Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness

Background: Antipsychotic medication use among elderly with Alzheimer's disease and related dementias (ADRD) and without severe mental illness is considered as low-value care. Our objective was to assess the factors associated with this inappropriate use of antipsychotic medications among community-dwelling Medicare beneficiaries with ADRD and without severe mental illness.Methods: This study used a retrospective cross-sectional design. Data for this study were derived from the nationally representative Medicare Current Beneficiary Survey (MCBS) and linked Medicare claims. Logistic regression models were used to examine factors associated with low-value care.Results: Overall 8.5% had low-value care. In the final adjusted logistic regression model, race other than Hispanic or Non-Hispanic White (AOR =0.54, 95% CI = [0.30,0.98]), individuals over 80 years of age (AOR =0.53, 95% CI = [0.36,0.76]), and obese individuals (AOR =0.55, 95% CI = [0.35,0.85]) had significantly lower odds of receiving low-value care. Those with depression (AOR =1.71, 95% CI = [1.21, 2.43]), who lived in the Midwest (AOR =1.7, 95% CI = [1.08,2.68]), and with a higher number of ADL limitations (AOR =1.28, 95% CI = [1.19,1.38]) had significantly higher odds of low-value care.Conclusions: There were subgroup differences in low-value care. Interventions may target these subgroups to reduce low-value care.

Increased Healthcare Utilization and Expenditures Associated With Chronic Opioid Therapy

OBJECTIVES

To assess the association of the transition from incident opioid use to incident chronic opioid therapy (COT) with the trajectories of healthcare utilization and expenditures.

STUDY DESIGN

We used a longitudinal, retrospective cohort design, including seven 120-day time periods covering preindex (t₁, t₂, and t₃), index (t₄), and postindex (t₅, t₆, and t₇) periods with data from adults aged 28 to 63 years at the index date, without cancer, and continuously enrolled in a primary commercial insurance plan (N = 20,201).

METHODS

Multivariable analyses were performed on utilization (population-averaged [PA] logistic regression), expenditures (PA generalized estimating equations), and expenditure estimates (counterfactual prediction). The data used were from a commercial claims database (10% random sample from the IQVIA Real-World Data Adjudicated Claims - US database) from 2006-2015.

RESULTS

Patients on COT were more likely to use inpatient services (adjusted odds ratio, 1.11; 95% CI, 1.01-1.21) compared with those who did not. Although expenditures peaked during the index period (t₄) for all users, differences in unadjusted average 120-day expenditures between COT and non-COT users were highest in t₄ for total ($4607) and inpatient ($2453) expenditures. COT users had significantly higher total (β = 0.183; P <.01) and inpatient (β = 0.448; P <.001) expenditures.

CONCLUSIONS

The period after incident opioid prescription but before transition to COT is an important time for payers to intervene.

Association between chronic hepatitis B infection and metabolic syndrome

Purpose

The association between chronic hepatitis B (CHB) infection and metabolic syndrome (MetS) remains inconclusive. This study was designed to determine the association between CHB infection and MetS among the US population with updated data and adjustments for a comprehensive set of risk factors.

Methods

Adults aged 18 years or older who were clinically assessed for Hepatitis B and MetS from the National Health and Nutrition Examination Survey (NHANES) 2003-2004, 2005-2006, 2007-2008, 2009-2010, 2011-2012, and 2013-2014 cycles were included in the study (N = 53,392,666). MetS was defined according to the NCEP/ATP III guideline. CHB was identified by the seropositivity of Hepatitis B surface antigen and core antibody in the absence of Hepatitis B surface antibody. Rao-Scott χ ²test and logistic regressions were employed in the analyses.

Results

MetS was less prevalent among adults with CHB compared to adults without CHB (12.1% vs. 18.8%, p = 0.073). In adjusted analyses, adults with CHB were 48% less likely to have MetS compared to those without CHB (95% Confidence Interval [CI]: 0.29-0.94). Regarding individual component of MetS, CHB was inversely associated with high waist circumference (AOR = 0.32, 95% CI: 0.21-0.49) and hypoalphalipoproteinemia (AOR = 0.48, 95% CI: 0.25-0.91). No association between CHB and other metabolic components were found.

Conclusions

CHB was inversely associated with MetS, high waist circumference, and hypoalphalipoproteinemia. No significant association was found between CHB and other MetS components.

Depressive symptoms and untreated coronal dental caries among adults ages 21-64 years, NHANES 2013-2014

BACKGROUND

Depression has been linked to poor oral health among patients seeking dental care. However, systematic research on the relationship between depressive symptoms and oral health is limited.

OBJECTIVE

To examine the association of depressive symptoms with untreated dental caries among adults aged 21-64 years.

BASIC RESEARCH DESIGN

Cross-sectional secondary analysis.

SETTING

The data were extracted national data collected in the United States (2013-2014 National Health Nutrition and Examination Survey).

PARTICIPANTS

The sample consisted of 3,127 non-institutionalized civilians.

MAIN OUTCOME MEASURE

Untreated coronal dental caries (yes, no) was the key outcome variable. Depressive symptom categories (none, moderate, and severe) were derived from the Patient Health Questionnaire-9 Depression Scale.

RESULTS

In the study sample, 33.4% of adults had untreated coronal dental caries. Most participants (77.9%) did not report depressive symptoms; 13.9% had mild and 8.2% had moderate or severe depressive symptoms. In unadjusted analyses, individuals with mild (Odds Ratio = 1.62 [95% CI: 1.26, 2.08] and moderate/severe depressive symptoms (Odds Ratio = 2.70 [95% CI: 1.81, 4.02]) were more likely to have untreated coronal caries as compared with individuals without depressive symptoms. When sex, race, age, education, family income-to-poverty ratio, dental visits, history of previous dental restorations, health insurance, and smoking were included into the model, the associations were no longer statistically significant (1.27 [95% CI: 0.96, 1.69] and 1.61 [95% CI: 0.95, 2.73], respectively).

CONCLUSION

The relationship between depressive symptoms and untreated coronal dental caries failed to remain significant after the addition of tobacco usage in the analysis.

The dynamic relationships between economic status and health measures among working-age adults in the United States

We examine the dynamic relationships between economic status and health measures using data from 8 waves of the Panel Study of Income Dynamics from 1999 to 2013. Health measures are self-rated health (SRH) and functional limitations; economic status measures are labor income (earnings), family income, and net wealth. We use 3 different types of models: (a) ordinary least squares regression, (b) first-difference, and (c) system-generalized method of moment (GMM). Using ordinary least squares regression and first difference models, we find that higher levels of economic status are associated with better SRH and functional status among both men and women, although declines in income and wealth are associated with a decline in health for men only. Using system-GMM estimators, we find evidence of a causal link from labor income to SRH and functional status for both genders. Among men only, system-GMM results indicate that there is a causal link from net wealth to SRH and functional status. Results overall highlight the need for integrated economic and health policies, and for policies that mitigate the potential adverse health effects of short-term changes in economic status.

Healthcare Utilization and Costs During the Initial Phase of Care Among Elderly Women With Breast Cancer

Background: Understanding the patterns of healthcare utilization and costs during the initial phase of care (12 months after breast cancer [BC] diagnosis) in older women (aged ≥65 years) is crucial in the allocation of Medicare resources. The objective of this study was to determine healthcare utilization and costs during the initial phase of care in older, female, Medicare fee-for-service beneficiaries diagnosed with BC, and to determine the factors associated with higher costs. Methods: A retrospective observational study using the SEER-Medicare linked database was conducted in 69,307 women aged ≥66 years diagnosed with primary incident BC in 2003-2009 to determine healthcare utilization, average costs, and costs for specific services during the initial phase of care. Generalized linear model regression was conducted to identify the factors associated with higher costs in a multivariate framework. Results: A total of 96% of women were treated with surgery during the initial phase of BC care, whereas 21% and 54% underwent chemotherapy and radiotherapy, respectively. Costs during the initial phase of care totalled $28,075 in 2012 USD, comprising $13,344 for physician services and $7,456 for outpatient services. Factors associated with higher costs during the initial phase of care were younger age (66-69 years), African American race, higher household income, advanced stages of BC, initial BC treatment, higher number of primary care physician visits, and presence of comorbidities and/or a mental condition. Conclusions: The economic burden of BC is substantial during the initial phase of care. Physician and outpatient services accounted for the highest proportion of costs. Predisposing factors, need-related factors, healthcare use, and external environmental healthcare factors significantly predicted costs during the initial phase of care.

Nonadherence to Statins and Antihypertensives and Hospitalizations Among Elderly Medicare Beneficiaries With Incident Cancer

Background: Incident cancer diagnosis may increase the risk of coronary artery disease (CAD)-related hospitalizations, especially in older individuals. Adherence to statins and/or angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs)/β-blockers reduces CAD-related hospitalizations. This study examined the relationship between medication adherence and CAD-related hospitalizations immediately following cancer diagnosis. Patients and Methods: A retrospective observational longitudinal study was conducted using SEER-Medicare data. Elderly Medicare fee-for-service beneficiaries with preexisting CAD and incident breast, colorectal, or prostate cancer (N=12,096) were observed for 12 months before and after cancer diagnosis. Hospitalizations measured every 120 days were categorized into CAD-related hospitalization, other hospitalization, and no hospitalization. Medication adherence was categorized into 5 mutually exclusive groups: adherent to both statins and ACEIs/ARBs/β-blockers (reference group), not adherent to both statins and ACEIs/ARBs/β-blockers, adherent to either statins or ACEIs/ARBs/β-blockers, use of one medication class and adherent to that class, and use of one medication class and not adherent to that class. The relationship between medication adherence and hospitalization was analyzed using repeated measures multinomial logistic regressions. Inverse probability treatment weights were used to control for observed group differences among medication adherence categories. Results: Adherence to both statins and ACEIs/ARBs/β-blockers was estimated at 31.2% during the 120-day period immediately following cancer diagnosis; 13.7% were not adherent to both medication classes during the same period, and 27.4% had CAD-related hospitalizations immediately after cancer diagnosis, which declined to 10.6% during the last 4 months of the postdiagnosis period. In the adjusted analyses, those not adherent to both statins and ACEIs/ARBs/β-blockers were more likely to have CAD-related hospitalization compared with those adherent to both medication classes (adjusted odds ratio, 1.82; 95% CI, 1.72-1.92; P<.0001). Conclusions: Given the complexity of interaction between CAD and cancer, it is important to routinely monitor medication adherence in general clinical practice and to provide linkages to support services that can increase medication adherence.

Clinical Oral Health Recommended Care and Oral Health Self-Report, NHANES, 2013-2014

PURPOSE

The purpose of this study was to determine the concordance of self-reported responses to oral health questions versus clinically evaluated recommended need for oral healthcare by calibrated dentists to determine usefulness of the questions for epidemiological studies. We additionally examined other factors associated with concordant self-reports versus clinical evaluations.

MATERIALS AND METHODS

We used a cross-sectional study design with 4,205 participants, ages 30 years and above, who had complete oral health self-perception data and dental referral data in the NHANES 2013-14. Calibrated dentists completed clinical oral healthcare assessments. The assessments were dichotomized to (1) recommendation for immediate care and (2) routine oral health care. Self-reported oral health needs were measured with 6 items (an overall oral health self-perception question, oral pain within the previous year, impact on job/school, suspected periodontal disease, tooth appearance, and tooth mobility). The key item of interest was the overall oral health self-perception question.

RESULTS

Concordance with clinically evaluated recommended need for oral healthcare varied from 52.0% (oral pain) to 65.4% (overall oral health self-perception). Many subgroup differences were observed.

CONCLUSIONS

The overall self-perception of oral health and the clinical evaluation of oral healthcare need were substantially concordant; other self-reported measures were moderately concordant. This is useful information and points to the need for a minimum set of measures that can provide actionable information and capture the need for clinical dental care.

Burden of Depression among Working-Age Adults with Rheumatoid Arthritis

OBJECTIVE

This study estimated the excess clinical, humanistic, and economic burden associated with depression among working-age adults with Rheumatoid Arthritis (RA).

METHODS

A retrospective cross-sectional study was conducted among working-age (18 to 64 years) RA patients with depression (N = 647) and without depression (N = 2,015) using data from the nationally representative Medical Expenditure Panel Survey for the years 2009, 2011, 2013, and 2015.

RESULTS

Overall, 25.8% had depression. In adjusted analyses, adults with RA and depression compared to those without depression were significantly more likely to have pain interference with normal work (severe pain: AOR = 2.22; 95% CI = 1.55, 3.18), functional limitations (AOR = 2.17; 95% CI = 1.61, 2.94), and lower mental health HRQoL scores. Adults with RA and depression had significantly higher annual healthcare expenditures ($14,752 versus 10,541, p < .001) and out-of-pocket spending burden. Adults with RA and depression were more likely to be unemployed and among employed adults, those with depression had a significantly higher number of missed work days annually and higher lost annual wages due to missed work days.

CONCLUSIONS

This study highlights the importance of effectively managing depression in routine clinical practice of RA patients to reduce pain and functional limitations, improve quality of life, and lower direct and indirect healthcare costs.

Food Security and Unmet Dental Care Needs in Adults in the United States

Purpose: Low food security is potentially related to poor dental health and unmet dental care needs. Food security has become a significant public health concern in the United States (U.S.) since the Great Recession beginning in 2007. The purpose of this study is to determine the association between low food security and unmet dental care need in adults in the U.S.Methods: A cross-sectional design with data from the National Health and Nutrition Examination Survey (NHANES) 2011-2012 was used for the study to measure unmet dental care need. The study population included 4,845 adults, ages 20 years and above. Chi square tests and logistic regressions were conducted for the statistical analysis.Results: Overall, 47% of participants had unmet dental care need and 16% were found to have low food security. A higher percentage of adults with low food security had unmet dental care need (70.0% vs. 41.0%; p < .000) as compared to adults with full food security. In adjusted analysis, adults with low food security were more likely to have unmet dental care need as compared to participants with full food security (Adjusted Odds Ratio, 1.58 [95% CI: 1.18, 2.12; p <.01]).Conclusions: A significant association between low food security and unmet dental care need was identified among adults in the United States. Dental professionals routinely provide community educational programs and regularly query patients about food intake due to its impact on oral and overall health. It is important for dental professionals to be able to discuss community food resource options or refer patients to social service providers to assist individuals with low food security.

Polypharmacy among patients with diabetes: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia

ObjectivesPatients with diabetes are at high risk for polypharmacy (ie, use of multiple medications) for treatment of diabetes, associated comorbidities and other coexisting conditions. This study aims to estimate the prevalence of polypharmacy and factors associated with polypharmacy among adult patients with diabetes.

METHODS

A cross-sectional retrospective observational study of adults with diabetes, who visited the outpatient clinic of a tertiary teaching hospital in Saudi Arabia, was conducted. Data were extracted from the Electronic Health Record database for a period of 12 months (January-December 2016). Polypharmacy was defined as the cumulative use of five or more medications. Polypharmacy among adults with diabetes was measured by calculating the average number of medications prescribed per patient. A multivariable logistic regression model was used to examine the factors associated with polypharmacy.

RESULTS

A total of 8932 adults with diabetes were included in this study. Of these, nearly 78% had polypharmacy which was more likely among women as compared with men and more likely among older adults (age ≥60 years) as compared with the adults. Also, polypharmacy was two times as likely among patients with coexisting cardiovascular conditions (adjusted OR (AOR)=2.89; 95% CI 2.54 to 3.29), respiratory disease (AOR=2.42; 95% CI 1.92 to 3.03) and mental health conditions (AOR=2.19; 95% CI 1.74 to 2.76), and three times as likely among patients with coexisting musculoskeletal disease (AOR=3.16; 95% CI 2.31 to 4.30) as compared with those without these coexisting chronic conditions categories.

CONCLUSIONS

Polypharmacy is common among patients with diabetes, with an even higher rate in older adults patients. Healthcare providers can help in detecting polypharmacy and in providing recommendations for simplifying medication regimens and minimising medications to enhance the outcome of diabetes care.

Direct medical expenditures associated with Alzheimer's and related dementias (ADRD) in a nationally representative sample of older adults - an excess cost approach

OBJECTIVE

To estimate the excess direct annual healthcare expenditures associated with Alzheimer's and related dementias(ADRD) among community-dwelling older adults in the United States.

METHODS

This retrospective cross-sectional study compared the annual healthcare expenditures between elderly individuals aged 65 years and older with ADRD (n = 662) and without ADRD (n = 13,398) using data from the Medical Expenditure Panel Survey (MEPS) for the years 2007, 2009, 2011 and 2013. Adjusted total annual medical expenditures was estimated using generalized linear model with gamma distribution and log link in 2013 U.S. dollars. Adjusted inpatient, outpatient, emergency, home healthcare and prescription drug expenditures, were estimated using two-part logit-generalized linear regression models.

RESULTS

The adjusted mean total healthcare expenditures were higher for the ADRD group as compared to the no ADRD group($14,508 vs. $10,096). Among those with ADRD, 34.3% of the expenditures were for home healthcare as compared to 4.4% among those without ADRD. Among users, the ADRD group had significantly higher home healthcare ($3,240 vs. $566) and prescription drug expenditures($3,471 vs. $2,471). There were no statistically significant differences in inpatient, emergency room and outpatient expenditures between the ADRD and no ADRD group.

CONCLUSION

ADRD in U.S. community-dwelling elders is associated with significant financial burden, primarily driven by increased home healthcare use.

Dynamics in Health and Employment: Evidence from Indonesia

This paper examines the consequences of disability, identifying for the first time, the separate impacts of onsets and recoveries from disability on both employment status and hours worked using panel data from Indonesia. We find that changes in physical functioning have no affect hours worked among the employed. However, we find that onsets of physical limitations lead to an increase in the probability of leaving employment, while recoveries increase the probability of returning to work. We also find a larger effect among self-employed workers compared to salaried workers. These results overall point towards a need for social protection policies with a focus on health, disability, and employment in Indonesia.

State-Level Variability in Veteran Reliance on Veterans Health Administration and Potentially Preventable Hospitalizations: A Geospatial Analysis

Most Veterans who use the Veterans Health Administration (VHA) also utilize private-sector health care providers. To better inform local and regional health care planning, we assessed the association between reliance on VHA ambulatory care and total and system-specific preventable hospitalization rates (PHRs) at the state level. We conducted a retrospective dynamic cohort study using Veterans with diabetes mellitus, aged 66 years or older, and dually enrolled in VHA and Medicare parts A and B from 2004 to 2010. While controlling for median age and proportion of males, we measured the association between reliance on VHA ambulatory care and PHRs at the state level using multivariable ordinary least square regression, geographically weighted regression, and generalized additive models. We measured geospatial patterns in PHRs using global Moran’s I and univariate local indicator spatial analysis. Approximately 30% of hospitalized Veterans experienced a preventable hospitalization. Reliance on VHA ambulatory care at the state level ranged from 13.92% to 67.78% and was generally not associated with PHRs. Geospatial analysis consistently identified a cluster of western states with low PHRs from 2006 to 2010. Given the generally low reliance on VHA ambulatory care and lack of association between this reliance and PHRs, policy changes to improve Veterans’ health care outcomes should address private-sector care in addition to VHA care.

Treatment for Depression and Health-Related Quality of Life among Adults with Arthritis

Depression treatment has been proven to relieve depressive symptoms and pain and may therefore improve the health-related quality of life (HRQoL) among adults with arthritis. The objective of the current study was to examine the HRQoL associated with depression treatment among adults with arthritis and depression. A retrospective longitudinal cohort study design using data from the Medical Expenditure Panel Survey (2009-2012) was adopted. The study sample consisted of adults (≥ 21 years) with co-existing arthritis and depression (N = 1692). Depression treatment was categorized into: antidepressants only, psychotherapy with or without antidepressants, and neither antidepressants nor psychotherapy. Multivariable Ordinary Least Square (OLS) regressions, which controlled for observed selection bias with inverse probability treatment weights (IPTW) were built to examine the association between depression treatment categories and the HRQoL scores. The OLS regression controlled for factors in the biological, psychological and social domains that may affect HRQoL. A majority of individuals reported taking antidepressants only (52%), 24.4% reported receiving psychotherapy with or without antidepressants and 23% did not receive either antidepressants or psychotherapy. In multivariable OLS regression with IPTWs, adults using only antidepressants had marginally higher physical component summary scores (beta = 0.96, p value = 0.096) compared to no depression treatment. There were no significant associations between depression categories and mental component summary scores. HRQoL was not affected by depression treatment in adults with coexisting arthritis and depression. Improvement in HRQoL may require a collaborative care approach and such intense care may not be replicated in real-world practice settings.

Alzheimer Disease and Related Disorders and Out-of-Pocket Health Care Spending and Burden Among Elderly Medicare Beneficiaries

OBJECTIVE

To estimate the excess burden of out-of-pocket health care spending associated with Alzheimer disease and related disorders (ADRD) among older individuals (age 65 y and older).

METHODS

We adopted a retrospective, cross-sectional study design with data from 2012 Medicare Current Beneficiary Survey. The study sample comprised of elderly community-dwelling individuals who had positive total health care expenditures, and enrolled in Medicare throughout the calendar year (462 with ADRD, and 7160 without ADRD). We estimated the per-capita total annual out-of-pocket spending on health care and out-of-pocket spending by service type: inpatient, outpatient, home health, prescription drugs, and other services. We measured out-of-pocket spending burden by calculating the percentage of income spent on health care and defined high out-of-pocket spending burden as having this percentage above 10%. Multivariable analyses included ordinary least squares regressions and logistic regressions and these analyses adjusted for predisposing, enabling, need, personal health care practices and external environment characteristics.

RESULTS

The average annual per-capita out-of-pocket health care spending was greater among individuals with ADRD compared with those without ADRD ($3285 vs. $1895); home health and prescription drugs accounted for 52% of total out-of-pocket spending among individuals with ADRD and 34% among individuals without ADRD. Elderly individuals with ADRD were more likely to have high out-of-pocket spending burden (adjusted odds ratio, 1.49; 95% confidence interval, 1.13-1.97) compared with those without ADRD.

CONCLUSION

ADRD is associated with excess out-of-pocket health care spending, primarily driven by prescription drugs and home health care use.

Predictors of Transitioning to Incident Chronic Opioid Therapy Among Working-Age Adults in the United States

BACKGROUND

Opioids have been prescribed and used for chronic noncancer pain at prolific rates in the United States during the past 2 decades. Patients who transition to incident chronic opioid therapy are at increased risk for significant negative health consequences, including cardiovascular risk, endocrine disorders, opioid use disorder, and death.

OBJECTIVE

To identify the leading predictors associated with transitioning to incident chronic opioid therapy among working-age adults without cancer.

METHOD

This retrospective observational cohort study is based on medical and pharmacy claims of a nationally representative sample of adults enrolled in commercial health insurance plans. Standard parametric (logistic regressions) and nonparametric methods based on a decision tree were used for prediction. To facilitate comparison with the available published literature, we also present adjusted odds ratios (AORs) and 95% confidence intervals (CIs). The 10% random sample of 491,442 patients included in the study who were working-age adults (age, 28-63 years) were insured in a commercial health plan, did not have cancer, and initiated opioid therapy between January 2007 and May 2015. Transition to incident chronic opioid therapy was defined as having claims for at least a 90-day supply of opioids within 120 days after the index date (ie, initiation of opioid therapy). Predictive models used for the analysis comprised a comprehensive list of factors available in the claims data, including opioid regimen characteristics, pain conditions, physical and mental health conditions, concomitant medications use (ie, benzodiazepine, stimulants, nonopioid analgesics, and polypharmacy), patient characteristics, and health insurance type.

RESULTS

In our sample, the transition to incident chronic opioid therapy was 1.3% and pain-specific diagnoses were documented for only one-third (31.7%) of patients. The 4 leading predictors of chronic opioid therapy were opioid duration of action (AOR, 12.28; 95% CI, 8.06-18.72), the parent opioid compound (eg, tramadol vs codeine; AOR, 7.26; 95% CI, 5.20-10.13), the presence of conditions that are very likely to cause chronic pain (AOR, 5.47; 95% CI, 3.89-7.68), and drug use disorders (AOR, 4.02; 95% CI, 2.53-6.40).

CONCLUSION

The initial opioid regimen's characteristics are powerful predictors of chronic opioid therapy. Predictive algorithms created from readily available claims data can be used to develop real-time predictions of the future risk for a patient's transition to chronic opioid use.

Dental Fluorosis over Time: A comparison of National Health and Nutrition Examination Survey data from 2001-2002 and 2011-2012

Purpose: Excessive fluoride ingestion has been associated with dental fluorosis. The purpose of this study was to determine if there was a difference in dental fluorosis prevalence comparing National Health and Nutrition Examination Survey (NHANES) trend data for adolescents, aged 16 and 17 years, when compared to data collected in 2001-2002 to data from 2011-2012.Methods: The sample included 875 participants. Data analyses included Chi square tests and logistic regressions. The data were from a nationally representative survey by calibrated dental examiners using the modified Dean's fluorosis classification system. The data analysis of the prevalence of fluorosis severity level was dichotomized to very mild/above vs. normal/questionable.Results: In 2001-2002, the weighted percentage prevalence of the denoted dental fluorosis categories were: 49.8% normal (i.e., unaffected), 20.5% questionable, and 29.7% very mild and above. In 2011-2012, the weighted percentage prevalence categories were: 31.2% normal, 7.5% questionable, and 61.3% very mild and above. When comparing years 2001-2002 with the years 2011-2012, the prevalence of very mild and above fluorosis increased by 31.6% (P <.0001) for the 2011-2012 group. In adjusted logistic regression, participants from the years 2011-2012 were more likely to have very mild and above dental fluorosis than participants in 2001-2002 as compared with normal/questionable fluorosis (Adjusted odds ratio= 3.85; 95% confidence interval= 2.20, 6.72; P <.0001).Conclusion: There was a difference of 31.6% in dental fluorosis prevalence between 2012-2011 when compared to data from 2002-2001 in adolescents aged 16 and 17 years. The continued increase in fluorosis rates in the U.S. indicates that additional measures need to be implemented to reduce its prevalence.

Colon Cancer Worry in Appalachia

Appalachia has a higher incidence of and mortality from colon cancer (CC) than other regions of the United States; thus, it is important to know the potential impact of elevated risk on cancer worry. Guided by the Self-regulation model, we investigated the association of demographic, cultural (e.g., fatalism, religious commitment), and psychological factors (e.g., perceived risk, general mood) with CC worry among a sample of Appalachian women. A mixed method design was utilized. Appalachian women completed surveys in the quantitative section (n = 134) and semi-structured interviews in the qualitative section (n = 24). Logistic regression was employed to calculate odds ratios (OR) for quantitative data, and immersion/crystallization was utilized to analyze qualitative data. In the quantitative section, 45% of the participants expressed some degree of CC worry. CC worry was associated with higher than high school education (OR 3.63), absolute perceived risk for CC (OR 5.82), high anxiety (OR 4.68), and awareness of easy access (OR 3.98) or difficult access (OR 3.18) to health care specialists as compared to not being aware of the access. there was no association between CC worry and adherence to CC screening guidelines. The qualitative section revealed fear, disengagement, depression, shock, and worry. Additionally, embarrassment, discomfort, and worry were reported with regard to CC screening. Fears included having to wear a colostomy bag and being a burden on family. CC worry was common in Appalachians and associated with higher perceptions of risk for CC and general anxiety, but not with adherence to screening guidelines. The mixed method design allowed for enhanced understanding of CC-related feelings, especially CC worry, including social/contextual fears.

Caregiver Burdens and Preventive Dental Care for Children with Autism Spectrum Disorder, Developmental Disability and/or Mental Health Conditions: National Survey of CSHCN, 2009-2010

Objective The purpose of this study is to examine the burdens of caregivers on perception of the need and receipt of preventive dental care for a subset of children with special health care needs-children with Autism Spectrum disorder, developmental disability and/or mental health conditions (CASD/DD/MHC). Methods The authors used the 2009-2010 National Survey of CSHCN. The survey included questions addressing preventive dental care and caregivers' financial, employment, and time-related burdens. The associations of these burdens on perceptions and receipt of preventive dental care use were analyzed with bivariate Chi square analyses and multinomial logistic regressions for CASD/DD/MHC (N = 16,323). Results Overall, 16.3 % of CASD/DD/MHC had an unmet preventive dental care need. There were 40.0 % of caregivers who reported financial burden, 20.3 % who reported employment burden, and 10.8 % who reported time burden. A higher percentage of caregivers with financial burden, employment burden, and time-related burden reported that their CASD/DD/MHC did not receive needed preventive dental care (14.1, 16.5, 17.7 % respectively) compared to caregivers without financial, employment, or time burdens (9.0, 9.6 %, 11.0 % respectively). Caregivers with financial burden (adjusted multinomial odds ratio, 1.38 [95 % CI 1.02, 1.86] and employment burden (adjusted multinomial odds ratio, 1.45 [95 % CI 1.02, 2.06] were more likely to report that their child did not receive preventive dental care despite perceived need compared to caregivers without financial or employment burdens. Conclusions for practice Unmet needs for preventive dental care were associated with employment and financial burdens of the caregivers of CASD/DD/MHC.

The Humanistic and Economic Burden Associated with Anxiety and Depression among Adults with Comorbid Diabetes and Hypertension

We conducted a retrospective cross-sectional study to estimate the humanistic and economic burden associated with depression and anxiety among adults with comorbid diabetes and hypertension. Pooled data from the 2013 and 2015 Medical Expenditure Panel Survey were used to include adults (≥18 years old) who were alive and diagnosed with both diabetes and hypertension during the observation period. We assessed the humanistic burden with health-related quality of life (HRQoL) and economic burden with the total annual healthcare expenditures. Depending on the presence/absence of depression and anxiety, the study sample was divided into four groups (i.e., no depression/anxiety, depression only, anxiety only, and depression and anxiety). Multivariable regression analyses were used to evaluate the associations between the depression/anxiety categories and disease burden measures. The incremental burden associated with depression and/or anxiety was estimated with the counterfactual recycled prediction. Of the 4560 adults with comorbid diabetes and hypertension, 13.2% reported depression only, 8.7% reported anxiety only, and 7.7% reported both. Results from adjusted analyses indicated that the presence/absence of depression and anxiety was associated with significantly poorer HRQoL, especially on the mental component. Having either depression or anxiety corresponded to reduced mental component summary scores by more than four points. The reduction was as high as 10.35 points when both conditions occurred. Comparing to adults without depression or anxiety, the per-capital incremental annual healthcare expenditures were $4607 for the depression group, $2481 for the anxiety group, and $8709 for adults with both conditions. Furthermore, adults with depression and anxiety were 58% more likely to spend at least 10% of annual household income on healthcare as compared to those with neither the conditions. Our results highlight the needs for integrating cost-effective mental health services into diabetes management to improve the HRQoL and reduce healthcare costs for adults with comorbid diabetes and hypertension.

Heterogeneous Relationships between Labor Income and Health by Race/Ethnicity

OBJECTIVE

To examine the race-stratified relationships between labor income and health among working-age adults in the United States.

DATA SOURCES

Data from eight waves of the Panel Study of Income Dynamics from 1999 through 2013 were used for this study.

STUDY DESIGN

The study utilized a retrospective observational longitudinal design with repeated measures of labor income and health measures. System-generalized method of moment and heteroscedasticity-based instrument regressions were used to examine the relationships between labor income and physical and mental health measures, respectively. Dynamic panel models were used to examine the effect of loss in income on health measures.

DATA COLLECTION/EXTRACTION METHODS

We performed secondary data analysis.

PRINCIPAL FINDINGS

Adults in higher labor income quartiles had better self-rated health than those in the lowest quartile regardless of racial group. The relationship between labor income and psychological distress varied by race groups. Reductions in labor income were associated with increases in psychological distress among whites only.

CONCLUSION

These findings suggest heterogeneous relationships between labor income and overall health across racial groups. Our results highlight the need to provide safety nets for adults who experience a decline in income to prevent deterioration in health.

Serious Psychological Distress and Emergency Room Use among Adults with Multimorbidity in the United States

OBJECTIVES

(1) To examine the association between serious psychological distress (SPD) and emergency room (ER) use in the past 12 months among adults with multimorbidity in the United States (US) and (2) to investigate the association between SPD and the reasons for ER use.

METHODS

The current study used a cross-sectional design with retrospective data from the 2015 National Health Interview Survey. Logistic regression models were used to assess the association between SPD and ER use among adults with multimorbidity. Among ER users, adjusted logistic regression models were conducted to examine the association between SPD and the reasons for the ER use.

RESULTS

After controlling for other variables, adults with multimorbidity and SPD were more likely to use ER than those with multimorbidity and no SPD (AOR = 1.61, 95% CI = 1.26, 2.04). Among ER users, there were no significant associations between SPD and the reasons for ER use after controlling for other variables.

CONCLUSION

Adults with multimorbidity and SPD were more likely to use ER as compared to those with multimorbidity and no SPD. Among adults with multimorbidity, routine screening for SPD may be needed to reduce the ER use.

Rural Veterans' dental utilization, Behavioral Risk Factor Surveillance Survey, 2014

INTRODUCTION

Rural residents are overrepresented in the military; however, access to Veteran services is limited in rural areas. There is a need to identify rural Veteran healthcare utilization. This study addresses that need and has two purposes: a) to determine if there is an association between rural dwelling and Veteran utilization of dental services; and b) to determine if there is an association between rural dwelling and the oral health outcome of missing teeth.

METHODS

Data from the 2014 Behavioral Risk Factor Surveillance Survey were used in this study. Chi square and logistic regression analyses were conducted.

FINDINGS

Rural Veterans were less likely to have a dental visit during the previous year as compared with metropolitan Veterans in unadjusted analysis (Odds ratio = 0.71, 95% Confidence Interval, 0.64, 0.77) and in adjusted analysis [0.87 (95% Confidence Interval, 0.78, 0.96)]. In cases in which all teeth were missing, rural Veterans had an unadjusted odds ratio of 1.79 [95% Confidence Interval, 1.55, 2.08] and an adjusted odds ratio of 1.37 [95% Confidence Interval, 1.17, 1.62] as compared with metropolitan Veterans.

DISCUSSION AND POLICY IMPLICATIONS

The Veterans Health Administration develops policies for establishing centers for care for Veterans. The policy development should take into consideration that rural Veterans have not been as likely as urban Veterans to utilize dental services and have poorer oral health outcomes.