONS: PCPs within the VA have varying perceptions of patients obtaining opioid medications from multiple healthcare systems, with pain complaints and opioid misuse as the primary themes. This knowledge about PCPs' perceptions can be incorporated into interventions to better manage pain and prescription opioid use by VA patients.


Asunto(s)
Analgésicos Opioides/administración & dosificación , Trastornos Relacionados con Opioides , Médicos de Atención Primaria/psicología , Veteranos , Humanos , Massachusetts , Trastornos Relacionados con Opioides/prevención & control , Percepción , Veteranos/estadística & datos numéricos
16.
Am J Public Health ; 109(9): 1205-1211, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31318595

RESUMEN

Objectives. To evaluate the risk of death and injury in residential fires started on upholstered furniture, with a focus on open flame and cigarette-related heat sources.Methods. We used civilian death and injury data from 34 081 residential fires in the Massachusetts Fire Incident Reporting System from 2003 to 2016. We compared outcomes associated with fires that started on upholstered furniture ignited by smoking materials versus open flames.Results. Although fires starting on upholstered furniture were not common (2.2% of total fires), odds of death and injury were significantly higher in these fires than in fires started on other substrates. Among furniture fires, odds of death were 3 times greater when those fires were ignited by smoking materials than when ignited by open flames (odds ratio = 3.4; 95% confidence interval = 1.3, 10.9).Conclusions. Furniture fires started by smoking materials were associated with more deaths than were furniture fires started by open flames.Public Health Implications. Historically, furniture flammability regulations have focused on open flame heat sources, resulting in the addition of toxic flame retardants to furniture. Interventions to reduce deaths should instead focus on smoking materials.


Asunto(s)
Fuego/estadística & datos numéricos , Retardadores de Llama , Diseño Interior y Mobiliario/estadística & datos numéricos , Quemaduras/etiología , Quemaduras/mortalidad , Humanos , Massachusetts/epidemiología , Medición de Riesgo , Productos de Tabaco
17.
Am J Public Health ; 109(9): 1273-1279, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31318603

RESUMEN

Objectives. To evaluate the effectiveness of video messaging on adolescent organ donor designation rates.Methods. We randomized adolescent driver education classes in Massachusetts, between July 2015 and February 2018, to receive 1 of 3 organ donation video messaging interventions (informational, testimonial, or blended). Adolescents completed questionnaires before and after the intervention and at 1-week follow-up; we compared their registration status at time of obtaining driver's license with that of a regionally matched historical comparison group.Results. Donor designation rates were higher for those exposed to video messaging than for the historical comparison group (60% vs 50%; P < .001). Testimonial (64%) and blended messaging (65%) yielded higher donor designation rates than informational messaging (51%; P = .013). There was a statistically significant messaging × time interaction effect for donation knowledge (P = .03), with blended and informational messaging showing more gains in knowledge from before to after the intervention (P < .001; d = 0.69 and P < .001; d = 0.45, respectively), compared with testimonial messaging (d = 0.09; P = .22).Conclusions. Testimonial messaging is most effective in producing a verifiable and demonstrable impact on donor designation rates among adolescents, and driver education classes are an efficient venue for disseminating organ donation messaging to youths.Trial Registration. ClinicalTrials.gov; identifier: NCT03013816.


Asunto(s)
Donantes de Tejidos/estadística & datos numéricos , Adolescente , Conducta del Adolescente , Conducción de Automóvil/educación , Femenino , Humanos , Masculino , Massachusetts/epidemiología , Distribución Aleatoria
19.
N Engl J Med ; 381(3): 252-263, 2019 07 18.
Artículo en Inglés | MEDLINE | ID: mdl-31314969

RESUMEN

BACKGROUND: Population-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk). METHODS: Using a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States. RESULTS: During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets. CONCLUSIONS: During the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).


Asunto(s)
Planes de Seguros y Protección Cruz Azul , Gastos en Salud/tendencias , Calidad de la Atención de Salud , Reembolso de Incentivo/economía , Planes de Seguros y Protección Cruz Azul/organización & administración , Massachusetts , Calidad de la Atención de Salud/economía , Calidad de la Atención de Salud/tendencias , Derivación y Consulta/tendencias , Mecanismo de Reembolso , Estados Unidos
20.
Matern Child Health J ; 23(9): 1152-1158, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31267339

RESUMEN

OBJECTIVES: The rate of severe maternal morbidity in the United States increased approximately 200% during 1993-2014. Few studies have reported on the health of the entire pregnant population, including women at low risk for maternal morbidity. This information might be useful for interventions aimed at primary prevention of pregnancy complications. To better understand this, we sought to describe the distribution of comorbid risk among all delivery hospitalizations in Massachusetts and its association with the distribution of severe maternal morbidity. METHODS: Using an existing algorithm, we assigned an obstetric comorbidity index (OCI) score to delivery hospitalizations contained in the Massachusetts pregnancy to early life longitudinal (PELL) data system during 1998-2013. We identified which hospitalizations included severe maternal morbidity and calculated the rate and frequency of these hospitalizations by OCI score. RESULTS: During 1998-2013, PELL contained 1,185,182 delivery hospitalizations; of these 5325 included severe maternal morbidity. Fifty-eight percent of delivery hospitalizations had an OCI score of zero. The mean OCI score increased from 0.60 in 1998 to 0.82 in 2013. Hospitalizations with an OCI score of zero comprised approximately one-third of all deliveries complicated by severe maternal morbidity, but had the lowest rate of severe maternal morbidity (22.8/10,000 delivery hospitalizations). CONCLUSIONS: The mean OCI score increased during the study period, suggesting that an overall increase in risk factors has occurred in the pregnant population in Massachusetts. Interventions that can make small decreases to the mean OCI score could have a substantial impact on the number of deliveries complicated by severe maternal morbidity. Additionally, all delivery facilities should be prepared for severe complications during low-risk deliveries.


Asunto(s)
Comorbilidad , Madres/estadística & datos numéricos , Complicaciones del Embarazo/mortalidad , Adolescente , Adulto , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Massachusetts/epidemiología , Persona de Mediana Edad , Embarazo , Complicaciones del Embarazo/epidemiología , Factores de Riesgo , Índice de Severidad de la Enfermedad
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