Assessment of Social Vulnerabilities of Care and Prognosis in Adult Ocular Melanomas in the US.

BACKGROUND: Prior works have studied the impact of social determinants on various cancers but there is limited analysis on eye-orbit cancers. Current literature tends to focus on socioeconomic status and race, with sparse analysis of interdisciplinary contributions. We examined social determinants as measured by the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), quantifying eye and orbit melanoma disparities across the United States. METHODS: A retrospective review of 15,157 patients diagnosed with eye-orbit cancers in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2017 was performed, extracting 6139 ocular melanomas. SVI scores were abstracted and matched to SEER patient data, with scores generated by weighted averages per population density of county's census tracts. Primary outcome was months survived, while secondary outcomes were advanced staging, high grading, and primary surgery receipt. RESULTS: With increased total SVI score, indicating more vulnerability, we observed significant decreases of 23.1% in months survival for melanoma histology (p < 0.001) and 19.6-39.7% by primary site. Increasing total SVI showed increased odds of higher grading (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.02-1.43) and decreased odds of surgical intervention (OR 0.94, 95% CI 0.92-0.96). Of the four themes, higher magnitude contributions were observed with socioeconomic status (26.0%) and housing transportation (14.4%), while lesser magnitude contributions were observed with minority language status (13.5%) and household composition (9.0%). CONCLUSIONS: Increasing social vulnerability, as measured by the CDC SVI and its subscores, displayed significant detrimental trends in prognostic and treatment factors for adult eye-orbit melanoma. Subscores quantified which social determinants contributed most to disparities. This lays groundwork for providers to target the highest-impact social determinant for non-clinical factors in patient care.

Using the Stratum-Specific Likelihood Ratio Method to Derive Outcome-Based Hospital Volume Categories for Total Knee Replacement.

BACKGROUND: Evidence of higher hospital volume being associated with improved outcomes for patients undergoing total knee replacement (TKR) is mostly based on arbitrary distribution-based thresholds. OBJECTIVE: We aimed to define outcome-based volume thresholds using data from a national database. METHODS: We used the MedPAR Limited Data Set inpatient data from 2010-2015 to identify patients who had undergone primary TKR. Surgical and TKR specific complications occurring within the index hospitalization and all-cause readmission within 90 days were considered adverse events. We derived an average annual TKR case volume for each hospital and applied the stratum-specific likelihood ratio method to determine volume categories indicative of a similar likelihood of 90-day post-operative complications. Hierarchical multivariable logistic regression with a random intercept for hospital nested within study year and adjusted for patient and hospital characteristics was performed to determine if these volume thresholds were still associated with the odds of 90-day readmission for complications after adjustment. RESULTS: SSLR analysis yielded 4 hospital volume categories based on the likelihood of 90-day postoperative complications: 1-31 (low), 32-127 (medium), 128-248 (high), and 429+ (very high) TKRs performed per year. The results of the hierarchical multivariable logistic regression showed significantly increased odds of 90-day complications at lower volume categories. Sensitivity analyses confirmed our main findings. CONCLUSIONS: This study is the first to provide national-level volume categories that are evidence-based. Publicizing these thresholds may enhance quality measures available to patients, providers, and payors.

Benchmark findings from a veteran electronic patient-reported outcomes evaluation from a chronic pain management telehealth program.

BACKGROUND: Chronic pain is a leading cause of disability and negatively impacts biological/physical, psychological, and social aspects of life resulting in significant pain interference or disability. This project was part of a longitudinal mixed-methods implementation evaluation of the TelePain-Empower Veterans Program (EVP), a non-pharmacological chronic pain intervention. The purpose of this quality management project was to examine electronic patient-reported outcome measures (ePROs) including primary pain-related (intensity, interference, catastrophizing, kinesiophobia) and secondary outcomes (physical, psychological, acceptance, social) to determine TelePain-EVP effectiveness. Secondary purpose was to examine dosing effects to better understand potential dose relationships between EVP use and ePROs. METHODS: Standardized ePRO measures were examined at week 1 (baseline), week 10 (post-EVP), and week 26 (follow-up). Qualtrics, a cloud-based platform was used to collect ePRO data at each time point. Veterans that completed at-least one survey at any specified time point were categorized as responders (n = 221). Linear-mixed models (LMMs) were fit to assess changes for each primary and secondary ePRO. RESULTS: Participants ranged from 24 to 81 years old; veterans were typically male (65.16%), black or African American (76.47%), married or partnered (41.63%), attended at-least some college or vocational school (67.87%), and reported low back as their primary pain location (29.41%). There was a significant decrease in pain catastrophizing from baseline to post-TelePain-EVP (p < .001). However, pain catastrophizing improvement from baseline was not present at week 26 (p = .116). Pain interference also decreased from baseline to post-treatment (p = .05), but this improvement did not exceed the adjusted significance threshold. Additional pre-post improvements were also observed for certain secondary ePROs: psychological (anxiety, depression), acceptance (activities engagement). Only the activities engagement effect remained 26 weeks from baseline. Mixed results were observed for EVP dose across primary and secondary outcomes. CONCLUSIONS: Evidence from this evaluation indicate that TelePain-EVP has positive outcomes for certain pain (catastrophizing), psychological (anxiety, depression), and acceptance (activities engagement) for veterans with chronic pain. More TelePain related studies and enterprise-wide evaluations are needed along with comparative and cost effectiveness methods to determine patient benefits and the economic value gained of treatment options such as TelePain-EVP.

Beyond 10-Year Risk: A Cost-Effectiveness Analysis of Statins for the Primary Prevention of Cardiovascular Disease.

BACKGROUND: Cholesterol guidelines typically prioritize primary prevention statin therapy on the basis of 10-year risk of cardiovascular disease. The advent of generic pricing may justify expansion of statin eligibility. Moreover, 10-year risk may not be the optimal approach for statin prioritization. We estimated the cost-effectiveness of expanding preventive statin eligibility and evaluated novel approaches to prioritization from a Scottish health sector perspective. METHODS: A computer simulation model predicted long-term health and cost outcomes in Scottish adults ≥40 years of age. Epidemiologic analysis was completed using the Scottish Heart Health Extended Cohort, Scottish Morbidity Records, and National Records of Scotland. A simulation cohort was constructed with data from the Scottish Health Survey 2011 and contemporary population estimates. Treatment and cost inputs were derived from published literature and health service cost data. The main outcome measure was the lifetime incremental cost-effectiveness ratio, evaluated as cost (2020 GBP) per quality-adjusted life-year (QALY) gained. Three approaches to statin prioritization were analyzed: 10-year risk scoring using the ASSIGN score, age-stratified risk thresholds to increase treatment rates in younger individuals, and absolute risk reduction (ARR)-guided therapy to increase treatment rates in individuals with elevated cholesterol levels. For each approach, 2 policies were considered: treating the same number of individuals as those with an ASSIGN score ≥20% (age-stratified risk threshold 20, ARR 20) and treating the same number of individuals as those with an ASSIGN score ≥10% (age-stratified risk threshold 10, ARR 10). RESULTS: Compared with an ASSIGN score ≥20%, reducing the risk threshold for statin initiation to 10% expanded eligibility from 804 000 (32% of adults ≥40 years of age without CVD) to 1 445 500 individuals (58%). This policy would be cost-effective (incremental cost-effectiveness ratio, £12 300/QALY [95% CI, £7690/QALY-£26 500/QALY]). Incremental to an ASSIGN score ≥20%, ARR 20 produced ≈8800 QALYs and was cost-effective (£7050/QALY [95% CI, £4560/QALY-£10 700/QALY]). Incremental to an ASSIGN score ≥10%, ARR 10 produced ≈7950 QALYs and was cost-effective (£11 700/QALY [95% CI, £9250/QALY-£16 900/QALY]). Both age-stratified risk threshold strategies were dominated (ie, more expensive and less effective than alternative treatment strategies). CONCLUSIONS: Generic pricing has rendered preventive statin therapy cost-effective for many adults. ARR-guided therapy is more effective than 10-year risk scoring and is cost-effective.

Utility of the Healthy Aging Brain Care Monitor as a Patient-Reported Symptom Monitoring Tool in Older Injury Survivors.

INTRODUCTION: The objective of this study was to evaluate the performance of the Healthy Aging Brain Care Monitor (HABC-M) as a patient-reported outcome tool to measure cognitive, functional, and psychological symptoms among older adults who sustained non-neurologic injuries requiring hospital admission. METHODS: We used data from a multicenter randomized controlled trial to evaluate the utility of the HABC-M Self-Report version in older patients recovering from traumatic injuries. A total of 143 patients without cognitive impairment were included in the analysis. Cronbach's alpha was used to measure the internal consistency, and Spearman's rank correlation test was used to evaluate the relationship of the HABC-M with standard measures of cognitive, functional, and psychological outcomes. RESULTS: The HABC-M subscales and the total scale showed satisfactory internal consistency (Cronbach's alpha = 0.64 to 0.77). The HABC-M cognitive subscale did not correlate with the Mini-Mental State Examination. The HABC-M functional and psychological subscales correlated with corresponding standard reference measures (|rs| = 0.24-0.59). CONCLUSIONS: The HABC-M Self-Report version is a practical alternative to administering multiple surveys to monitor functional and psychological sequelae in older patients recovering from recent non-neurologic injuries. Its clinical application may facilitate personalized, multidisciplinary care coordination among older trauma survivors without cognitive impairment.

Disparities in access to robotic technology and perioperative outcomes among patients treated with radical prostatectomy.

BACKGROUND: Most radical prostatectomies are completed with robotic assistance. While studies have previously evaluated perioperative outcomes of robot-assisted radical prostatectomy (RARP), this study investigates disparities in access and clinical outcomes of RARP. STUDY DESIGN: The National Cancer Database (NCDB) was used to identify patients who received radical prostatectomy for cancer between 2010 and 2017 with outcomes through 2018. RARP was compared to open radical prostatectomy (ORP). Odds of receiving RARP were evaluated while adjusting for covariates. Overall survival was evaluated using a propensity-score matched cohort. RESULTS: Overall, 354 752 patients were included with 297 676 (83.9%) receiving RARP. Patients who were non-Hispanic Black (82.8%) or Hispanic (81.3%) had lower rates of RARP than non-Hispanic White (84.0%) or Asian patients (87.7%, p < 0.001). Medicaid or uninsured patients were less likely to receive RARP (75.5%) compared to patients with Medicare or private insurance (84.4%, p < 0.001). Medicaid or uninsured status was associated with decreased odds of RARP in adjusted multivariable analysis (OR 0.61, 95% CI 0.49-0.76). RARP was associated with decreased perioperative mortality and improved overall survival compared to ORP. CONCLUSION: Patients who were underinsured were less likely to receive RARP. Improved access to RARP may lead to decreased disparities in perioperative outcomes for prostate cancer.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans.

BACKGROUND: Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management. OBJECTIVES: The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation. METHODS: A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO. RESULTS: Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures. DISCUSSION: Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial.

BACKGROUND: Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills. OBJECTIVE: The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners. METHODS: A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program. RESULTS: At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes. CONCLUSIONS: Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Cost-effectiveness analysis of overground robotic training versus conventional locomotor training in people with spinal cord injury.

BACKGROUND: Few, if any estimates of cost-effectiveness for locomotor training strategies following spinal cord injury (SCI) are available. The purpose of this study was to estimate the cost-effectiveness of locomotor training strategies following spinal cord injury (overground robotic locomotor training versus conventional locomotor training) by injury status (complete versus incomplete) using a practice-based cohort. METHODS: A probabilistic cost-effectiveness analysis was conducted using a prospective, practice-based cohort from four participating Spinal Cord Injury Model System sites. Conventional locomotor training strategies (conventional training) were compared to overground robotic locomotor training (overground robotic training). Conventional locomotor training included treadmill-based training with body weight support, overground training, and stationary robotic systems. The outcome measures included the calculation of quality adjusted life years (QALYs) using the EQ-5D and therapy costs. We estimate cost-effectiveness using the incremental cost utility ratio and present results on the cost-effectiveness plane and on cost-effectiveness acceptability curves. RESULTS: Participants in the prospective, practice-based cohort with complete EQ-5D data (n = 99) qualified for the analysis. Both conventional training and overground robotic training experienced an improvement in QALYs. Only people with incomplete SCI improved with conventional locomotor training, 0.045 (SD 0.28), and only people with complete SCI improved with overground robotic training, 0.097 (SD 0.20). Costs were lower for conventional training, $1758 (SD $1697) versus overground robotic training $3952 (SD $3989), and lower for those with incomplete versus complete injury. Conventional overground training was more effective and cost less than robotic therapy for people with incomplete SCI. Overground robotic training was more effective and cost more than conventional training for people with complete SCI. The incremental cost utility ratio for overground robotic training for people with complete spinal cord injury was $12,353/QALY. CONCLUSIONS: The most cost-effective locomotor training strategy for people with SCI differed based on injury completeness. Conventional training was more cost-effective than overground robotic training for people with incomplete SCI. Overground robotic training was more cost-effective than conventional training for people with complete SCI. The effect estimates may be subject to limitations associated with small sample sizes and practice-based evidence methodology. These estimates provide a baseline for future research.

Randomized Trial Evaluating Health System Expenditures with Transitional Care Services for Adults with No Usual Source of Care at Discharge.

BACKGROUND: Multidisciplinary transitional care services reduce readmissions for high-risk patients, but it is unclear if health system costs to offer these intensive services are offset by avoidance of higher downstream expenditures. OBJECTIVE: To evaluate net costs for a health system offering transitional care services DESIGN: One-year pragmatic, randomized trial PARTICIPANTS: Adults aged ≥ 18 without a usual source of follow-up care at the time of hospital discharge were enrolled through a high-volume, urban academic medical center in Chicago, IL, USA, from September 2015 through February 2016. INTERVENTIONS: Eligible patients were silently randomized before discharge by an automated electronic health record algorithm allocating them in a 1:3 ratio to receive routine coordination of post-discharge care (RC) versus being offered intensive, multidisciplinary transitional care (TC) services. MAIN MEASUREMENTS: Health system costs were collected from facility administrative systems and transformed to standardized costs using Medicare reference files. Multivariable generalized linear models estimated proportional differences in net costs over one year. KEY RESULTS: Study patients (489 TC; 164 RC) had a mean age of 44 years; 34% were uninsured, 55% had public insurance, and 49% self-identified as Black or Latinx. Over 90 days, cost differences between groups were not statistically significant. Over 180 days, the TC group had 41% lower ED/observation costs (adjusted cost ratio [aCR], 0.59; 95% CI, 0.36-0.97), 50% lower inpatient costs (aCR, 0.50; 95% CI, 0.27-0.95), and 41% lower total healthcare costs (aCR, 0.59; 95% CI, 0.36-0.99) than the RC group. Over 365 days, total cost differences remained of similar magnitude but no longer were statistically significant. CONCLUSIONS: Offering TC services for vulnerable adults at discharge reduced net health system expenditures over 180 days. The promising economic case for multidisciplinary transitional care interventions warrants further research. TRIAL REGISTRATION: National Clinical Trials Registry (NCT03066492).

Primary care virtual resource use prior and post COVID-19 pandemic onset.

BACKGROUND: The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset. METHODS: VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes. RESULTS: Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset. CONCLUSIONS: These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.

Did the Affordable Care Act Decrease Veteran Enrollment in the Veterans Health Administration?

BACKGROUND: Provisions of the Affordable Care Act (ACA) provided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends. METHODS: The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were compared between 3 enrollment groups: pre-2012, pre-ACA (2012-2013), and post-ACA (2014-2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics. RESULTS: A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups. CONCLUSIONS: The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care.

Effects of 2 Forms of Practice Facilitation on Cardiovascular Prevention in Primary Care: A Practice-randomized, Comparative Effectiveness Trial.

BACKGROUND: Effective quality improvement (QI) strategies are needed for small practices. OBJECTIVE: The objective of this study was to compare practice facilitation implementing point-of-care (POC) QI strategies alone versus facilitation implementing point-of-care plus population management (POC+PM) strategies on preventive cardiovascular care. DESIGN: Two arm, practice-randomized, comparative effectiveness study. PARTICIPANTS: Small and mid-sized primary care practices. INTERVENTIONS: Practices worked with facilitators on QI for 12 months to implement POC or POC+PM strategies. MEASURES: Proportion of eligible patients in a practice meeting "ABCS" measures: (Aspirin) Aspirin/antiplatelet therapy for ischemic vascular disease, (Blood pressure) Controlling High Blood Pressure, (Cholesterol) Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, and (Smoking) Tobacco Use: Screening and Cessation Intervention, and the Change Process Capability Questionnaire. Measurements were performed at baseline, 12, and 18 months. RESULTS: A total of 226 practices were randomized, 179 contributed follow-up data. The mean proportion of patients meeting each performance measure was greater at 12 months compared with baseline: Aspirin 0.04 (95% confidence interval: 0.02-0.06), Blood pressure 0.04 (0.02-0.06), Cholesterol 0.05 (0.03-0.07), Smoking 0.05 (0.02-0.07); P<0.001 for each. Improvements were sustained at 18 months. At 12 months, baseline-adjusted difference-in-differences in proportions for the POC+PM arm versus POC was: Aspirin 0.02 (-0.02 to 0.05), Blood pressure -0.01 (-0.04 to 0.03), Cholesterol 0.03 (0.00-0.07), and Smoking 0.02 (-0.02 to 0.06); P>0.05 for all. Change Process Capability Questionnaire improved slightly, mean change 0.30 (0.09-0.51) but did not significantly differ across arms. CONCLUSION: Facilitator-led QI promoting population management approaches plus POC improvement strategies was not clearly superior to POC strategies alone.

Impact of Medicaid expansion on access and healthcare among individuals with sickle cell disease.

PURPOSE: Sickle cell disease (SCD) is associated with high acute healthcare utilization. The purpose of this study was to examine whether Medicaid expansion in California increased Medicaid enrollment, increased hydroxyurea prescriptions filled, and decreased acute healthcare utilization in SCD. METHODS: Individuals with SCD (≤65 years and enrolled in Medicaid for ≥6 total calendar months any year between 2011 and 2016) were identified in a multisource database maintained by the California Sickle Cell Data Collection Program. We describe trends and changes in Medicaid enrollment, hydroxyurea prescriptions filled, and emergency department (ED) visits and hospital admissions before (2011-2013) and after (2014-2016) Medicaid expansion in California. RESULTS: The cohort included 3635 individuals. Enrollment was highest in 2014 and lowest in 2016 with a 2.8% annual decease postexpansion. Although <20% of the cohort had a hydroxyurea prescription filled, the percentage increased by 5.2% annually after 2014. The ED visit rate was highest in 2014 and decreased slightly in 2016, decreasing by 1.1% annually postexpansion. Hospital admission rates were similar during the pre- and postexpansion periods. Young adults and adults had higher ED and hospital admission rates than children and adolescents. CONCLUSIONS: Medicaid expansion does not appear to have improved enrollment or acute healthcare utilization among individuals with SCD in California. Future studies should explore whether individuals with SCD transitioned to other insurance plans or became uninsured postexpansion, the underlying reasons for low hydroxyurea utilization, and the lack of effect on hospital admissions despite a modest effect on ED visits.

Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics?

Background and Purpose- Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods- We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results- There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions- We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.

Community Health and Employee Work Performance in the American Manufacturing Environment.

Although better community health has long been assumed to be good for local businesses, evidence demonstrating the relationship between community health and employee performance is quite limited. Drawing on human resources data on 6103 employees from four large US manufacturing plants, we found that employees living in counties with poor community health outcomes had considerably higher rates of absenteeism and tardiness (ABT). For example, in one company, employees living in communities with high rates of children on free or reduced lunch had higher rates of ABT compared to other employees [adjusted odds ratio (OR) 2.76, 95% confidence interval (CI) 2.52-3.04], and employees living in communities with high rates of drug overdose deaths had higher rates of ABT (OR 1.51, 95% CI 1.29-1.77). In one plant, the annual value of lost wages due to ABT was over $1.3 million per year. Employees reported that poor community health (e.g., poverty, caregiving burdens, family dysfunction, drug use) resulted in "mental stress" leading to distraction, poor job performance, and more rarely, lapses in safety. These findings bolster the case for greater private sector investment in community health.

Reduced Hospitalizations, Emergency Room Visits, and Costs Associated with a Web-Based Health Literacy, Aligned-Incentive Intervention: Mixed Methods Study.

BACKGROUND: The association between health literacy and health care costs, particularly for hospitalizations and emergency room services, has been previously observed. Health information interventions aimed at addressing the negative impacts of inadequate health literacy are needed. The MedEncentive Mutual Accountability and Information Therapy (MAIT) Program is a Web-based system designed to improve health and lower costs by aligning patient-doctor incentives. OBJECTIVE: In this mixed methods study of a Web-based patient-doctor aligned-incentive, information therapy program conducted in an 1800-member employee health plan, we aimed to (1) determine the program's quantitative impact on hospitalization and emergency room utilization and costs, and (2) assess survey responses about the program's perceived value. METHODS: We used a mixed methods, single within-group, pre-post, descriptive study design. We analyzed quantitative data using pre-post mean utilization and cost differences and summarized the data using descriptive statistics. We used open-ended electronic survey items to collect descriptive data and analyzed them using thematic content analysis. RESULTS: Hospitalizations and emergency room visits per 1000 decreased 32% (26.5/82.4) and 14% (31.3/219.9), respectively, after we implemented the program in 2015-2017, relative to 2013-2014. Correspondingly, the plan's annual per capita expenditures declined US $675 (95% CI US $470-865), or 10.8% ($675/$6260), after program implementation in 2015-2017 (US $5585 in 2013-2014 dollars), relative to the baseline years of 2013-2014 (US $6260; P<.05). Qualitative findings suggested that respondents valued the program, benefiting from its educational and motivational aspects to better self-manage their health. CONCLUSIONS: Analyses suggested that the reported reductions in hospitalizations, emergency room visits, and costs were associated with the program. Qualitative findings indicated that targeted users perceived value in participating in the MAIT Program. Further research with controls is needed to confirm these outcomes and more completely understand the health improvement and cost-containment capabilities of this Web-based health information, patient-doctor, aligned-incentive program.

Corporate Philanthropy Toward Community Health Improvement in Manufacturing Communities.

Virtually all large employers engage in corporate philanthropy, but little is known about the extent to which it is directed toward improving community health. We conducted in-depth interviews with leaders of corporate philanthropy from 13 of the largest manufacturing companies in the US to understand how giving decisions were made, the extent to which funding was directed towards improving community health, and whether companies coordinate with local public health agencies. We found that corporate giving was sizable and directed towards communities in which the manufacturers have a large presence. Giving was aligned with the social determinants of health (i.e., aimed at improving economic stability, the neighborhood and physical environment, education, food security and nutrition, the community and social context, and the health care system). However, improving public health was not often cited as a goal of corporate giving, and coordination with public health agencies was limited. Our results suggest that there may be opportunities for public health agencies to help guide corporate philanthropy, particularly by sharing community-level data and offering their measurement and evaluation expertise.

Risk management of emergency service vehicle crashes in the United States fire service: process, outputs, and recommendations.

BACKGROUND: Emergency service vehicle crashes (ESVCs) are a leading cause of death in the United States fire service. Risk management (RM) is a proactive process for identifying occupational risks and reducing hazards and unwanted events through an iterative process of scoping hazards, risk assessment, and implementing controls. We describe the process, outputs, and lessons learned from the application of a proactive RM process to reduce ESVCs in US fire departments. METHODS: Three fire departments representative of urban, suburban, and rural geographies, participated in a facilitated RM process delivered through focus groups and stakeholder discussion. Crash reports from department databases were reviewed to characterize the context, circumstances, hazards and risks of ESVCs. Identified risks were ranked using a risk matrix that considered risk likelihood and severity. Department-specific control measures were selected based on group consensus. Interviews, and focus groups were used to assess acceptability and utility of the RM process and perceived facilitators and barriers of implementation. RESULTS: Three to six RM meetings were conducted at each fire department. There were 7.4 crashes per 100 personnel in the urban department and 10.5 per 100 personnel in the suburban department; the rural department experienced zero crashes. All departments identified emergency response, backing, on scene struck by, driver distraction, vehicle/road visibility, and driver training as high or medium concerns. Additional high priority risks varied by department; the urban department prioritized turning and rear ending crashes; the suburban firefighters prioritized inclement weather/road environment and low visibility related crashes; and the rural volunteer fire department prioritized exiting station, vehicle failure, and inclement weather/road environment related incidents. Selected controls included new policies and standard operating procedures to reduce emergency response, cameras to enhance driver visibility while backing, and increased training frequency and enhanced training. The RM process was generally acceptable to department participants and considered useful. All departments reported that the focused and systematic analysis of crashes was particularly helpful. Implementation of controls was a commonly cited challenge. CONCLUSIONS: Proactive RM of ESVCs in three US fire departments was positively received and supported the establishment of interventions tailored to each department's needs and priorities.

Correction to: Risk management of emergency service vehicle crashes in the United States fire service: process, outputs, and recommendations.

CORRECTION: After publication of the article [1], it has been brought to our attention that the second author's name was published incorrectly. Previously included as "Keshia P. Porter", the full and correct name should be "Keshia Pollack Porter". This has now been corrected in the original version of the article.