Assessing Disparities in Medicaid Home- and Community-Based Services: A Systematic Review.

In recent years, expansion of home and community-based services (HCBS) for older adults and persons with disabilities has become a national priority in the U.S. In addition, lawmakers and health-care providers are pursuing opportunities to minimize disparities in healthcare service delivery. Marrying these priorities will require policymakers to identify existing Medicaid HCBS disparities toward development of new, more equitable policies. This study provides a systematic literature review using an adapted theoretical framework to describe disparities in Medicaid HCBS. Key findings are organized into four domains: availability, accessibility, accommodation, and acceptability. We found a lack of concerted research effort targeting Medicaid HCBS disparities in the context of all four domains, with an especially notable dearth of content related to acceptability. We also identified very few articles that focused on specific marginalized groups, suggesting a need for more research into whether Medicaid HCBS are available, accessible, accommodating, and acceptable for a variety of diverse populations. Our findings underscore the need for researchers and policymakers to conceptualize and evaluate existing Medicaid HCBS policy toward development of a more equitable Medicaid HCBS program design in the future.

Outcomes for Long-Stay Nursing Facility Residents Following On-Site Acute Care under a CMS Initiative.

OBJECTIVES: The goal of this study was to describe outcomes of long-term nursing facility (NF) residents treated for one of 6 conditions on-site in the NF and to compare outcomes to those treated for the same conditions in the hospital. DESIGN: Cross-sectional retrospective study. SETTINGS AND PARTICIPANTS: The Centers for Medicare & Medicaid Services (CMS) Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents-Payment Reform enabled participating NFs to bill Medicare for providing on-site care to eligible long-stay residents meeting specified severity criteria due to any of 6 medical conditions, as an alternative to hospitalization. For billing purposes, residents were required to meet clinical criteria severe enough to warrant hospitalization. METHODS: We used the Minimum Data Set assessments to identify eligible long-stay NF residents. We used Medicare data to identify residents who were treated, either on-site or in the hospital, for the 6 conditions and measure outcomes including subsequent hospitalization and death. To compare residents treated in the 2 modes, we used logistic regression models and adjusted for demographics, functional and cognitive status, and comorbidities. RESULTS: Among residents treated on-site for the 6 conditions, 13.6% were subsequently hospitalized and 7.8% died, within 30 days, compared to 26.5% and 17.0%, respectively, among those treated in the hospital. Based on multivariate analysis, those treated in the hospital were more likely to be readmitted (OR = 1.666, P < .001) or to die (OR = 2.251, P < .001). CONCLUSIONS AND IMPLICATIONS: Although unable to fully account for differences in unobserved severity of illness between residents treated on-site vs in the hospital, our results do not indicate any harm, but rather a possible benefit, to being treated on-site.

Coins as intermediate targets: reconstructive analysis with synthetic body models.

The phenomenon of intermediate targets is well known in wound ballistics. In forensic science, models are used to reconstruct injury patterns to answer questions regarding the dynamic formation of these unusual injuries. Soft-tissue substitutes or glycerin soap and ordnance gelatin have been well established. Recently, based on previous experiences with artificial bone, a skull-brain model was developed. The goal of this study was to create and analyze a model-supported reconstruction of a real forensic case with a coin as an intermediate target. It was possible not only to demonstrate the "bullet-coin interaction," but also to recreate the wound pattern found in the victim. This case demonstrates that by using ballistic models, gunshot cases can be reproduced simply and economically, without coming into conflict with ethical guidelines.

Generalized Empirical Bayes Modeling via Frequentist Goodness of Fit.

The two key issues of modern Bayesian statistics are: (i) establishing principled approach for distilling statistical prior that is consistent with the given data from an initial believable scientific prior; and (ii) development of a consolidated Bayes-frequentist data analysis workflow that is more effective than either of the two separately. In this paper, we propose the idea of "Bayes via goodness-of-fit" as a framework for exploring these fundamental questions, in a way that is general enough to embrace almost all of the familiar probability models. Several examples, spanning application areas such as clinical trials, metrology, insurance, medicine, and ecology show the unique benefit of this new point of view as a practical data science tool.

Cerebral accumulation of Tc-99m ethyl cysteinate dimer (ECD) in severe, transient hypothyroidism.

Thyroid dysfunction is a well-known contributor to psychiatric morbidity. To investigate the mechanism(s) by which thyroid hormone availability affects cerebral activity, a group of thyroidectomized individuals were studied at two points in time: when markedly hypothyroid in preparation for a thyroid cancer metastatic survey and when clinically and/or biochemically euthyroid. The analysis consisted of single photon emission computed tomography (SPECT) using a lipophilic radiopharmaceutical, technetium-99m (Tc-99m) ethyl cysteinate dimer (ECD), and measurement of mood, anxiety, and psychomotor function, at both points in time. Both increases and decreases in regional cerebral radiotracer activity were found in the hypothyroid condition relative to the euthyroid condition, and the neuropsychological assessment demonstrated significantly greater depression, anxiety, and psychomotor slowing during the hypothyroid state. Increased radiotracer activity was seen in frontal and temporal regions, posterior cingulate gyrus, thalamus, and putamen. Decreased activity was seen in the occipital cortex, and the pre- and postcentral gyri. This distribution pattern is partially consistent with findings in persons with depression and anxiety unrelated to thyroid disease, supporting the link between the symptoms observed in our subjects and their marked hypothyroidism. Finally, these results support the need to consider the effect of the thyroid state on cellular mechanisms of uptake and retention of cerebral blood flow radiopharmaceuticals when studying 'noneuthyroid' individuals.

Comparison of four techniques to estimate radiation dose to skin during angiographic and interventional radiology procedures.

PURPOSE: Four techniques used to estimate radiation risk were compared to determine whether commonly used dosimetry measurements permit reliable estimates of skin dose. Peak skin dose (PSD) is known to be the most reliable estimate of risk to skin. The purpose of this study is to determine peak skin dose with use of real-time software measurements and to correlate other measures of dose with PSD. MATERIALS AND METHODS: Two hundred twelve patients undergoing arch aortography and bilateral carotid arteriography (referred to as "carotid"), abdominal aortography and bilateral lower extremity runoff ("runoff"), or tunneled chest wall port placement ("port") were studied. Fluoroscopy time, dose-area product (DAP), and cumulative dose at the interventional reference point were recorded for all procedures; PSD was recorded for a subset of 105 procedures. The dose index, defined as the ratio between PSD and cumulative dose, was also determined. RESULTS: In general, correlation values for comparisons between fluoroscopy time and the other measures of dose (r =.29 to.78) were lower than values for comparisons among DAP, cumulative dose, and PSD (r =.52 to.94). For all procedures, pair-wise correlations between DAP, cumulative skin dose, and PSD were statistically significant (P <.01) The ratio between PSD and cumulative skin dose (dose index) was significantly different for ports versus other procedures (carotid, Z = 4.62, P <.001; runoff, Z = 4.52, P <.001), but carotid and runoff procedures did not differ significantly in this regard (Z = 0.746, P =.22). Within each individual procedure type, the range of values for the dose index varied 156.7-fold for carotid arteriography, 3.2-fold for chest ports, and 175-fold for aortography and runoff. CONCLUSION: Fluoroscopy time is a poor predictor of risk because it does not correlate well with PSD. Cumulative dose and DAP are not good analogues of PSD because of weak correlations for some procedures and because of wide variations in the dose index for all procedures.