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Objective: The aims of this study were to assess the characteristics of all acute poisoning admissions among adult emergency department (ED) patients, to identify factors associated with admission and to calculate direct medical cost. Methods: Data of 2017 (1st January to 31st December) were collected and analyzed retrospectively using patients’ medical records and hospital invoices. Factors associated with type of hospitalization were identified using appropriate statistics. Results: A total of 1,214 hospital admissions were included, accounting for 3.6% of all ED admissions. Men (62.2%) and the age group 21–40 years (43.0%) accounted for the largest proportion. Substances most commonly involved were ethanol (52.9%), benzodiazepines (9.7%), cocaine (4.9%), cannabis (4.6%), antidepressants (4.6%) and psychostimulants (4.6%). A total of 4,561 treatment acts were recorded, most commonly monitoring of vital signs (63.6%) and medication and/or intravenous drip administration (62.9%). Patients were discharged home after having received care in the emergency department (ED-amb) in 54.5% of admissions, were admitted to the emergency-department-24-hours-observation unit (ED-24h) or were hospitalized (Hosp) in 24.6% and 20.9% of admissions, respectively. Factors found to be associated with hospitalization type were age, hour of admission, victim location, degree of severity, use of antidotes, involvement of antidepressants, antipsychotics, psychostimulants, benzodiazepines and ethanol. Total cost was €1,512,346 with an average of €1,287 per admission. Conclusion: Poisonings entail a considerable percentage of patients admitted to an ED and financial burden. In particular, ethanol poisonings account for the largest proportion of all ED admissions. Comparison of our figures with other data is hampered by the heterogeneity in inclusion criteria. Availability of a uniform template would facilitate comparison and allow better monitoring policies for prevention and cost reduction. [ABSTRACT FROM AUTHOR]

Urinary tract infections (UTIs) are one of the most common infections in older people and are associated with increased morbidity and mortality. UTIs are also associated with increased risk of antimicrobial resistance (AR). This study examined changes in AR among older inpatients with a primary diagnosis of UTIs in the United States over an 8-year period and the impact of AR on clinical outcomes and hospital costs. Data were obtained from the longitudinal hospital HCUP-NIS database from 2009 to 2016 for inpatient episodes that involved those aged 65+ years. The ICD-9 and ICD-10 codes were used to identify episodes with a primary diagnosis of UTIs, comorbidities, AR status and age-adjusted Deyo-Charlson comorbidity index (ACCI) for the patient concerned. Weighted multivariable regression was used to examine the impact of AR on all-cause inpatient mortality, discharge destination, length of stay and hospital expenditures, adjusted for socio-demographic and clinical covariates. The proportion of admissions with AR increased, from 3.64% in 2009 to 6.88% in 2016 (p<0.001), with distinct patterns for different types of resistance. The likelihood of AR was higher in admissions with high ACCI scores and admissions to hospitals in urban areas. Admissions with AR were more likely to be discharged to healthcare facilities (e.g. care homes) compared to routine discharge (OR 1.81; 95%CI, 1.75–1.86), had increased length of stay (1.12 days; 95%CI, 1.06–1.18) and hospital costs (1259 USD; 95%CI, 1178–1340). Resistance due to MRSA was specifically associated with increased hospital mortality (OR 1.33; 95%CI, 1.15–1.53). Our findings suggest that the prevalence of AR has increased among older inpatients with UTIs in the USA. The study highlights the impact of AR among older inpatients with a primary diagnosis of UTIs on clinical outcomes and hospital costs. These relationships and their implications for the care homes to which patients are frequently discharged warrant further research. [ABSTRACT FROM AUTHOR]

Background: Though mass evacuation may increase the need for long-term care (LTC) services, how the need for LTC services increases and how the public LTC system affects it is not well understood. We evaluated changes in public LTC benefits for the people living in the mandatory evacuation areas established after the 2011 Fukushima nuclear disaster and examined the roles of the universal LTC insurance system in Japan. Methods: In order to evaluate the effect of the mandatory evacuation on LTC benefits, we examined the trends of LTC benefits in the Fukushima evacuation group and the nationwide non-evacuation group. We first decomposed per-elderly-individual benefits at the municipality level into the LTC certification rate and per-certified-individual benefits, and then implemented difference-in-differences analysis using these variables as outcomes. Results: Per-elderly-individual benefits significantly increased from 2012 onward in the evacuation group, and this was explained by an increase in the certification rate rather than in per-certified-individual benefits. Increases in per-elderly-individual benefits and the certification rate in the post-disaster period were observed in all but the highest care level, and the corresponding outcomes for the highest care level decreased immediately after the disaster. We also found that the increase in the certification rate had been mostly realized by an increase in the number of certified individuals. Conclusions: The increase in LTC benefits can be associated with the impact of the increase in the number of people newly certified to receive LTC benefits after the mandatory evacuation. In order to cope with the increase in utilization of long-term care and associated costs after disasters in aging societies, both formal long-term care services and social support for informal care for evacuees should be considered important. [ABSTRACT FROM AUTHOR]

Purpose: Triple negative breast cancer (TNBC) patients frequently receive neoadjuvant chemotherapy (NAC). Only 50% will achieve pathological complete response (pCR). In this retrospective study, we evaluated TNBC outcomes with NAC vs. AC. Methods: Patients with stages II and III TNBC treated with NAC or AC between 2010 and 2013 were identified from the National Cancer Database. Baseline characteristics were compared with χ2 and two sample t tests. Kaplan-Meier survival analyses were computed in patients treated with NAC or AC, and log-rank tests used to examine differences. Unadjusted analyses of trends in proportions over time were performed using Cochran–Armitage tests. Log-binomial models were applied to estimate relative risks of non-pCR following NAC. Results: Of 19,151 patients, 5,621 (29.4%) received NAC, 13,530 (70.6%) received AC. NAC treated patients had worse OS compared to AC treated patients (73.4% vs. 76.8%; p<0.0001). pCR rate following NAC was 47.4%, and was associated with improved 5 year OS compared to non-pCR (86.2% vs. 62.3%; p<0.0001). In patients who received NAC, age, black race, clinical stage, diagnosis year, and Charlson-Deyo comorbidity score predicted non-pCR status. Use of NAC increased over the study period from 2010 to 2013 (27.8% - 31.2%; p = 0.0002). Conclusions: NAC may be inferior to AC in TNBC, likely related to the high frequency of non-pCR following NAC. It is unclear if removing the primary tumor prior to chemotherapy will have a beneficial biologic impact on therapeutic efficacy. These data should be considered hypothesis-generating as it is possible that the findings are due to selection bias, as physicians may use NAC for TNBC patients with more advanced local disease. Although, NAC still has a role in TNBC, developing biomarkers to identify patients likely to achieve pCR and benefit from NAC is an urgent need. [ABSTRACT FROM AUTHOR]

Measuring disaster resilience is a key component of successful disaster risk management and climate change adaptation. Quantitative, indicator-based assessments are typically applied to evaluate resilience by combining various indicators of performance into a single composite index. Building upon extensive research on social vulnerability and coping/adaptive capacity, we first develop an original, comprehensive disaster resilience index (CDRI) at municipal level across Italy, to support the implementation of the Sendai Framework for Disaster Risk Reduction 2015–2030. As next, we perform extensive sensitivity and robustness analysis to assess how various methodological choices, especially the normalisation and aggregation methods applied, influence the ensuing rankings. The results show patterns of social vulnerability and resilience with sizeable variability across the northern and southern regions. We propose several statistical methods to allow decision makers to explore the territorial, social and economic disparities, and choose aggregation methods best suitable for the various policy purposes. These methods are based on linear and non-liner normalization approaches combining the OWA and LSP aggregators. Robust resilience rankings are determined by relative dominance across multiple methods. The dominance measures can be used as a decision-making benchmark for climate change adaptation and disaster risk management strategies and plans. [ABSTRACT FROM AUTHOR]

Objectives: To examine the morbidities associated with workplace injury and to explore how clinical variables modify the risk of injury recurrence. Methods: A case-control study was designed using Florida’s statewide inpatient, outpatient, and emergency visits data obtained from the Healthcare Cost and Utilization Project. We included adults who were admitted for a workplace injury (WPI) or injury at other places (IOP), and a matched population of random controls without WPI/IOP. The associations between WPI and clinical morbidities were assessed by univariate and multivariable regression, ranking predictors by information gain, area under the receiver operating characteristic (AUROC), and odds ratios. We analyzed WPI recurrence using survival methods (Kaplan-Meier, Cox regression, survival decision trees) and developed prediction models via regularized logistic regression, random forest, and AdTree. Performance was assessed by 10-fold cross-validation comparing AUROC, sensitivity, specificity, and Harrell’s c-index. Results: A total of 80,712 WPI, 161,424 IOP, and 161,424 control patients were included; 485 distinct clinical diagnostic and 160 procedure codes were analyzed after filtering. Acute bronchitis and bronchiolitis, sprains and strains of shoulder and upper arm, ankle and foot, or other and unspecified parts of back, accidents caused by cutting and piercing instruments or objects, and overexertion and strenuous movements were identified as important consequences of WPI. The prediction models of injury recurrence identified several key factors, such as insurance type and prior injury events, although none of the models exhibited high predictive performance (best AUROC = 0.60, best c-index = 0.62). Conclusions: WPI is associated to diverse serious physical comorbidity burden. There are demographic, social and clinical comorbidity components associated to the risk of WPI recurrence, although their predictive value is moderate, which warrants future investigation in other information source domains, e.g. deepening into the environmental and societal sphere. [ABSTRACT FROM AUTHOR]

Objectives: Changes in treatment choice of therapy and size of treated population that can lead to under- or overestimate of payer’s budget are less likely to be reassured after reimbursement adoption of a new drug. The aim of this study was to evaluate the effects of febuxostat introduction and the modifications in its insurance coverage on the utilization and expenditure of urate-lowering therapy (ULT). Methods: Electronic medical records for adults patients prescribed any ULT during 2010–2015 was derived from the largest medical organization in Taiwan. Aggregated estimates of ULT use and costs were assessed per 3-month and per patient per month (PPPM). Factors associated with total ULT expenditure were assessed using a time series design with factored Autoregressive Integrated Moving Average (ARIMA) models. Results: ULT prevalent users increased 34.1% from 2010 to 2015 and a 123% increase in total ULT expenditure. Numbers on allopurinol and sulfinpyrazone both declined 31%, and on benzbromarone and febuxostat gradually increased to 38.21% and 22.89% of all users in 2015. Insurance payments PPPM ($4.44 to $9.22) and total monthly ULT cost ($32,946 to $ 85,732) growth more than doubled in 6 years, trend changes generated mostly by individuals switching to febuxostat. Conclusions: ULT use moved to favor benzbromarone and febuxostat; greater expensive uptake for febuxostat led to a rapid rise in ULT cost. Marginal values of increasing access to febuxostat for asymptomatic hyperuricemia should be focus on future studies to facilitate drug prices negotiation and ensure appropriate ULT use. [ABSTRACT FROM AUTHOR]

We construct two examples of shareholder networks in which shareholders are connected if they have shares in the same company. We do this for the shareholders in Turkish companies and we compare this against the network formed from the shareholdings in Dutch companies. We analyse the properties of these two networks in terms of the different types of shareholder. We create a suitable randomised version of these networks to enable us to find significant features in our networks. For that we find the roles played by different types of shareholder in these networks, and also show how these roles differ in the two countries we study. [ABSTRACT FROM AUTHOR]

Background: Data on initiation and utilization of direct-acting antiviral therapies for hepatitis C virus infection in the United States are limited. This study evaluated treatment initiation, time to treatment, and real-world effectiveness of direct-acting antiviral therapy in individuals with hepatitis C virus infection treated during the first 2 years of availability of all-oral direct-acting antiviral therapies. Methods: A retrospective cohort analysis was undertaken using electronic medical records and chart review abstraction of hepatitis C virus-infected individuals aged >18 years diagnosed with chronic hepatitis C virus infection between January 1, 2014, and December 31, 2015 from the Indiana University Health database. Results: Eight hundred thirty people initiated direct-acting antiviral therapy during the 2-year observation window. The estimated incidence of treatment initiation was 8.8%±0.34% at the end of year 1 and 15.0%±0.5% at the end of year 2. Median time to initiating therapy was 300 days. Using a Cox regression analysis, positive predictors of treatment initiation included age (hazard ratio, 1.008), prior hepatitis C virus treatment (1.74), cirrhosis (2.64), and history of liver transplant (1.5). History of drug abuse (0.43), high baseline alanine aminotransferase levels (0.79), hepatitis B virus infection (0.41), and self-pay (0.39) were negatively associated with treatment initiation. In the evaluable population (n = 423), 83.9% (95% confidence interval, 80.1–87.3%) of people achieved sustained virologic response. Conclusion: In the early years of the direct-acting antiviral era, <10% of people diagnosed with chronic hepatitis C virus infection received direct-acting antiviral treatment; median time to treatment initiation was 300 days. Future analyses should evaluate time to treatment initiation among those with less advanced fibrosis. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) is the third greatest cancer burden in the United States. The remarkably diverse Mountain West state of Nevada has uncharacteristically high CRC mortality compared to other Western states. We aimed to study the determinants of the CRC excess burden by using data from the Nevada Central Cancer Registry from 2003–2013. Five-year cause-specific age-adjusted survival from colorectal cancer was calculated and stratified by sex, race/ethnicity and region of Nevada. Cox Proportional Hazards regression modelling was used to study the impact of demographic, social, and clinical factors on CRC survival in Nevada, assessing follow-up as accurately as possible. The extent to which differences in survival can be explained by receipt of stage-appropriate treatment was also assessed. 12,413 CRC cases from 2003–2013 in Nevada were analyzed. Five-year CRC survival was low: 56.0% (95% CI: 54.6–57.5) among males and 59.5% (95% CI: 58.0–61.1) among females; significantly lower than national 5-year survival of 65.1% and 66.5%, respectively. Low survival was driven by populous Southern Nevada; after adjustment for all covariates, Southern Nevadans were at 17% higher risk of death than their counterparts in Northwestern Nevada (HR:1.17; 95% CI:1.08–1.27). Many patients did not receive stage-appropriate treatment, although this only partly explained the poor survival, uniformly low for every race/ethnicity in Nevada. The observed disparity for this one state within a single nation merits public health attention; regardless of the state or region of residence, all Americans deserve equal opportunity for optimum health outcomes in the face of a cancer diagnosis. The current study provides baseline information critical to clinicians, public health professionals, and all relevant stakeholders as they attempt to discern why Nevada’s outcomes are vastly divergent from its neighboring Western states and make plans for remediation. [ABSTRACT FROM AUTHOR]

The current study investigated whether we could encourage Australian residents to become better prepared for floods by inviting them to make a specific commitment to do so. We sampled 374 residents of the state of Victoria (56% male, 81% metropolitan) and 400 residents of the state of New South Wales (45% male, 59% metropolitan) who lived in locations that were potentially at risk of floods. They residents were sampled so that their distributions of ages, genders and living locations were as representative as possible of the population of those two states. These residents completed two surveys that ascertained their preparedness for floods at two points in time, separate by a two-week period. At the end of the first survey all residents received information about how they could better prepare for floods. In addition, approximately half the residents were randomly selected to be invited to commit to becoming better prepared for floods. We found that 74% of residents who were invited to commit to becoming better prepared for floods, were willing to make this commitment. We found that the group that was invited to commit to become better prepared for floods increased their preparedness for floods over the two-week period that separated the two surveys more than the group that was not invited to make this commitment, F(1, 772) = 4.53, p = .034, η2 = .006. We conclude that when emergency services inform residents of flood-prone areas how to better prepare for floods, they should also attempt to elicit from the residents a commitment to become better prepared for floods. [ABSTRACT FROM AUTHOR]

This study compares husbands' and wives' views on the person in a couple who should be responsible for preparing for hurricane hazards; it also examines whether the varying levels of agreement reached by husbands and wives regarding this responsibility are associated with actual preparedness behaviors. An online survey targeting married, heterosexual couples living in Sarasota County, Florida, USA was sent out between March and May, 2015. Both the husbands and the wives were asked to fill out the survey. A total of 170 surveys were used for analysis. Results suggested that husbands and wives felt that they had shared responsibility for most of the 19 preparedness behaviors considered. However, a few stereotypically masculine preparedness behaviors were found to typically fall to husbands. Husbands' and wives' views of perceived responsibility were not statistically different, but husbands tended to favor individual responsibility, while wives tended to favor joint responsibility. Higher levels of agreement were significantly associated with greater engagement in planning-related preparedness behaviors. Policy implications are discussed. [ABSTRACT FROM AUTHOR]

Risk management is a problem humans have faced throughout history and across societies. One way to manage risk is to transfer it to other parties through formal and informal insurance systems. One informal method of self-insurance is limited risk pooling, where individuals can ask for help only when in need. Models suggest that need-based transfer systems may require coordination and common knowledge to be effective. To explore the impact of common knowledge on social coordination and risk pooling in volatile environments, we designed and ran a Risk Pooling Game. We compared participants who played the game with no advance priming or framing to participants who read one of two texts describing real-world systems of risk pooling. Players in the primed games engaged in more repetitive asking and repetitive giving than those in the control games. Players in the primed games also gave more in response to requests and were more likely to respond positively to requests than players in the control games. In addition, players in the primed games were more tolerant of wide differences between what the two players gave and received. These results suggest that the priming texts led players to pay less attention to debt and repayment and more attention to the survival of the other player, and thus to more risk pooling. These results are consistent with findings from fieldwork in small-scale societies that suggest that humans use need-based transfer systems to pool risk when environmental volatility leads to needs with unpredictable timing. Models suggest that the need-based transfer strategy observed in this experiment can outperform debt-based strategies. The results of the present study suggest that the suite of behaviors associated with need-based transfers is an easily triggered part of the human behavioral repertoire. [ABSTRACT FROM AUTHOR]

Objective: Despite their efficacy in lowering hemoglobin A1c, recent data suggest that sulfonylureas are associated with cardiovascular risk and hypoglycemia. The objective of this study was to determine whether prescribers decreased sulfonylurea use in favor of newer medications in the United States over seven years. Research design and methods: This cross-sectional study utilized data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey. Patient visits between 2009 and 2015 were included for patients who were at least 18 years old, had a documented prescription for a non-insulin antidiabetic medication, and a diagnosis of type 2 diabetes. Sample survey data were extrapolated to national estimates using data weights. Prescribing rates were calculated as the number of visits with a documented medication class divided by the total number of visits with a prescription for any diabetes medication class, times 100%. Results: A total of 303 million patient visits were included in this study. The median (IQR) patient age was 64 (55–73) years old and 49.8% were male. Sulfonylurea prescribing rates decreased from 43% in 2009 to 36.5% in 2015. Prescribing of GLP-1 receptor agonists increased from 2009 to 2014 (3.95% to 5.30%), but then decreased to 4.19% in 2015. SGLT-2 inhibitor prescribing began in 2013 and increased to 7.3% by 2015. Metformin prescribing remained relatively stable over the study period (range 70% to 72%). Conclusions: National ambulatory sulfonylurea prescribing decreased from 2009 to 2015 with a corresponding increase in newer non-insulin antidiabetic agent prescribing. [ABSTRACT FROM AUTHOR]

Although injury-related deaths have been documented among children and adult populations, insufficient attention has been directed towards injury-related infant deaths. The objective of this retrospective study was to investigate maternal and infant characteristics associated with injury-related infant deaths in West Virginia. Birth and infant mortality data for 2010–2014 were sourced from the West Virginia Bureau for Public Health, Charleston. Relative risk was calculated using log-binomial regression utilizing generalized estimating equations. Maternal characteristics associated with injury-related infant mortality in West Virginia were race/ethnicity ( = 7.48, p = .03), and smoking during pregnancy (, p < .00). Risk of a Black Non-Hispanic infant suffering an injury-related death was 4.0 (95% CL 1.7, 9.3) times that of infants of other races/ethnicities. Risk of an infant dying from an injury-related cause, if the mother smoked during pregnancy, was 2.9 (95% CL 1.6, 5.0) times the risk of such a death if maternal smoking status during pregnancy is unknown or no smoking, controlling for race/ethnicity. This study provides important information to public health stakeholders at both the state and local levels in designing interventions for partial reduction or prevention of injury-related infant mortality in West Virginia. [ABSTRACT FROM AUTHOR]

Background: Borderline personality disorder (BPD) is associated with unemployment and impaired functioning. However, a comprehensive understanding of barriers and facilitators to employment from a multidisciplinary perspective is currently lacking. Therefore, the aim of this qualitative study was to explore barriers and facilitators in gaining and maintaining employment in BPD from the perspectives of patients, mental health practitioners (MHPs) and insurance physicians (IPs). Methods: Fifteen semi-structured interviews were conducted in patients with BPD and two focus groups were carried out among MHPs (n = 7) and IPs (n = 6) following a thematic content analysis approach. Results: All participants described barriers and facilitators relating to three overall themes: characteristics of BPD, stigma, and support to employment. Barriers to employment mainly related to characteristics of BPD, such as low self-image, difficulty posing personal boundaries, difficulty regulating emotions, and lack of structure. MHPs and IPs additionally mentioned externalization and overestimation of competencies on the part of patients. Enhancing emotion regulation and self-reflection by successful treatment was suggested as a facilitator to enhance employment. Increasing collaboration between mental health and vocational rehabilitation services, and increasing knowledge about BPD, were suggested to increase sustainable employment and decrease stigma. Conclusions: The present findings revealed that both facilitators and barriers are important in gaining and maintaining employment in BPD in which diminishing symptoms, examining stigma and increasing support to employment are key. As a next step, supported employment strategies that follow patient preferences and integrate employment and mental health services, should be studied in the context of BPD. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this qualitative oral health needs assessment was to probe and better understand the oral health knowledge, beliefs, and barriers of District residents, particularly in DC wards where oral health disparities are most prevalent. Methods: Forty-eight (n = 48) participants were recruited for four focus groups. The focus group instrument consisted of a structured interview guide addressing the following topics: oral health history, perceived barriers to oral health, knowledge and perceptions about oral systemic health, and preferred message channels for receiving information on oral/dental health. Content analysis was performed using NVivo, a computerized, qualitative informatics tool. Results: The majority of participants in this study practiced both brushing and flossing in their daily dental routine and did not believe that tooth loss is a normal part of ageing. There was lack of knowledge on the connection between oral and systemic health, specifically impact of smoking, alcohol use, and sweets and sexual activity. Focus groups identified two main barriers to healthcare access–communication and affordability. Participants who had a dentist were satisfied and felt that their needs were met. Conclusion: Our findings indicate a need for educational intervention and improved communication from oral health providers to increase awareness of the impact of systemic health and risky behaviors can have on oral health. [ABSTRACT FROM AUTHOR]

Phosphodiesterase-5 inhibitors (PDE-5I) have demonstrated improvement in disease symptoms and quality of life for patients with pulmonary arterial hypertension (PAH). Despite these benefits, reported adherence to PDE-5I therapy is sub-optimal. Clinical pharmacists at an integrated practice site are in a unique position to mitigate barriers related to PAH therapy including medication adherence and costs. The primary objective of this study was to assess medication adherence to PDE-5I therapy within an integrated care model at an academic institution. The secondary objective was to assess the impact of out-of-pocket (OOP) cost, frequency of dosing, adverse events (AE) and PAH-related hospitalizations on medication adherence. We performed a retrospective cohort analysis of adult patients with PAH who were prescribed PDE-5I therapy by the center's outpatient pulmonary clinic and who received medication management through the center's specialty pharmacy. We defined optimal medication adherence as proportion of days covered (PDC) ≥ 80%. Clinical data including AEs and PAH-related hospitalizations were extracted from the electronic medical record, and financial data from pharmacy claims. Of the 131 patients meeting inclusion criteria, 94% achieved optimal adherence of ≥ 80% PDC. In this study population, 47% of patients experienced an AE and 27% had at least one hospitalization. The median monthly OOP cost was $0.62. Patients with PDC<80% were more likely to report an AE compared to patients with PDC≥ 80% (p = 0.002). Hospitalization, OOP cost, and frequency of dosing were not associated with adherence in this cohort. Patients receiving PDE-5I therapy through an integrated model achieved high adherence rates and low OOP costs. [ABSTRACT FROM AUTHOR]

Background: In patients with diabetes, foot amputations among Black patients have been historically higher compared with White patients. Using the National Inpatient Sample database, we sought to determine if disparities in foot amputations and resource utilization have improved over time. We hypothesized there would be improvements and reduced differences in foot amputations between the two races as quality of care and access to healthcare has improved. Methods and findings: Patients over 18 years old with a principal diagnosis of diabetic foot complications and secondary diagnosis of Diabetes Mellitus were selected. We compared the primary outcome of foot amputations between Black and White patients. Adjusted rates, odds ratios (aOR) and trends of foot amputations among Black and White patients were studied. Healthcare utilization was measured via length of hospital stay (LOS). Of 262,924 patients, 18% were Black. Following adjustment for confounders, major foot amputations decreased among Whites (1.5% in 2003 to 1.1% in 2014) and Blacks (2.1% in 2003 to 0.9% in 2014). On pooled analysis, Black patients had higher adjusted odds of major foot amputations in 2003–2004 [aOR 1.7; (1.16–2.57), p<0.01]. Disparities in major foot amputations disappeared in 2013–2014 [aOR: 0.92 (0.58–1.44), p = 0.70]. Black patients had declining but persistently longer LOS (adjusted mean difference (aMD): 1.1 days (0.52–1.6) p<0.01 in 2003–2004 and 0.46 days (0.18–0.73) p<0.01 in 2013–2014). The main limitation of the study was that the NIS uses ICD-9 and ICD-10 CM codes, and hence prone to incorrect or missing codes. Conclusions: Major foot amputations declined among Black and White patients hospitalized with Diabetic foot complications between 2003 and 2014. The observed difference for amputations in 2003–2004 was absent by 2013–2014. Future research to determine specific contributors for this reduction in health disparities is needed for ongoing improvements and sustainability. [ABSTRACT FROM AUTHOR]

Background: NTZ is approved in Russia for the treatment of highly active relapsing remitting multiple sclerosis and is reimbursed via federal budget program. However, no data about NTZ treatment in Russia and the effect of federal reimbursement have been performed so far. Objective: To characterize the population of patients receiving natalizumab and assess the efficacy and risk-management plan (RMP) implementation of NTZ therapy in routine clinical practice in Russia. Methods: We analyzed data for 334 patients, who received at least one infusion of NTZ. Relapse rate, MRI activity, NEDA-3 status after 2 years were assessed. Anti-JC virus antibodies status and RMP implementation were evaluated. Drop-out rate and reasons for therapy discontinuation were analyzed. Results: Patients switched to natalizumab in Russia are mainly female (63%), with median EDSS score of 3.5 and high disease activity: 93% had at least 1 relapse and 58% had both T1Gd+ and new T2 lesion a year before therapy initiation. Introduction of federal reimbursement allowed patients with less relapses to start therapy with natalizumab. The only predictor of 6-month progression was EDSS score at the baseline of therapy (HR = 2.1375, 95%CI 1.0026–4.5570, p = 0.0492). 82% patients reached NEDA-3 at 24 month of therapy. 25% of patients discontinued NTZ for reasons: tolerability (14.5%), JCV antibody status (61%), and patient’s decision (17%). RMP was implemented in only 36% patients. Conclusion: Natalizumab appeared to have high efficacy in Russian clinical practice. Federal reimbursement allowed less active patients to start natalizumab. More efforts should be done to improve RMP implementation. [ABSTRACT FROM AUTHOR]

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians–with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America. [ABSTRACT FROM AUTHOR]

Importance: Febrile neutropenia (FN) is the most common oncologic emergency and is among the most deadly. Guidelines recommend risk stratification and outpatient management of both pediatric and adult FN patients deemed to be at low risk of complications or mortality, but our prior single-center research demonstrated that the vast majority (95%) are hospitalized. Objective: From a nationwide perspective, to determine the proportion of cancer patients of all ages hospitalized after an emergency department (ED) visit for FN, and to analyze variability in hospitalization rates. Our a priori hypothesis was that >90% of US cancer-associated ED FN visits would end in hospitalization. Design: Analysis of data from the Nationwide Emergency Department Sample, 2006–2014. Setting: Stratified probability sample of all US ED visits. Participants: Inclusion criteria were: (1) Clinical Classification Software code indicating cancer, (2) diagnostic code indicating fever, and (3) diagnostic code indicating neutropenia. We excluded visits ending in transfer. Exposure: The hospital at which the visit took place. Main outcomes and measures: Our main outcome is the proportion of ED FN visits ending in hospitalization, with an a priori hypothesis of >90%. Our secondary outcomes are: (a) hospitalization rates among subsets, and (b) proportion of variability in the hospitalization rate attributable to which hospital the patient visited, as measured by the intra-class correlation coefficient (ICC). Results: Of 348,868 visits selected to be representative of all US ED visits, 94% ended in hospitalization (95% Confidence Interval [CI] 93–94%). Each additional decade of age conferred 1.23x increased odds of hospitalization. Those with private (92%), self-pay (92%), and other (93%) insurance were less likely to be hospitalized than those with public insurance (95%, odds ratios [OR] 0.74–0.76). Hospitalization was least likely at non-metropolitan hospitals (84%, OR 0.15 relative to metropolitan teaching hospitals), and was also less likely at metropolitan non-teaching hospitals (94%, OR 0.64 relative to metropolitan teaching hospitals). The ICC adjusted for hospital random effects and patient and hospital characteristics was 26% (95%CI 23–29%), indicating that 26% of the variability in hospitalization rate was attributable to which hospital the patient visited. Conclusions and relevance: Nearly all cancer-associated ED FN visits in the US end in hospitalization. Inter-hospital variation in hospitalization practices explains 26% of the limited variability in hospitalization decisions. Simple, objective tools are needed to improve risk stratification for ED FN patients. [ABSTRACT FROM AUTHOR]

We propose a novel laboratory experiment to document the pressure to share income within social networks in Africa. We find that the redistributive pressure exerted via the possibility of receiving a claim increases altruism, while the possibility of hiding from such claim reduces it. Our results indicate that sharing norms are crucial drivers of giving to other members of the network. We also find that pressure to share has a detrimental effect on the undertaking of profitable but risky investments. [ABSTRACT FROM AUTHOR]

Introduction: Only a few, large population-based studies, have reported on whiplash-associated disorder (WAD). However, none of them have investigated the influence of crash severity on WAD outcome. In the present study, we aimed to determine whether crash severity predicts outcomes among patients with no-fault government insurance for acute WAD. Methods: We utilized data from a compulsory, no-fault government automobile liability insurance agency in Japan. Individuals involved in a car accident between April 2001 and June 2015 with residual disabilities reported at the end of the treatment between October 2014 and September 2015 were included. Crash severity was assessed based on property damage costs, size of the other vehicle (large car, medium car, small car, or two-wheeled vehicles), and collision types (rear-end collision, contact with vehicle moving in the same direction, or in the opposite direction). Outcomes included the time to claim closure and the number of treatment visits. Results: We analyzed data for a total of 52,251 individuals (28,571 male and 23,680 female) with a median age of 44 years (range: 2–95 years). The median time to claim closure was 220 days (range: 1–4,938 days), and the median number of treatment visits was 102 (range: 1–2,492). There was no significant association between outcomes and property damage costs or size of the other vehicle. Collision types exhibited no consistent association with outcomes. However, older age and affected body parts, in addition to the neck, were independent risk factors for delayed claim closure and a large number of visits, although, all odds ratios were low (often less than 2.0). Conclusions: There was no obvious association of outcomes with property damage costs, size of the other vehicle, or collision types in acute WAD patients. Further studies should investigate the influence of psychological factors, compensation systems, and cultural conditions. [ABSTRACT FROM AUTHOR]

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII (neck complaint and musculoskeletal sign(s)). Effective management in the acute stage is required to prevent development of chronicity; an issue for 60% of patients. An Active Behavioural Physiotherapy Intervention (ABPI) was developed to address both physical and psychological components of WAD. The ABPI is a novel complex intervention designed through a rigorous sequential multiphase project to prevent transition of acute WAD to chronicity. An external pilot and feasibility cluster randomised double-blind (assessor, participants) parallel two-arm clinical trial was conducted in the UK private sector. The trial compared ABPI versus standard physiotherapy to evaluate trial procedures and feasibility of the ABPI for managing acute WADII in preparation for a future definitive trial. Six private physiotherapy clinics were recruited and cluster randomised using a computer-generated randomisation sequence. Twenty-eight (20 ABPI, 8 standard physiotherapy) participants [median age 38.00 (IQR = 21.50) years] were recruited. Data were analysed descriptively with a priori establishment of success criteria. Ninety-five percent of participants in the ABPI arm fully recovered (Neck Disability Index ≤4, compared to 17% in the standard physiotherapy arm); required fewer treatment sessions; and demonstrated greater improvement in all outcome measures (pain intensity, Cervical Range of Motion, Pressure Pain Threshold, EuroQol-5 Dimensions) except for the Impact of Events Scale and Fear Avoidance Beliefs Questionnaire. The findings support the potential value of the ABPI, and that an adequately powered definitive trial to evaluate effectiveness (clinical, cost) is feasible with minor modifications to procedures. [ABSTRACT FROM AUTHOR]

Background: Guangxi is one of the provinces having the highest notification rate of tuberculosis in China. However, spatial and temporal patterns and the association between environmental diversity and tuberculosis notification are still unclear. Objective: To detect the spatiotemporal pattern of tuberculosis notification rates from 2010 to 2016 and its potential association with ecological environmental factors in Guangxi Zhuang autonomous region, China. Methods: We performed a spatiotemporal analysis with prediction using time series analysis, Moran’s I global and local spatial autocorrelation statistics, and space-time scan statistics to detect temporal and spatial clusters of tuberculosis notifications in Guangxi between 2010 and 2016. Spatial panel models were employed to identify potential associating factors. Results: The number of reported cases peaked in spring and summer and decreased in autumn and winter. The predicted number of reported cases was 49,946 in 2017. Moran's I global statistics were greater than 0 (0.363–0.536) during the study period. The most significant hot spots were mainly located in the central area. The eastern area exhibited a low-low relation. By the space-time scanning, the clusters identified were similar to those of the local autocorrelation statistics, and were clustered toward the early part of 2016. Duration of sunshine, per capita gross domestic product, the treatment success rate of tuberculosis and participation rate of the new cooperative medical care insurance scheme in rural areas had a significant negative association with tuberculosis notification rates. Conclusion: The notification rate of tuberculosis in Guangxi remains high, with the highest notification cluster located in the central region. The notification rate is associated with economic level, treatment success rate and participation in the new cooperative medical care insurance scheme. [ABSTRACT FROM AUTHOR]

Objective: The American College of Critical Care Medicine recommends that children with persistent fluid, catecholamine, and hormone-resistant septic shock be considered for extracorporeal membrane oxygenation (ECMO) support. Current national estimates of ECMO use in hospitalized children with sepsis are unknown. We sought to examine the use of ECMO in these children and to examine the overall outcomes such as in-hospital mortality, length of stay (LOS), and hospitalization charges (HC). Methods: A retrospective analysis of the National Inpatient Sample, which approximates a 20% stratified sample of all discharges from United States community hospitals, was performed. All children (≤ 17 years) who were hospitalized for sepsis between 2012 and 2014 were included. The associations between ECMO and outcomes were examined by multivariable linear and logistic regression models. Results: A total of 62,310 children were included in the study. The mean age was 4.2 years. ECMO was provided to 415 of the children (0.67% of the cohort with sepsis). Comparative outcomes of sepsis in children who received ECMO versus those who did not included in-hospital mortality rate (41% vs 2.8%), mean HC ($749,370 vs $90,568) and mean LOS (28.8 vs 9.1 days). After adjusting for confounding factors, children receiving ECMO had higher odds of mortality (OR 11.15, 95% CI 6.57–18.92, p < 0.001), longer LOS (6.6 days longer, p = 0.0004), and higher HC ($510,523 higher, p < 0.0001). Conclusions: Use of ECMO in children with sepsis is associated with considerable resource utilization but has 59% survival to discharge. Further studies are needed to examine the post discharge and neurocognitive outcomes in survivors. [ABSTRACT FROM AUTHOR]

Improvement in Home Dialysis (HoD) utilizations as a mean to improve the patient reported and health services outcomes, has been a long-held goal of the providers and healthcare system in United States. However, measures to improve HoD rates have yielded limited success so far. Lack of patient awareness of chronic kidney disease (CKD) and its management options, is one of the important barriers against patient adoption of HoD. Despite ample evidence that Comprehensive pre-ESERD Patient Education (CPE) improves patient awareness and informed HoD choice, use of CPE among US advanced CKD patients is low. Need for significant resources, lack of validated data showing unequivocal and reproducible benefits, and the lack of validated CPE protocols proven to have consistent efficacy in improving not only patient awareness but also HoD rates in US population, are major limitations deterring adoption of CPE in routine clinical practice. We recently demonstrated that if a structured, protocol based CPE is integrated within the routine nephrology care for patients with advanced CKD, it substantially improves informed HoD choice and utilizations. However, this requires establishing CPE resources within each nephrology practice. Efficacy of a stand-alone CPE model, independent of clinical care, has not been examined till date. In this report we report the efficacy of our structured CPE protocol, delivered outside the realm of routine nephrology care—as a stand-alone patient education program, in a geographically distant region, and show that: when provided opportunity for informed dialysis choice, a majority of advanced CKD patients in US would prefer HoD. We also show that initiating CPE leads to accelerated growth in HoD utilizations and reduces disparities in HoD utilizations, goals for system improvements. Finally, the reproducibility of our structured CPE protocol with consistent efficacy data suggest that initiating such programs at institutional levels has the potential to improve informed dialysis selection and HoD rates across any similar large healthcare institute within US. [ABSTRACT FROM AUTHOR]

Objective: We investigated the presence of non-neuromuscular phenotypes in patients affected by Spinal Muscular Atrophy (SMA), a disorder caused by a mutation in the Survival of Motor Neuron (SMN) gene, and whether these phenotypes may be clinically detectable prior to clinical signs of neuromuscular degeneration and therefore independent of muscle weakness. Methods: We utilized a de-identified database of insurance claims to explore the health of 1,038 SMA patients compared to controls. Two analyses were performed: (1) claims from the entire insurance coverage window; and (2) for SMA patients, claims prior to diagnosis of any neuromuscular disease or evidence of major neuromuscular degeneration to increase the chance that phenotypes could be attributed directly to reduced SMN levels. Logistic regression was used to determine whether phenotypes were diagnosed at significantly different rates between SMA patients and controls and to obtain covariate-adjusted odds ratios. Results: Results from the entire coverage window revealed a broad spectrum of phenotypes that are differentially diagnosed in SMA subjects compared to controls. Moreover, data from SMA patients prior to their first clinical signs of neuromuscular degeneration revealed numerous non-neuromuscular phenotypes including defects within the cardiovascular, gastrointestinal, metabolic, reproductive, and skeletal systems. Furthermore, our data provide evidence of a potential ordering of disease progression beginning with these non-neuromuscular phenotypes. Conclusions: Our data point to a direct relationship between early, detectable non-neuromuscular symptoms and SMN deficiency. Our findings are particularly important for evaluating the efficacy of SMN-increasing therapies for SMA, comparing the effectiveness of local versus systemically delivered therapeutics, and determining the optimal therapeutic treatment window prior to irreversible neuromuscular damage. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines recommend that metformin be continued after insulin is initiated among patients with type 2 diabetes, yet little is known regarding how often metformin or other non-insulin diabetes medications are continued in this setting. Methods: We conducted a retrospective cohort study to characterize rates and use patterns of six classes of non-insulin diabetes medications: biguanides (metformin), sulfonylureas, thiazolidinediones (TZDs), glucagon-like peptide 1 receptor agonists (GLP1 receptor agonists), dipeptidyl peptidase 4 inhibitors (DPP4 inhibitors), and sodium-glucose co-transporter inhibitors (SGLT2 inhibitors), among patients with type 2 diabetes initiating insulin. We used the 2010–2015 MarketScan Commercial Claims and Encounters data examining 72,971 patients with type 2 diabetes aged 18–65 years old who initiated insulin and had filled a prescription for a non-insulin diabetes medication in the 90 days prior to insulin initiation. Our primary outcome was the proportion of patients refilling the various non-insulin diabetes medications during the first 90 days after insulin initiation. We also used time-to-event analysis to characterize the time to discontinuation of specific medication classes. Results: Metformin was the most common non-insulin medication used prior to insulin initiation (N = 53,017, 72.7%), followed by sulfonylureas (N = 25,439, 34.9%) and DPP4 inhibitors (N = 8,540, 11.7%). More than four out of five patients (N = 65,902, 84.7%) refilled prescriptions for any non-insulin diabetes medications within 90 days after insulin initiation. Within that period, metformin remained the most common medication with the highest continuation rate of 84.6%, followed by SGLT2 inhibitors (81.9%) and TZDs (79.3%). Sulfonylureas were the least likely medications to be continued (73.6% continuation) though they remained the second most common medication class used after insulin initiation. The median time to discontinuation varied by therapeutic class from the longest time to discontinuation of 26.4 months among metformin users to the shortest (3.0 months) among SGLT2 inhibitor users. Conclusion: While metformin was commonly continued among commercially insured adults starting insulin, rates of continuation of other non-insulin diabetes medications were also high. Further studies are needed to determine the comparative effectiveness and safety of continuing insulin secretagogues and newer diabetes medications after insulin initiation. [ABSTRACT FROM AUTHOR]

Objective: To explore influential factors contributing to the choice of primary care facilities (PCFs) for the initial treatment among rural and urban residents in Southwestern China. Methods: A face-to-face survey was conducted on a multistage stratified random sample of 456 rural and 459 urban residents in Sichuan Province from January to August in 2014. A structured questionnaire was used to collect data on residents’ characteristics, provider of initial treatment and principal reason for the choice. Multivariate logistic regression was performed to identify factors associated with choosing PCFs for the initial treatment. Results: The result showed that 65.4% of the rural residents and 50.5% of the urban residents chose PCFs as their initial contact for medical care. Among both rural and urban residents, the principal reason for choosing medical institutions for the initial treatment was convenience (42.3% versus 40.5%, respectively), followed by high quality of medical care (26.5% versus 29.4%, respectively). Compared to rural residents, urban residents were more likely to value trust in doctors and high quality of medical care but were less likely to value the insurance designation status of the facilities. Logistic regression analysis showed that both rural and urban residents were less likely to choose PCFs for the initial treatment if they lived more than 15 minutes (by walk) from the nearest facilities (rural: OR = 0.15, 95%CI = 0.09–0.26; urban: OR = 0.19, 95%CI = 0.10–0.36), had fair (rural: OR = 0.49, 95%CI = 0.26–0.92; urban: OR = 0.31, 95%CI = 0.15–0.64) or poor (rural: OR = 0.14, 95%CI = 0.07–0.30; urban: OR = 0.22, 95%CI = 0.11–0.44) self-reported health status. Among rural residents, attending college or higher education (OR = 0.21, 95%CI = 0.08–0.59), being retired (OR = 0.90, 95%CI = 0.44–1.84) and earning a per capita annual income of household of 10,000–29,999 (OR = 0.24, 95%CI = 0.11–0.52) and 30,000–49,999 (OR = 0.26, 95%CI = 0.07–0.92) were associated with lower rates of seeking care at PCFs. Conclusion: Efforts should be made to improve the accessibility of PCFs and to upgrade the services capability of PCFs both in rural and urban areas in China. At the same time, resources should be prioritized to residents with poorer self-reported health status, and rural residents who retire or have better education and higher income levels should be taken into account. [ABSTRACT FROM AUTHOR]

Background: Universal health coverage has become a policy goal in most developing economies. We assess the association of health insurance (HI) schemes in general, and RSBY (National Health Insurance Scheme) in particular, on extent and pattern of healthcare utilization. Secondly, we assess the relationship of HI and RSBY on out-of-pocket (OOP) expenditures and financial risk protection (FRP). Methods: A cross-sectional study was undertaken to interview 62335 individuals among 12,134 households in 8 districts of three states in India i.e. Gujarat, Haryana and Uttar Pradesh (UP). Data on socio-demographic characteristics, assets, education, occupation, consumption expenditure, illness in last 15 days or hospitalization during last 365 days, treatment sought and its OOP expenditure was collected. We computed catastrophic health expenditures (CHE) as indicator for FRP. Hospitalization rate, choice of care provider and CHE were regressed to assess their association with insurance status and type of insurance scheme, after adjusting for other covariates. Results: Mean OOP expenditures for outpatient care among insured and uninsured were INR 961 (USD 16) and INR 840 (USD 14); and INR 32573 (USD 543) and INR 24788 (USD 413) for an episode of hospitalization respectively. The prevalence of CHE for hospitalization was 28% and 26% among the insured and uninsured population respectively. No significant association was observed in multivariate analysis between hospitalization rate, choice of care provider or CHE with insurance status or RSBY in particular. Conclusion: Health insurance in its present form does not seem to provide requisite improvement in access to care or financial risk protection. [ABSTRACT FROM AUTHOR]

Objective: Many cancer survivors are facing difficulties in getting a life insurance; raised premiums and declinatures are common. We generated a prediction model estimating the conditional extra mortality risk of breast cancer patients in the Netherlands. This model can be used by life insurers to accurately estimate the additional risk of an individual patient, conditional on the years survived. Methodology: All women diagnosed with stage I-III breast cancer in 2005–2006, treated with surgery, were selected from the Netherlands Cancer Registry. For all stages separately, multivariable logistic regression was used to estimate annual mortality risks, conditional on the years survived, until 10 years after diagnosis, resulting in 30 models. The conditional extra mortality risk was calculated by subtracting mortality rates of the general Dutch population from the patient mortality rates, matched by age, gender and year. The final model was internally and externally validated, and tested by life insurers. Results: We included 23,234 patients: 10,101 stage I, 9,868 stage II and 3,265 stage III. The final models included age, tumor stage, nodal stage, lateralization, location within the breast, grade, multifocality, hormonal receptor status, HER2 status, type of surgery, axillary lymph node dissection, radiotherapy, (neo)adjuvant systemic therapy and targeted therapy. All models showed good calibration and discrimination. Testing of the model by life insurers showed that insurability using the newly-developed model increased with 13%, ranging from 0%-24% among subgroups. Conclusion: The final model provides accurate conditional extra mortality risks of breast cancer patients, which can be used by life insurers to make more reliable calculations. The model is expected to increase breast cancer patients’ insurability and transparency among life insurers. [ABSTRACT FROM AUTHOR]

Background: In 2015 there were 36,252 firearm-related deaths and 84,997 nonfatal injuries in the United States. The longitudinal burden of these injuries through readmissions is currently underestimated. We aimed to determine the 6-month readmission risk and hospital costs for patients injured by firearms. Methods: We used the Nationwide Readmission Database 2010–2015 to assess the frequency of readmissions at 6 months, and hospital costs associated with readmissions for patients with firearm-related injuries. We produced nationally representative estimates of readmission risks and costs. Results: Of patients discharged following a firearm injury, 15.6% were readmitted within 6 months. The average annual cost of inpatient hospitalizations for firearm injury was over $911 million, 9.5% of which was due to readmissions. Medicare and Medicaid covered 45.2% of total costs for the 5 years, and uninsured patients were responsible for 20.1%. Conclusions: From 2010–2015, the average total cost of hospitalization for firearm injuries per patient was $32,700, almost 10% of which was due to readmissions within 6 months. Government insurance programs and the uninsured shouldered most of this. [ABSTRACT FROM AUTHOR]

Objective: This study was carried out to determine the prevalence of suspected dysphagia and its features in both independent and dependent older people living at home. Materials and methods: The 10-Item Eating Assessment Tool (EAT-10) questionnaire was sent to 1,000 independent older people and 2,000 dependent older people living at home in a municipal district of Tokyo, Japan. The participants were selected by stratified randomization according to age and care level. We set the cut-off value of EAT-10 at a score of ≥3. The percentage of participants with an EAT-10 score ≥3 was defined as the prevalence of suspected dysphagia. The chi-square test was used for analyzing prevalence in each group. Analysis of the distribution of EAT-10 scores, and comparisons among items, age groups, and care levels to identify symptom features were performed using the Kruskal-Wallis test and Mann-Whitney U test. Results: Valid responses were received from 510 independent older people aged 65 years or older (mean age 75.0 ± 7.2) and 886 dependent older people (mean age 82.3 ± 6.7). The prevalences of suspected dysphagia were 25.1% and 53.8%, respectively, and showed significant increases with advancing age and care level. In both groups, many older people assigned high scores to the item about coughing, whereas individuals requiring high-level care assigned higher scores to the items about not only coughing but also swallowing of solids and quality of life. Conclusion: In independent people, approximately one in four individuals showed suspected dysphagia and coughing was the most perceivable symptom. In dependent people, approximately one in two individuals showed suspected dysphagia and their specifically perceivable symptoms were coughing, difficulties in swallowing solids and psychological burden. [ABSTRACT FROM AUTHOR]

This study investigates the effects of the number of medical institutions visited on risk of death. This study conducted a nested case-control design using the National Health Insurance Service–Senior database from 2002 to 2013. Cases were defined as those with death among outpatients who had first diagnosis of diabetes mellitus (E10-E14) after entry into the base cohort and controls were selected by incidence density sampling and matched to cases based on age, and sex. Our main results were presented by conditional logistic regression for nested case-controls design. Of total 55,558 final study samples, there were 9,313 (16.8%) cases and 46,245 (83.2%) controls. With an increase by one point in the number of hospitals per medical utilization, risk of death significantly increased by 4.1% (odds ratio (OR): 1.041, 95% confidence interval [CI]: 1.039–1.043). In both medical utilization and number of hospitals, those with high medical utilization (OR: 1.065, 95% CI: 1.059–1.070) and number of hospitals (OR: 1.049, 95% CI: 1.041–1.058) for risk of death were significantly higher than those with low medical utilization (OR: 1.040, 95% CI: 1.037–1.043) and number of hospitals (OR: 1.029, 95% CI: 1.027–1.032), respectively. The number of medical institution visited was significantly associated with risk of death. Therefore, diabetics should be warned about the potential of risk of death incurred from excessive access to medical utilizations. [ABSTRACT FROM AUTHOR]

Introduction: In Lao People’s Democratic Republic (PDR), community-based health insurance (CBHI) is the only voluntary insurance scheme; it typically targets self-employed people, most of whom reside in rural areas and are dependent on agricultural activities for subsistence. However, until very recently, the enrollment rate has fallen short and failed to reach a large percentage of the target group. To promote the CBHI scheme and increase demand, some supporting components should be considered for inclusion together with the health infrastructure component. Objectives: This paper provides empirical evidence that the benefit package components of hypothetical CBHI schemes have causal effects on enrollment probabilities. Furthermore, we examine the distribution of willingness to pay (WTP) in response to policy changes based on a sample of 5,800 observations. Methods: A randomized conjoint experiment is conducted in rural villages in Savannakhet Province, Lao PDR, to elicit stated preference data. Each respondent ranks three options—two hypothetical alternatives and the CBHI status quo scheme. The levels of seven attributes—insurance coverage for medical consultations, hospitalizations, traffic accidents, pharmaceuticals and transportation; premiums; and prepaid discounts—are randomly and simultaneously assigned to the two alternatives. Results: The findings suggest that the average WTP is at least as large as 10.9% of the per capita income of those who live in rural areas, which is higher than the WTP for health insurance averaged across low- and middle-income countries (LMICs) in the literature. The component of round-trip transportation insurance coverage has a significant effect on WTP distribution, particularly increasing the share of the highest bin. Conclusion: Therefore, the low CBHI scheme enrollment rate in Lao PDR does not necessarily imply low demand among the targeted population, as the finding from the WTP analysis illustrates potential demand for the CBHI scheme. Specifically, if transportation is addressed, enrollment is likely to significantly increase. [ABSTRACT FROM AUTHOR]

Pre-harvest contamination of produce has been a major food safety focus. Insight into the behavior of enteric pathogens on produce in pre-harvest conditions will aid in developing pre-harvest and post-harvest risk management strategies. In this study, the attachment strength (SR) and die-off rate of E. coli on the surface of watermelon fruits and the efficacy of aqueous chlorine treatment against strongly attached E. coli population were investigated. Watermelon seedlings were transplanted into eighteen plots. Prior to harvesting, a cocktail of generic E. coli (ATCC 23716, 25922 and 11775) was inoculated on the surface of the watermelon fruits (n = 162) and the attachment strength (SR) values and the daily die-off rates were examined up to 6 days by attachment assay. After 120 h, watermelon samples were treated with aqueous chlorine (150 ppm free chlorine for 3 min). The SR value of the E. coli cells on watermelon surfaces significantly increased (P<0.05) from 0.04 to 0.99 in the first 24 h, which was primarily due to the decrease in loosely attached population, given that the population of strongly attached cells was constant. Thereafter, there was no significant change in SR values, up to 120 h. The daily die-off rate of E. coli ranged from -0.12 to 1.3 log CFU/cm2. The chlorine treatment reduced the E. coli level by 4.2 log CFU/cm2 (initial level 5.6 log CFU/cm2) and 0.62 log CFU/cm2 (initial level 1.8 log CFU/cm2), on the watermelons that had an attachment time of 30 min and 120 h respectively. Overall, our findings revealed that the population of E. coli on watermelon surfaces declined over time in an agricultural environment. Microbial contamination during pre-harvest stages may promote the formation of strongly attached cells on the produce surfaces, which could influence the efficacy of post-harvest washing and sanitation techniques. [ABSTRACT FROM AUTHOR]

Background: Randomized phase III trials have established the efficacy of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors as first-line treatment for EGFR mutation-positive advanced non–small-cell lung cancer (EGFR Mut+ NSCLC). This retrospective cohort study examined the management patterns and outcomes of patients with EGFR Mut+ NSCLC in a real-world setting. Materials and methods: Data were extracted from the US Flatiron Electronic Health Record-derived database. Adult patients with stage IIIB/IV EGFR Mut+ NSCLC (exon 19 deletion or exon 21 L858R mutation) who had received first-line systemic therapy between 2011 and 2016 were included. Demographic and clinical characteristics were analyzed. Outcomes evaluated were time to next treatment (a surrogate for progression-free survival) and overall survival. Results: Of the 22,258 patients with advanced NSCLC in the database, 961 met the inclusion criteria. Median age was 69.0 years (range: 61–78) and the majority were female (68.0%), with stage IV (93.9%), non-squamous cell carcinoma (97.4%). EGFR tyrosine kinase inhibitors were the most widely prescribed first-line therapy (72.8%). The likelihood of receiving an EGFR tyrosine kinase inhibitor or chemotherapy was unaffected by the type of medical insurance patients had. Patients treated with an EGFR tyrosine kinase inhibitor had significantly longer time to next treatment than those given other first-line systemic therapies (p < 0.0001). There were no significant differences in overall survival according to treatment type. Conclusion: Results from this large US cohort study reflect those obtained in randomized trials of patients with advanced EGFR Mut+ NSCLC and demonstrate their transferability into a real-world setting. [ABSTRACT FROM AUTHOR]

Background: Population-based estimates of the incidence and prognosis of brain metastases at diagnosis of hepatocellular carcinoma (HCC) are lacking. The aim of this study was to characterize the incidence proportion and survival of newly diagnosed hepatocellular carcinoma with brain metastases (HCCBM). Materials and methods: Data from Surveillance, Epidemiology, and End Results (SEER) program between 2010 and 2014 was evaluated. Patients with HCCBM were included. Multivariable logistic and Cox regression were performed to identify predictors of the presence of brain metastases at diagnosis and prognostic factors of overall survival (OS). We also built a nomogram based on Cox model to predict prognosis for HCCBM patients. Results: We identified 97 patients with brain metastases at the time of diagnosis of HCC, representing 0.33% of the entire cohort. Logistic regression showed patients with bone or lung metastases had greater odds of having brain metastases at diagnosis. Median OS for HCCBM was 2.40 months. Cox regression revealed unmarried and bone metastases patients suffered significantly shorter survival time. A nomogram was developed with internal validation concordance index of 0.639. Conclusions: This study provided population-based estimates of the incidence and prognosis for HCCBM patients. The nomogram could be a convenient individualized predictive tool for prognosis. [ABSTRACT FROM AUTHOR]

Background: Lifestyle choices are important determinants of individual health. Few studies have investigated changes in health behaviors and preventive activities brought about by the 2007 implementation of Urban Resident Basic Health Insurance (URBMI) in China. This study, therefore, aimed to explore whether URBMI has reduced individuals’ incentives to adopt healthy behaviors and utilize preventive care services. Methods: Data were drawn from two waves of the China Health and Nutrition Survey. Respondents were categorized according to their insurance situation before and after the URBMI reform in 2006 and 2011. Propensity score matching and difference-in-differences methods were used to measure levels of preventive care and behavior changes over time. Estimations were also made based on gender, self-reported health, and income. Results: We found that URBMI implementation did not change residents’ utilization of preventive care services or their smoking habits, drinking habits, or other risky behaviors overall. However, the likelihood of sedentariness did increase by five percentage points. Females tended to be more sedentary while males were less likely to drink soft drinks. Residents with poor self-reported health exercised less while those who reported good health were more likely to be sedentary. Low- and middle-income residents were likely to be sedentary while middle-income people tended to smoke after becoming insured. Conclusion: Since URBMI implementation, some unhealthy behaviors like sedentariness have increased among those who were newly insured, and different subgroups have reacted differently. This suggests that the insurance design needs to be optimized and effective measures need to be adopted to help improve people’s lifestyle choices. [ABSTRACT FROM AUTHOR]

Background: The growing popularity of traditional medicine (TM) is reflected in the increasing trend for its use worldwide. Many people are turning to use TM as a complementary or integrative treatment. The aim of this study is to present the first nationwide report describing the use of TM in two countries (South Korea and Taiwan). Materials and methods: To present the TM utilization patterns between South Korea and Taiwan, we analyzed data from the National Health Insurance cohorts in each country, each of which has approximately one million inhabitants. Results: In total, 261,478 (25.5%) of 1,025,340 people in South Korea and 260,529 (26.8%) of 970,866 people in Taiwan used TM services at least once under the National Health Insurance in 2011. Using multivariable logistic regression, TM users in South Korea were significantly more likely to be female, 61–80 years of age and individuals with a high income, and those in Taiwan were significantly more likely to be female, 21–40 years of age and individuals with a middle income. The two countries showed similar utilization patterns in visit seasons. People visited TM clinics more frequently than TM hospitals in both countries. The most common TM treatment in South Korea was acupuncture, whereas in Taiwan, various powdered Chinese herbal preparations were the most commonly used treatment. The most common diseases for people seeking TM services were musculoskeletal system and connective tissue diseases in South Korea and Symptoms, signs, and ill-defined conditions in Taiwan. Conclusion: According to the National Health Insurance database, about one fourth of the NHI beneficiaries of South Korea and Taiwan had TM use in 2011. Different TM utilization patterns existed between South Korea and Taiwan, which might be due to the differences in insurance coverage between the two countries. [ABSTRACT FROM AUTHOR]

Introduction: In this study we developed the Disability Beliefs Scale to assess Veterans’ beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran’s being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD. Methods: Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits. Results: No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use. Conclusion: The association between Veterans’ use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection—finances, validation of Veterans’ experiences, and the involvement of significant others—might also help motivate Veterans’ use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement. [ABSTRACT FROM AUTHOR]

The financial risk not only affects the development of the company itself, but also affects the economic development of the whole society; therefore, the financial risk assessment of company is an important part. At present, numerous methods of financial risk assessment have been researched by scholars. However, most of the extant methods neither integrated fuzzy sets with quantitative analysis, nor took into account the historical data of the past few years. To settle these defects, this paper proposes a novel financial risk assessment model for companies based on heterogeneous multiple-criteria decision-making (MCDM) and historical data. Subjective and objective indexes are comprehensively taken into consideration in the financial risk assessment index system of the model, which combines fuzzy theory with quantitative data analysis. Moreover, the assessment information obtained from historical financial information of company, credit rating agency and decision makers, including crisp numbers, triangular fuzzy numbers and neutrosophic numbers. Furthermore, the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) method is used to determine the ranking order of companies according to their financial risk. Finally, an empirical study of financial risk assessment for companies is conducted, and the results of comparative analysis and sensitivity analysis suggest that the proposed model can effectively and reliably obtain the company with the lowest financial risk. [ABSTRACT FROM AUTHOR]

This research examined the psychometric properties and construct validity of the Short Grit Scale (Grit-S) in Chinese insurance employees (N = 2,363; 37% males; mean age = 35.14). Exploratory factor analysis and confirmatory factor analysis (CFA) were used to determine the factor structure of the Grit-S. The resulting model was tested by multi-group CFA for the factorial invariance of the Grit-S across genders and age groups. Results showed that the Grit-S could be best explained by a two-factor model containing consistency of interest (α = .70) and perseverance of effort (α = .75). The factor model was equivalent across genders and age groups. The scores of the Grit-S were significantly correlated with external criteria variables including mental wellbeing and job performance. Overall, our findings suggested that the Grit-S can be a promising assessment of the grit trait in Chinese employees. [ABSTRACT FROM AUTHOR]

Background: Whether inpatient services can be successfully substituted by office-based services has been debated for many decades, but the evidence is still inconclusive. This study aims to investigate the effect of office-based care on use and the expenditure for other healthcare services in patients with type II diabetes (T2D). Methods: A generalized propensity score matching approach was used on pooled Medical Expenditure Panel Survey (MEPS) data for 2000–2012 to explore a dose-response effect. Patients were matched by using a comprehensive set of variables selected following a standard model on access to care. Findings: Office-based care (up to 5 visits/year) acts as a substitute for other healthcare services and is associated with lower use and expenditure for inpatient, outpatient and emergency care. After five visits, office-based care becomes a complement to other services and is associated with increases in expenditure for T2D. Above 20 to 26 visits per year, depending on the healthcare service under consideration, the marginal effect of an additional office-based visit becomes non-statistically significant. Conclusions: Office-based visits appear to be an effective instrument to reduce use of inpatient care and other services, including outpatient and emergency-care, in patients with T2D without any increase in total healthcare expenditure. [ABSTRACT FROM AUTHOR]

Objectives: Admission rates have increased in China, despite the fact that accessibility to primary care is improving. Hospital care could be cost-inefficient, and little is currently known about the appropriateness of admissions to tertiary hospitals in China. This study aims to measure the extent of inappropriate admissions in the cardiology and orthopedics departments of a tertiary hospital in Shanghai, to explore the factors associated with inappropriateness for each department, and to identify the causes of inappropriate admissions. Methods: The records of inpatients discharged on randomly sampled two days each week during March 2013 to February 2014 from the two departments were extracted. Two reviewers were recruited to assess the records according to the Chinese version of the Appropriateness Evaluation Protocol (C-AEP). Demographic, socio-economic, and other admissions-related variables were collected. Logistic regression analysis was adopted to determine the associated factors of inappropriateness. Results: 35.0% (N = 120) of the 343 admissions and 38.7% (N = 179) of the 463 admissions of the cardiology and orthopedics departments were not justified by the C-AEP, respectively. Age (OR = 0.717), self-pay (OR = 3.752), admission via outpatient sector (OR = 5.332), and readmission (OR = 2.501) were identified as factors affecting the appropriateness of admissions in the cardiology department. Age (OR = 0.930), self-pay (OR = 2.597), admission during 12:00–17:59 (OR = 3.211), and admission via outpatient sector (OR = 7.060) were determined to be associated with appropriateness of admission in the orthopedics department. The main reason for inappropriateness was premature admission for both departments. Conclusions: The magnitude of inappropriate admissions was considerable in the departments. To improve appropriateness, the results suggest that further interventions should be focused on both external and internal factors. [ABSTRACT FROM AUTHOR]

Elderly patients and those with comorbid conditions are at high risk for poor outcomes after Clostridium difficile infection (CDI) but outcomes in a healthier, nonelderly population are not well described. We sought to investigate gastrointestinal diagnoses and CDI during hospitalizations in the 24 to 36 months after an initial episode of CDI in nonelderly patients in a cohort with an overall low prevalence of comorbid conditions. We performed a retrospective analysis of hospital admissions from 2010–2013 using the Truven MarketScan database of employment-based private insurance claims. Subjects <65 years of age and their adult dependents (> = 18 years old); a CDI diagnosis in 2011 (index date); at least 12 months of pre-index continuous enrollment; and 24–36 months of continuous post-index enrollment were included. The 12 months of each subject’s enrollment prior to the index date for a CDI served as the reference period for the analyses of that subject’s post-CDI time periods. Hospital claims during the follow-up period were evaluated for gastrointestinal diagnoses and/or CDI ICD-9 codes. The risk of gastrointestinal diagnoses was assessed using Cox proportional hazards models adjusted for a pre-specified set of baseline demographic and clinical factors. During 2011, 5,632 subjects with CDI met the inclusion criteria for our study. The risk of gastrointestinal diagnoses in patients with a CDI diagnostic code for the same admission was almost 8-fold higher 3 months post-CDI (hazard ratio (HR) = 7.56; 95% confidence interval (CI): 2.97–19.19) than for subjects without CDI and remained statistically significant until month 24 (HR = 1.47; 95% CI = 1.04–2.08). After CDI, patients remained at risk for gastrointestinal symptoms with CDI for up to two years. There is an important, long-term healthcare burden after CDI in this population. [ABSTRACT FROM AUTHOR]

Background: China adopted family doctor (FD) to help achieve “Healthy China 2030” through providing continuous, comprehensive, and life-cycle contract services. However, there is a disparity between actual and targeted FD use, as residents continue to visit specialists in large hospitals. The government implemented initiatives to improve residents’ willingness to sign up with and visit their FDs. Factors that influence contract behavior are therefore significant for frontier policy research. Methods: Two survey waves were conducted in Shanghai (2013 and 2016). The first wave included 2754 people and the second 1995 people. Exploratory factor analysis was used to synthesize “satisfaction” as a predictor of contract behavior. Pearson’s chi-square, pooled and logistic regression models were used to estimate associations between influencing factors and contract behavior, and clarify variations in factors across the two waves. Results: Four factors were extracted from 15 satisfaction items: “Treatment Environment,” “Medical Technology,” “Service Specification” and “Service Attitude”. Consistent with descriptive analysis, longitudinal analysis showed sociodemographic characteristics (age, education, marital status, and hukou) were significant predictors of contract behavior. The odds ratio of non-communicable diseases (NCD) patients for contract behavior was 2.218 times that of residents without NCD. Contract behavior was positively correlated with awareness of FD services (OR = 21.674, 95%CI = 15.043–31.229), satisfaction with Service Attitude (OR = 1.210, 95%CI = 1.009–1.451), and visit compliance (OR = 1.959, 95%CI = 1.564–2.452). Over time, the odds ratios of the married, Shanghai hukou, NCD, and awareness of FD services declined from 0.456, 1.795, 2.492, 28.690 to 0.443, 1.678, 1.910 and 14.031 respectively, while those of age, and visit compliance increased from 1.027, 1.521 to 1.041 and 2.305 respectively. In 2016, an education-contract gradient had formed (the higher the education level, the higher probability of signing with a FD), whereas high school education had the highest odds ratio (OR = 1.163,95%CI = 0.740–1.827) in 2013. Service Attitude was the only significant satisfaction-related predictor (OR = 1.358, 95%CI = 1.001–1.842) in 2016, compared with “Treatment Environment” (OR = 1.224, 95%CI = 1.001–1.496) and “Service Specification” in 2013(OR = 1.270, 95%CI = 1.040–1.552). Conclusions: Except for the socio-demographic variables, NCD, awareness of FD services, satisfaction and visit compliance were significant predictors of contract behavior with FDs. The effect of visit compliance had increased over time while NCD and awareness of FD services were losing impact over time. Significant satisfaction factors had also changed from “Treatment Environment” and “Service Specification” to “Service Attitude”. [ABSTRACT FROM AUTHOR]

Background: The goal is to determine the delays and reduced rates of kidney transplant (KTx) for the Indigenous Americans and variables predictive of these outcomes at a large single transplant center. Methods: 300 Indigenous Americans and 300 non-Hispanic white American patients presenting for KTx evaluation from 2012–2016 were studied. Results: Compared to whites, the Indigenous Americans had the following: more diabetes, dialysis, physical limitation and worse socioeconomic characteristics(p<0.01); median difference of 20 day delay from referral to KTx evaluation, 17 day delay from approval to UNOS listing and 126.5 longer delay on the waitlist compared to whites(p<0.001). Of the Indigenous Americans listed, more died, were removed, or were still waiting than transplanted compared to whites (p<0.001). Variables predictive of delay from referral to transplant evaluation included: Indigenous race, distance from transplant center, coronary artery disease, and time on dialysis (p<0.05). Cumulative incidence of waitlisting and KTx was lower for Indigenous Americans (p<0.0001). Independent predictors of decreased likelihood of waitlisting included age, peripheral vascular disease, no caregiver, physical limitation, and illegal drug use history (p<0.05). Variables predictive of lower likelihood of KTx included Indigenous race, percentage of time inactive on the waitlist, no caregiver, and O blood type. Conclusions: Among patients referred and evaluated for KTx, the Indigenous American race was independently associated with significant delays in the KTx process after accounting for co-morbid and socioeconomic factors. Cardiovascular morbidity and physical limitation were identified as important determinants of delay and decreased likelihood of waitlisting. Further quantitative and qualitative work is needed to identify and intervene on modifiable barriers to improve access to KTx for the Indigenous Americans. [ABSTRACT FROM AUTHOR]