The Impact of Personal Protective Equipment on Speech Discrimination and Verbal Communication in the Operating Room and the Role of Audio Communication Devices.

INTRODUCTION: Recent work has highlighted communication difficulties when wearing personal protective equipment (PPE) in the clinical setting, but currently, there are little objective data on its effects. We assessed the impact of PPE on verbal communication in a simulated operating room and evaluated use of an audio communication device. METHODOLOGY: Frontline health professionals across specialties including surgery, anesthetics, and nursing undertook speech discrimination testing with and without standardized levels of PPE in a simulated operating room environment. Background noise (30- and 70-a-weighted decibel multitalker babble) at 2 distances (2 and 4 m) were selected representative of operating room environments. Bamford-Kowal-Bench (BKB) scoring (192 sentences per participant) was performed. A Digital Multichannel Transceiver System (DMTS) was evaluated. We assessed the effects of PPE use, distance, and use of the DMTS with pairwise comparisons, using a Bonferroni correction, and assessed participant experience via Likert scales. RESULTS: Thirty-one healthcare professionals were tested. Without PPE in 70-a-weighted decibel "babble," median BKB sentence scores were 90% and 76% at 2 and 4 m (adjusted P < 0.0005). The median BKB sentence scores dropped to 8% and 4% at 2 and 4 m in PPE (adjusted P < 0.0005). Improved speech discrimination was achieved with DMTS use to 70% and 76% at 2 and 4 m. Personal protective equipment led to a statistically significant reduction in BKB scores across all conditions compared with baseline. Overall participant confidence in PPE clinical communication was low. CONCLUSIONS: Addition of PPE dramatically impairs speech discrimination and communication in high levels of background noise characteristic of clinical environments, which can be significantly improved using DMTS. Measures should be taken by teams through both through reduction of background noise and consideration of assistive technologies maximizing patient safety. This may be further rehearsed in a simulation environment.

Patterns of Care and Utilization of Radiation for Women With Good-Risk Ductal Carcinoma In Situ: A National Cancer Database Analysis.

Purpose/objective(s) Lumpectomy followed by whole-breast radiation therapy (WBRT) provides a 50% recurrence rate reduction in ductal carcinoma in situ (DCIS) patients when compared to lumpectomy alone. Certain factors increase the risk of recurrence, including higher nuclear grade, large size, age less than 50, and close margins. RTOG 9804 demonstrated a reduction in local failure after WBRT with the use of adjuvant radiation in women with "good-risk disease" (mammographically detected, measuring less than or equal to 2.5 cm, with a predominant nuclear grade of 1 or 2, and a margin of greater than or equal to 1 cm, or a negative re-excision). The purpose of this study is to retrospectively identify the patterns of care in women with low-risk DCIS utilizing the National Cancer Database (NCDB). We hypothesize that with the utilization of hypofractionation, there may be an increase in the delivery of RT for these "good-risk" patients. Materials/methods The National Cancer Database was queried to identify women treated with lumpectomy for <2.5 cm, nuclear grade 1 or 2 DCIS of the breast from 2004 to 2016. Data were collected regarding age, tumor size, endocrine therapy use, ER receptor status, race, insurance type, and distance from the treatment center. The distance was stratified into quartiles consisting of 0-3.9, 4-8, 8.1-15.8, and > 15.8 miles, respectively. Radiation fractionation was collected and categorized as hypofractionation, standard fractionation, or other if fractionation could not be ascertained. Clinical and patient-related factors were compared between patients who received radiation and those who received no radiation. The frequency distributions between categorical variables were compared using the Chi-square test. Multivariable logistic regression was used to identify covariables that impacted the receipt of radiation. Results The eligibility criteria were met by a total of 12,846 patients. Of those, 6,600 (51.4%) received adjuvant WBRT. On multivariable regression, patients whose tumors were ER (OR 1.24, P<0.001) and those who had not received endocrine therapy (OR 2.24, P<0.001) were more likely to receive WBRT. Factors less likely to receive WBRT included increasing age over 50 (age 50-65 OR 0.83, P<0.001; age>65 OR 0.58, P<0.001), and distance of >15.8 miles (OR 0.78, P<0.001). The fractionation technique was categorized as standard or hypofractionated in 52.2% of patients. Of those, the use of hypofractionation increased from 0.4% in 2004 to 8.9% in 2010 and to 53.8% in 2016. Conclusion This NCDB analysis demonstrated that patients who meet the RTOG 9804 criteria for "good-risk" DCIS are less likely to receive RT as time progresses despite an increase in the utilization of hypofractionation techniques. Overall, slightly more than half of these patients receive adjuvant RT.

An effort-based social feedback paradigm reveals aversion to popularity in socially anxious participants and increased motivation in adolescents.

We created a novel social feedback paradigm to study how motivation for potential social links is influenced in adolescents and adults. 88 participants (42F/46M) created online posts and then expended physical effort to show their posts to other users, who varied in number of followers and probability of positive feedback. We focused on two populations of particular interest from a social feedback perspective: adolescents relative to young adults (13-17 vs 18-24 years of age), and participants with social anxiety symptoms. Individuals with higher self-reported symptoms of social anxiety did not follow the typical pattern of increased effort to obtain social feedback from high status peers. Adolescents were more willing to exert physical effort on the task than young adults. Overall, participants were more likely to exert physical effort for high social status users and for users likely to yield positive feedback, and men were more likely to exert effort than women, findings that parallel prior results in effort-based tasks with financial rather than social rewards. Together the findings suggest social motivation is malleable, driven by factors of social status and the likelihood of a positive social outcome, and that age, sex, and social anxiety significantly impact patterns of socially motivated decision-making.

Visual Search for Circumscribed Interests in Autism Is Similar to That of Neurotypical Individuals.

Intense interests are a core symptom of autism spectrum disorders (ASD) and can be all-encompassing for affected individuals. This observation raises the hypothesis that intense interests in ASD are related to pervasive changes in visual processing for objects within that category, including visual search. We assayed visual processing with two novel tasks, targeting category search and exemplar search. For each task, three kinds of stimuli were used: faces, houses, and images personalized to each participant's interest. 25 children and adults with ASD were compared to 25 neurotypical (NT) children and adults. We found no differences in either visual search task between ASD and NT controls for interests. Thus, pervasive alterations in perception are not likely to account for ASD behavioral symptoms.

Prevalent and sex-biased breathing patterns modify functional connectivity MRI in young adults.

Resting state functional connectivity magnetic resonance imaging (fMRI) is a tool for investigating human brain organization. Here we identify, visually and algorithmically, two prevalent influences on fMRI signals during 440 h of resting state scans in 440 healthy young adults, both caused by deviations from normal breathing which we term deep breaths and bursts. The two respiratory patterns have distinct influences on fMRI signals and signal covariance, distinct timescales, distinct cardiovascular correlates, and distinct tendencies to manifest by sex. Deep breaths are not sex-biased. Bursts, which are serial taperings of respiratory depth typically spanning minutes at a time, are more common in males. Bursts share features of chemoreflex-driven clinical breathing patterns that also occur primarily in males, with notable neurological, psychiatric, medical, and lifespan associations. These results identify common breathing patterns in healthy young adults with distinct influences on functional connectivity and an ability to differentially influence resting state fMRI studies.

Smoking Cessation at a Safety-Net Hospital: A Radiation Oncology Resident-Led Quality Improvement Initiative.

PURPOSE: Continued smoking among patients with cancer has been associated with increased toxicities, resistance to treatment, and recurrence. This resident-led quality improvement study attempted to increase smoking cessation by providing free smoking cessation medications in the radiation oncology clinic. METHODS AND MATERIALS: Twenty currently smoking patients with nonmetastatic cancer were prospectively enrolled. First line treatment was protocol-standardized combined nicotine replacement therapy (patches and lozenges). Therapy was initiated before radiation therapy and given for 12 weeks. Patient self-reported tobacco use was assessed at midtreatment, end of 12-week treatment, 3-month follow-up, 6-month follow-up, and 12-month follow-up. RESULTS: Within the initial cohort of 20 patients, average years smoked was 36.3 years (median = 37.5). In addition, 85% had attempted to quit previously. Among patients initially enrolled, 3 did not initiate radiation therapy, and 4 were removed from the study by midtreatment due to noncompliance. Midway through treatment, patients had cut self-reported cigarette use to 31% of baseline. However, 75% or more of patients had smoked within the last week at all timepoints assessed. With further follow-up, the number of cigarettes smoked daily continued to rise, reaching 61% of baseline by the 12-month follow-up. CONCLUSIONS: Patients reduced cigarette consumption, but all patients eventually resumed smoking during the 12-month follow-up. Although it is unfortunate that this study did not result in long-term smoking cessation, the results demonstrate the difficulties faced in helping patients with cancer quit, particularly patients seen at a safety-net hospital. Future efforts could be directed at intensified smoking cessation programs, likely incorporating a more standardized counseling component.

Utilization of Simulation Techniques to Enhance Quality Improvement Processes in the Emergency Department.

Introduction Quality improvement projects can help improve clinical practice in an emergency department (ED). However, it is difficult to measure outcomes in rare clinical conditions. We used a simulation program to evaluate a new protocol and workflow in the emergency blood transfusion process as well as provide additional trauma training. To determine if implementing a trauma simulation would help improve the self-reported understanding of the emergency blood transfusion process by both the ED and laboratory staff. Methods Emergency medicine residents and nursing staff participated in a high-fidelity trauma simulation. ED nursing and hospital laboratory staff used the simulation to test a new process for notification and transport of blood within the hospital. All of the participants were provided a four-item Likert scale questionnaire immediately after the training to evaluate their understanding of the ED blood process.  Results There was a significant improvement in overall scores based on paired t-tests in the full group (pre 15.0 versus post 17.6, p = 0.0005) and ED group (pre 14.7 versus post 17.8, p = 0.0007) but not in the lab group (pre 15.8 versus post 17.2, p = 0.296).  Conclusion Simulation appears to be helpful to evaluate and implement a new ED protocol or workflow.

Early Experience With Methylprednisolone on SARS-CoV-2 Infection in the African American Population, a Retrospective Analysis.

BACKGROUND: Coronavirus disease-19 (COVID-19) is associated with acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) with high mortality rates. In African American (AA) populations, COVID-19 presentations and outcomes are more severe. NIH and Interim WHO guidelines had suggested against the use of corticosteroids unless in clinical trials until the recent publication of the RECOVERY trial. Here, we analyzed the treatment effect of methylprednisolone on patients with AKI and ARDS during the initial 2 months of COVID-19 and detail the learning effect within our institution. METHODS: Between March 1 and April 30, 2020, 75 AA patients met our inclusion criteria for ARDS and AKI, of which 37 had received corticosteroids. Twenty-eight-day mortality, improvement in PaO2/FiO2 ratio, and renal function were analyzed. The impact of methylprednisolone treatment was assessed with multivariable methods. RESULTS: Survival in the methylprednisolone group reached 51% at 21 days compared to 29% in the non-corticosteroid group (P < .001). Methylprednisolone improved the likelihood of renal function improvement. PaO2/FiO2 ratio in the methylprednisolone group improved by 73% compared to 45% in the non-corticosteroid group (P = .01). Age, gender, BMI, preexisting conditions, and other treatment factors did not show any impact on renal or PaO2/FiO2 ratio improvement. The use of anticoagulants, the month of treatment, and AKI during hospitalization also influenced outcomes. CONCLUSION: In AA COVID-19 positive patients with ARDS and AKI, IV methylprednisolone lowered the incidence of mortality and improved the likelihood of renal and lung function recovery. Further investigation with a randomized control trial of corticosteroids is warranted.

Home Health Utilization in Assisted Living Settings.

Home health agencies (HHAs) are one of the most commonly used third-party providers in the assisted living (AL) setting. One way ALs may be potentially able to meet the needs of their residents despite increased impairment is through supplementing the services offered with those delivered by HHAs. We explore the growth in the delivery of HHA services to Medicare beneficiaries in AL compared with other home settings between 2012 and 2014. We also examine demographic, cognitive, and functional characteristics of beneficiaries; HHA provider characteristics; and the variation in the percentage of home health use in ALs across the country. Our findings suggest that there was a slight growth in the share of HHA services being delivered in AL. HHA recipients in AL were more likely to have cognitive and activities of daily living impairments than those receiving HHA services in other settings. This is among the first studies to examine HHA utilization in AL.

Adolescent-Specific Motivation Deficits in Autism Versus Typical Development.

Differences in motivation during adolescence relative to childhood and adulthood in autism was tested in a cross-sectional study. 156 Typically developing individuals and 79 individuals with autism ages 10-30 years of age completed a go/nogo task with social and non-social cues. To assess age effects, linear and quadratic models were used. Consistent with prior studies, typically developing adolescents and young adults demonstrated more false alarms for positive relative to neutral social cues. In autism, there were no changes in attention across age for social or non-social cues. Findings suggest reduced orienting to motivating cues during late adolescence and early adulthood in autism. The findings provide a unique perspective to explain the challenges for adolescents with autism transitioning to adulthood.

Characteristics of respiratory measures in young adults scanned at rest, including systematic changes and "missed" deep breaths.

Breathing rate and depth influence the concentration of carbon dioxide in the blood, altering cerebral blood flow and thus functional magnetic resonance imaging (fMRI) signals. Such respiratory fluctuations can have substantial influence in studies of fMRI signal covariance in subjects at rest, the so-called "resting state functional connectivity" technique. If respiration is monitored during fMRI scanning, it is typically done using a belt about the subject's abdomen to record abdominal circumference. Several measures have been derived from these belt records, including the windowed envelope of the waveform (ENV), the windowed variance in the waveform (respiration variation, RV), and a measure of the amplitude of each breath divided by the cycle time of the breath (respiration volume per time, RVT). Any attempt to gauge respiratory contributions to fMRI signals requires a respiratory measure, but little is known about how these measures compare to each other, or how they perform beyond the small studies in which they were initially proposed. Here, we examine the properties of these measures in hundreds of healthy young adults scanned for an hour each at rest, a subset of the Human Connectome Project chosen for having high-quality physiological records. We find: 1) ENV, RV, and RVT are all correlated, and ENV and RV are more highly correlated to each other than to RVT; 2) respiratory events like deep breaths exhibit characteristic heart rate elevations, fMRI signal changes, head motions, and image quality abnormalities time-locked to large deflections in the belt traces; 3) all measures can "miss" deep breaths; 4) RVT "misses" deep breaths more than ENV or RV; 5) all respiratory measures change systematically over the course of a 14.4-min scan. We discuss the implications of these findings for the literature and ways to move forward in modeling respiratory influences on fMRI scans.

Distinctions among real and apparent respiratory motions in human fMRI data.

Head motion estimates in functional magnetic resonance imaging (fMRI) scans appear qualitatively different with sub-second image sampling rates compared to the multi-second sampling rates common in the past. Whereas formerly the head appeared still for much of a scan with brief excursions from baseline, the head now appears to be in constant motion, and motion estimates often seem to divulge little information about what is happening in a scan. This constant motion has been attributed to respiratory oscillations that do not alias at faster sampling rates, and investigators are divided on the extent to which such motion is "real" motion or only "apparent" pseudomotion. Some investigators have abandoned the use of motion estimates entirely due to these considerations. Here we investigate the properties of motion in several fMRI datasets sampled at rates between 720 and 1160 ms, and describe 5 distinct kinds of respiratory motion: 1) constant real respiratory motion in the form of head nodding most evident in vertical position and pitch, which can be very large; 2) constant pseudomotion at the same respiratory rate as real motion, occurring only in the phase encode direction; 3) punctate real motions occurring at times of very deep breaths; 4) a low-frequency pseudomotion in only the phase encode direction at and after very deep breaths; 5) slow modulation of vertical and anterior-posterior head position by the respiratory envelope. We reformulate motion estimates in light of these considerations and obtain good concordance between motion estimates, physiologic records, image quality measures, and events evident in the fMRI signals. We demonstrate how variables describing respiration or body habitus separately scale with distinct kinds of head motion. We also note heritable aspects of respiration and motion.

Rigidity coincides with reduced cognitive control to affective cues in children with autism.

The present study tested whether salient affective cues would negatively influence cognitive control in children with and without autism spectrum disorder (ASD). One hundred children aged 6-12 years who were either typically developing or had ASD performed a novel go/no-go task to cues of their interest versus cues of noninterest. Linear mixed-effects (LME) models for hit rate, false alarms, and the sensitivity index d' were used to test for group differences. Caregivers completed the Repetitive Behavior Scale-Revised to test associations between repetitive behaviors and task performance. Children with ASD had reduced cognitive control toward their interests compared with typically developing children. Further, children with ASD showed reduced cognitive control to interests compared with noninterests, a pattern not observed in typically developing children. Decreased cognitive control toward interests was associated with higher insistence on sameness behavior in ASD, but there was no association between sameness behavior and cognitive control for noninterests. Together, children with ASD demonstrated decreased cognitive flexibility in the context of increased affective salience related to interests. These results provide a mechanism for how salient affective cues, such as interests, interfere with daily functioning and social communication in ASD. Further, the findings have broader clinical implications for understanding how affective cues can drive interactions between restricted patterns of behavior and cognitive control. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Medicare Outpatient Physical Therapy Expenditures Vary by Diagnosis and Functional Mobility.

BACKGROUND: Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood. OBJECTIVE: The objectives of this study were to examine variations in annual outpatient physical therapy expenditures of Medicare fee-for-service beneficiaries by primary diagnosis and baseline functional mobility, and to assess whether case mix groups based on primary diagnosis and functional mobility scores would be useful for expenditure differentiation. DESIGN: This was an observational, longitudinal study. METHODS: Volunteer providers in community settings participated in data collection with Continuity Assessment Record and Evaluation-Community (CARE-C) assessments for Medicare fee-for-service beneficiaries. Annual outpatient physical therapy expenditures were calculated using allowed charges on Medicare claims; primary diagnosis and baseline functional mobility were obtained from CARE-C assessments. Whether annual expenditures varied significantly across primary diagnosis groups and within diagnosis groups by functional mobility was examined. RESULTS: Data for 4210 patients (mean [SD] age = 72.9 [9.9] years; 64.6% women) from 127 providers were included. Mean expenditures differed significantly across 12 primary diagnosis groups created from CARE-C clinician-reported diagnoses (F = 12.73; df = 11). Twenty-five pairwise differences in 66 pairwise diagnosis group comparisons were statistically significant. Within 8 diagnosis groups, expenditures were significantly higher for low-mobility subgroups than for high-mobility subgroups; borderline significance was achieved for 1 diagnosis group. LIMITATIONS: The small convenience sample limited the statistical power and the generalizability of the results. CONCLUSIONS: Significant variations in physical therapy expenditures based on primary diagnosis and baseline functional mobility support the use of these variables in predicting outpatient physical therapy expenditures. Although Medicare's annual therapy spending cap was repealed effective January 2018, the data from this study provide an initial foundation to inform any future policy efforts, such as targeted medical review, risk-adjusted therapy payments, or case mix groups as potential payment alternatives. Additional research with larger samples is needed to further develop and test case mix groups and improve generalizability to the national population. Refined case mix groups could also help providers prognosticate physical therapy expenditures based on patient profiles.

Customized head molds reduce motion during resting state fMRI scans.

Head motion causes artifacts in functional magnetic resonance imaging (fMRI) scans, a problem especially relevant for task-free resting state paradigms and for developmental, aging, and clinical populations. In a cohort spanning 7-28 years old (mean age 15) we produced customized head-anatomy-specific Styrofoam molds for each subject that inserted into an MRI head coil. We scanned these subjects under two conditions: using our standard procedure of packing the head coil with foam padding about the head to reduce head motion, and using the customized molds to reduce head motion. In 12 of 13 subjects, the molds reduced head motion throughout the scan and reduced the fraction of a scan with substantial motion (i.e., volumes with motion notably above baseline levels of motion). Motion was reduced in all 6 head position estimates, especially in rotational, left-right, and superior-inferior directions. Motion was reduced throughout the full age range studied, including children, adolescents, and young adults. In terms of the fMRI data itself, quality indices improved with the head mold on, scrubbing analyses detected less distance-dependent artifact in scans with the head mold on, and distant-dependent artifact was less evident in both the entire scan and also during only low-motion volumes. Subjects found the molds comfortable. Head molds are thus effective tools for reducing head motion, and motion artifacts, during fMRI scans.

A Retrospective Study of Administrative Data to Identify High-Need Medicare Beneficiaries at Risk of Dying and Being Hospitalized.

BACKGROUND: Developing a definition of what constitutes high need among Medicare beneficiaries using administrative data is an important prerequisite to evaluating value-based payment reforms. While various definitions of high need exist, their predictive validity for different patient outcomes in the following year has not been systematically assessed for both fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries. OBJECTIVE: To develop a definition of high need using administrative data in 2014 and to examine its predictive validity for patient outcomes in 2015 as compared to alternative definitions for both FFS and MA beneficiaries. DESIGN: Retrospective cohort study of national Medicare claims and post-acute assessment data. PARTICIPANTS: All Medicare beneficiaries in 2014 who survived until the end of the year (n = 54,717,039). MAIN MEASURES: Two or more complex conditions, 6 or more chronic conditions, acute or post-acute health services utilization, indicators of frailty, complete dependency in mobility or in any activities of daily living in post-acute care assessments, hospitalization, mortality, days in community, Medicare expenditures. KEY RESULTS: Based on our definition of high-need patients, 13.17% of FFS and 8.85% of MA beneficiaries were identified as high need in 2014. High-need FFS patients had mortality rates 7.1 times higher (16.23% vs. 2.27%) and hospitalization rates 3.4 times higher (40.69 vs. 12.03) in 2015 compared to other beneficiaries. Competing high-need definitions all had good specificity (≥ 0.88). Having 3 or more Hierarchical Chronic Conditions yielded a good positive predictive value for hospitalization, at 0.50, but only identified 19.71% of FFS beneficiaries hospitalized and 28.46% of FFS decedents that year as high need, as opposed to 33.92% and 51.98% for the new definition. Results were similar for MA beneficiaries. CONCLUSIONS: The proposed high-need definition has better sensitivity and yields a sample of almost 5 million FFS and 1.5 million MA beneficiaries, facilitating outcome performance comparisons across health systems.

Cervical aortic arch: an unusual cause of a pulsatile neck mass.

A 72-year-old man presented with epistaxis on two occasions requiring admission. Prior to performing a bilateral sphenopalatine artery ligation diathermy, anaesthetic concern was raised regarding what the patient described as a 'congenital aortic aneurysm', with an overlying scar secondary to explorative surgery as a child. The abnormality was a cervical aortic arch (CAA). CAA is a rare vascular anomaly, which most commonly manifests as a pulsatile neck mass. In this case, we discuss the differential diagnosis for a pulsatile neck mass and considerations to be made in the workup. We also highlight the importance of cardiovascular risk factor management in patients with CAA.

Effects of Medicare Medical Reviews on Ambiguous Short-Stay Hospital Admissions.

OBJECTIVE: To examine the effects of Medicare's Medical Review (MR) program on short-stay inpatient hospitalization. DATA SOURCES/STUDY SETTING: One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007-2010). STUDY DESIGN: Retrospective observational study using a difference-in-differences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed size, system membership, and inpatient admission rate to test for differential effects. The comparison group was hospital visits occurring in those MACs that had yet to implement, as well as those that did not implement during the period of interest. DATA COLLECTION: None. PRINCIPAL FINDINGS: Medical Review significantly reduced the likelihood of inpatient admission for patients with an intake diagnosis of "Non-Specific Chest Pain" by 1.29 percentage points (p < .001). This effect was stronger in larger hospitals (-2.03, p < .001), nonsystem hospitals (-2.54, p < .001), and those with a lower inpatient rate (-1.86, p < .001). CONCLUSIONS: Short inpatient hospitalizations were emphasized by MR, and our results show that MR modestly reduced their prevalence among certain patients and certain hospitals. Future work should examine whether this resulted in adverse patient outcomes.

Increasing Prevalence of Assisted Living as a Substitute for Private-Pay Long-Term Nursing Care.

OBJECTIVE: Given the tremendous growth in assisted living (AL) over the past 20 years, it is important to understand how expansion has affected the demand for long-term care (LTC) provided in nursing homes (NHs). We estimated the effect of a change in county-level AL beds on the prevalence of private-pay residents and private-pay resident days at the NH-level. DATA SOURCES: National census of large AL providers (25+ beds), and Minimum Data Set combined with Medicare enrollment records and claims from 2007 and 2014. STUDY DESIGN: Retrospective longitudinal analysis of LTC markets. PRINCIPAL FINDINGS: Mean AL beds per county increased from 285 to 324, while NHs exhibited a decrease in private-pay residents (20.1 to 17.7 percent) and resident days (21.3 to 17.5 percent). An increase of 1,000 AL beds at the county level is associated with a reduction of 0.44 percentage points in private-pay resident days but is not significantly associated with percent of private-pay residents. CONCLUSIONS: These results suggest that increases in AL capacity have potentially allowed NH residents to delay or decrease their privately financed lengths of stay. As demand for AL continues to grow, it will be important to assess the effects on other LTC sectors.