Hospitalizations reduce health care utilization of household members

OBJECTIVE

To examine whether the financial burden of hospitalizations affects the health care utilization of household members of the admitted patient.

DATA SOURCES

We utilized health care claims data from the Massachusetts All-Payer Claims Database, 2010-2015, to identify emergency hospitalizations of patients on family insurance plans and the health care utilization of the family members on those plans.

STUDY DESIGN

We used an event-study analysis to compare health care spending and utilization of family members of a hospitalized individual and family members of an individual who was hospitalized 1 year later. We examine whether such hospitalizations were associated with changes in medical spending, the frequency of ambulatory office visits, other ambulatory care, and preventive care.

DATA COLLECTION/EXTRACTION METHODS

The analyses include household members of patients with an emergency admission and a length of stay between 5 and 90 days.

PRINCIPAL FINDINGS

Unexpected hospital admissions reduced household members' health care spending and utilization by more than 6.4% (95% confidence interval [CI]: -8.2%, -4.5%) on average in the year following the hospitalization. Household members had fewer ambulatory visits with primary care physicians (PCPs), fewer referrals to specialists, and reduced utilization of other ambulatory care, including high-value preventive services. These changes were observed for both children and adults and were exacerbated if members of the household had previously been on Medicaid. The reduction in utilization was less pronounced when the admitted patient and household member shared the same PCP and when their health insurance plan had a family deductible.

CONCLUSIONS

Compared with families without a hospitalized family member, family members of hospitalized individuals reduced their medical spending and utilization, including a substantial reduction in the use of preventive care. This study highlights the challenges of providing continuity in care when families face financial hardship.

Comparing risk adjustment estimation methods under data availability constraints

The Italian National Healthcare Service relies on per capita allocation for healthcare funds, despite having a highly detailed and wide range of data to potentially build a complex risk-adjustment formula. However, heterogeneity in data availability limits the development of a national model. This paper implements and ealuates machine learning (ML) and standard risk-adjustment models on different data scenarios that a Region or Country may face, to optimize information with the most predictive model. We show that ML achieves a small but generally statistically insignificant improvement of adjusted R² and mean squared error with fine data granularity compared to linear regression, while in coarse granularity and poor range of variables scenario no differences were observed. The advantage of ML algorithms is greater in the coarse granularity and fair/rich range of variables set and limited with fine granularity scenarios. The inclusion of detailed morbidity- and pharmacy-based adjustors generally increases fit, although the trade-off of creating adverse economic incentives must be considered.

Uncertainty in lung cancer stage for survival estimation via set-valued classification

The difficulty in identifying cancer stage in health care claims data has limited oncology quality of care and health outcomes research. We fit prediction algorithms for classifying lung cancer stage into three classes (stages I/II, stage III, and stage IV) using claims data, and then demonstrate a method for incorporating the classification uncertainty in survival estimation. Leveraging set‐valued classification and split conformal inference, we show how a fixed algorithm developed in one cohort of data may be deployed in another, while rigorously accounting for uncertainty from the initial classification step. We demonstrate this process using SEER cancer registry data linked with Medicare claims data.

COVID-19 pandemic in the United States

OBJECTIVES

The paper highlights US health policy and technology responses to the COVID-19 pandemic from January 1, 2020 - August 9, 2020.

METHODS

A review of primary data sources in the US was conducted. The data were summarized to describe national and state-level trends in the spread of COVID-19 and in policy and technology solutions.

RESULTS

COVID-19 cases and deaths initially peaked in late March and April, but after a brief reduction in June cases and deaths began rising again during July and continued to climb into early August. The US policy response is best characterized by its federalist, decentralized nature. The national government has led in terms of economic and fiscal response, increasing funding for scientific research into testing, treatment, and vaccines, and in creating more favorable regulations for the use of telemedicine. State governments have been responsible for many of the containment, testing, and treatment responses, often with little federal government support. Policies that favor economic re-opening are often followed by increases in state-level case numbers, which are then followed by stricter containment measures, such as mask wearing or pausing re-opening plans.

CONCLUSIONS

While all US states have begun to "re-open" economic activities, this trend appears to be largely driven by social tensions and economic motivations rather than an ability to effectively test and surveil populations.

Mental Health Risk Adjustment with Clinical Categories and Machine Learning

OBJECTIVE

To propose nonparametric ensemble machine learning for mental health and substance use disorders (MHSUD) spending risk adjustment formulas, including considering Clinical Classification Software (CCS) categories as diagnostic covariates over the commonly used Hierarchical Condition Category (HCC) system.

DATA SOURCES

2012-2013 Truven MarketScan database.

STUDY DESIGN

We implement 21 algorithms to predict MHSUD spending, as well as a weighted combination of these algorithms called super learning. The algorithm collection included seven unique algorithms that were supplied with three differing sets of MHSUD-related predictors alongside demographic covariates: HCC, CCS, and HCC + CCS diagnostic variables. Performance was evaluated based on cross-validated R² and predictive ratios.

PRINCIPAL FINDINGS

Results show that super learning had the best performance based on both metrics. The top single algorithm was random forests, which improved on ordinary least squares regression by 10 percent with respect to relative efficiency. CCS categories-based formulas were generally more predictive of MHSUD spending compared to HCC-based formulas.

CONCLUSIONS

Literature supports the potential benefit of implementing a separate MHSUD spending risk adjustment formula. Our results suggest there is an incentive to explore machine learning for MHSUD-specific risk adjustment, as well as considering CCS categories over HCCs.

Subscales, subscores, or summative score: evaluating the contribution of Braden Scale items for predicting pressure ulcer risk in older adults receiving home health care

PURPOSE

The purpose of this study was to determine whether certain Braden subscales or subscores were more important than others or the summative score in predicting stage I to IV pressure ulcers among older adults receiving home health care.

DESIGN

A retrospective cohort study (secondary analysis) was used.

SETTING AND SUBJECTS

The cohort sample included 1684 nonhospice patients who were not receiving intravenous therapy and who were admitted to the Intermittent Skilled Nursing Division of a large midwestern home health care agency between January 1995 and March 1996. The patients were > or =60 years and free of pressure ulcers.

METHODS

Demographic data and data on the Braden Scale were extracted from admission information. Patient records were followed forward chronologically to 1 of 2 outcomes: development or absence of pressure ulcers (ie, free of pressure ulcers upon discharge, institutionalization, death, or the end of the study period).

RESULTS

Following admission, a stage I to IV pressure ulcer developed in 107 subjects (incidence = 6.3%). Cox regression analysis revealed that activity and moisture subscale scores predicted pressure ulcer development. Regression modeling of individual Braden Scale subscores (response categories) revealed that problems with friction/shear, being very limited in mobility, and being constantly moist, very moist, or occasionally moist predicted pressure ulcer development. When the overall level of risk was added to each of these models, the Braden Scale summative score was most strongly related to pressure ulcer development. No simplified scale improved risk prediction.

CONCLUSIONS

When the Braden Scale was used, the summative score rather than any subscale or subscore best predicted pressure ulcer risk among the older adults receiving home health care.

Braden scale: validity in community-based older adults receiving home health care

The purpose of this study was to examine the validity of the Braden Scale and optimal frequency of risk reassessment in older adults receiving home health care. Data were collected from the records of 1,711 nonhospice patients aged 60 years or older who did not have pressure ulcers at the beginning of home health care. Patient records were followed forward chronologically to one of two outcomes: pressure ulcer development or pressure ulcer absence (pressure ulcer free when home health services were no longer required, institutionalization, death, or end of study period). After commencement of home health care, 108 subjects developed a stage I-IV pressure ulcer (incidence = 6.3%). A Braden Scale cutoff score of 19 provided the best measure of sensitivity (61%) and specificity (68%). Findings suggest initial assessment of pressure ulcer risk for older adults should begin on entry into home health care, and they indicate the need for weekly reassessments for the first 4 weeks with every other week reassessments thereafter until day 62, dependent on patient condition and the frequency of home visits. Reassessment with each subsequent 62-day recertification period may be sufficient for patients remaining on the active caseload.

Bone and joint infections in the elderly: practical treatment guidelines

Two types of haematogenous osteomyelitis that are seen in the elderly are vertebral and long bone osteomyelitis. Osteomyelitis secondary to contiguous foci of infection can occur in older adults without vascular insufficiency (secondary to pressure ulcers) or with vascular insufficiency due to diabetes mellitus or peripheral vascular disease from atherosclerosis. Most cases of osteomyelitis can be reasonably treated with adequate drainage, thorough debridement, obliteration of dead space, wound protection, and antimicrobial therapy. Patients are initially given a broad spectrum antimicrobial that is changed to specific antimicrobial therapy based on meticulous bone cultures taken at debridement surgery or from deep bone biopsies. Surgical management is often required in the treatment of osteomyelitis and includes adequate drainage, extensive debridement of all necrotic tissue, obliteration of dead spaces, stabilisation, adequate soft tissue coverage, and restoration of an effective blood supply. Bone repair and bone mineral density may be significantly retarded and may be corrected by eliminating risk factors, supplementing the diet with calcium, bisphosphonates, and/or vitamin D, and treating with testosterone and/or estrogen when deficient. Sodium fluoride treatment and anabolic steroids may be used as alternatives. Septic arthritis is a medical emergency, and prompt recognition and rapid and aggressive treatment are critical to ensuring a good prognosis. The treatment of septic arthritis includes appropriate antimicrobial therapy and joint drainage. Adverse effects of prescribed antibacterials occur more often in the elderly patient than in young adults. The physician can help to minimise the incidence of adverse effects and improve outcomes by being aware of the principles of clinical pharmacology, the characteristics of specific drugs, and the special physical, psychological and social needs of older patients.

Pressure ulcers in community-based older adults receiving home health care. Prevalence, incidence, and associated risk factors

OBJECTIVES

To determine the prevalence and incidence of pressure ulcers in community-based adults receiving home health care and to identify risk factors for incident Stage II to IV pressure ulcers.

DESIGN

Retrospective cohort study.

SETTING

A large midwestern urban home health care agency.

PATIENTS

The study cohort was 1711 nonhospice, nonintravenous therapy subjects admitted between January 1995 and March 1996 who were > or = age 60 and pressure ulcer-free on admission.

MEASUREMENTS

Data on risk factors were extracted from admission information. Patient records were followed forward chronologically to the outcomes: pressure ulcer development or no pressure ulcer.

MAIN RESULTS

The incidence of Stage II to IV pressure ulcers was 3.2%. Cox regression analyses revealed that limitation in activity to a wheelchair, needing assistance with the activities of daily living--dressing, bowel and/or bladder incontinence, a Braden Scale mobility subscore of very limited, anemia, adult child as primary caregiver, male gender, a recent fracture, oxygen use, and skin drainage predicted pressure ulcer development (P < or = 0.05) in this exploratory model.

CONCLUSIONS

Patients > or = age 60 who are admitted to a home health care agency with 1 or more of these risk factors require close monitoring for pressure ulcer development and should be taught preventive interventions on admission.

Adoption of a research-based practice for treatment of pressure ulcers

Evaluation of a skin care protocol for the treatment of pressure ulcers in this institution showed that practitioners did adopt research-based practice. This change in practice was associated with a corresponding decrease in costs for treatment. More pressure ulcers received treatment after implementation of the protocol. Furthermore, the majority of pressure ulcers were being treated with wound care modalities identified by research as supportive of healing. Use of antiseptic agents harmful to the healing process declined as did use of topical agents with little research base to support their efficacy. The shift to practice patterns that were more consistent with research findings was associated with a corresponding decrease in costs for pressure ulcer treatment. Factors in this situation that lead to the positive outcome of knowledge utilization were an organizational model that promoted accountability of individual practitioners, staff participation in decision making, agency regard for research, and consultation with a nurse expert. Informal individual utilization of knowledge related to the treatment of pressure ulcers reinforced use of the research-based practice and expedited formal implementation of a policy/procedure related to their treatment. The process of knowledge utilization that occurred in this institution provides a prototype of how research can be translated into practice. Although limited to one specific clinical problem, the results of this process can be applied to any clinical condition where there are sufficient research findings to support development of recommendations for practice.

The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long-term care facility

Although concern for the costs associated with pressure ulcer treatments persists, studies that precisely quantify costs are limited. A retrospective research design was used to describe the costs incurred by an 830-bed, long-term care facility to treat 81 pressure ulcers over a one-year period following implementation of a research-based, skin care protocol. The total cost for the study period was $30,079 with 73% of these expenditures attributable to nursing care. Mean cost of treatment was $3.74/pressure ulcer/day, which was a reduction from the $5.35/pressure ulcer/day cost prior to implementation of the skin care protocol. These findings suggest that implementing a research-based, skin care protocol can promote a reduction in treatment costs.

Parish nursing--a conceptual framework

Parish nursing is a current nursing care delivery model that practices holistic health care. Parish nurses provide care to a faith community, emphasizing the relationship between faith and health. Specific nursing activities address physical, emotional, and spiritual health and well-being, closely attending to the inseparability of these dimensions. Parish nurses may assume one or more roles associated with this practice to accomplish parish nursing activities and achieve the holistic health and well-being of individuals, families, and groups within the faith community. The five broad categories of client, health, nurse, environment, and nursing process provide a framework for organizing the concept of parish nursing for future nursing theory, research, and practice.

Demonstration of immunoglobulin G with affinity for dopamine in cerebrospinal fluid from psychotic patients

Using an enzyme-linked immunosorbent assay, significantly raised concentrations of immunoglobulin G with affinity for the neurotransmitter dopamine were demonstrated in cerebrospinal fluid from psychotic patients. We have varied the antigen presentation in order to find a conjugate with low unspecific binding. The conjugation of dopamine to carbodiimide-activated poly-L-glutamic acid and that to activated succinimide ester of biotin are described. The use of glutaraldehyde conjugation is not recommended because of the risk of formation of tetrahydroisoquinolines. A strong correlation (r = 0.94, P < 0.001) between the results obtained with dopamine conjugated to poly-L-glutamic acid and dopamine conjugated to biotin was observed. Forty-two human cerebrospinal fluid samples from 20 psychotic patients, (12 with a bipolar disorder and 8 with schizophrenia) and 22 control patients, with various neurological diseases but no apparent psychiatric diseases were investigated. A significantly higher incidence (P < 0.001) of antibodies with affinity for dopamine were found in the group of psychotic patients compared with the neurological control group.

Radio-immunoassay of atrial natriuretic peptide (ANP) and characterization of ANP immunoreactivity in human plasma and atrial tissue

A sensitive radio-immunoassay (RIA) was developed to determine the occurrence of atrial natriuretic peptide (ANP) in plasma and atrial extracts from patients undergoing open heart surgery. The immunoreactive ANP (irANP) was characterized by high-pressure liquid chromatography coupled with RIA. The plasma irANP response to releasing stimuli during the operation was determined in simultaneously sampled venous and arterial blood, in order to evaluate any differences. The antiserum recognized the intact ring-structure of alpha-humanANP (alpha-hANP) and its propeptide gamma-hANP, as well as beta-hANP, an anti-parallel dimer of alpha-hANP. Less bioactive N-or C-terminal fragments of alpha-hANP, or an N-terminal fragment of the propeptide, gamma-hANP 1-67, did not cross-react with the antiserum. Sep Pak C18-extraction of plasma resulted in an 80% recovery of synthetic alpha-hANP. The assay had a sensitivity of 1.9 pmol l-1, well below the venous plasma concentrations of irANP found in healthy volunteers (7.4 +/- 1.3 pmol l-1, mean +/- SEM, n = 19), and the local standard was identical to an international standard of alpha-hANP. In atrial extracts three major peaks of irANP were identified as alpha-, beta- and gamma-hANP, with gamma-hANP as the most abundant form. In plasma alpha-hANP dominated, but in two cases high plasma levels of beta-hANP were seen, reflecting the high atrial content in these patients. In peripheral arterial blood, irANP was on an average 56% +/- 20% (p less than 0.01, n = 18) higher than in venous blood; this was associated with more distinct arterial irANP responses to releasing stimuli during the operation.

Reduction of immunoreactive ACTH in plasma following intravenous injection of delta sleep-inducing peptide in man

Eleven healthy male volunteers, ages 25-39 years, received a single dose of synthetic delta sleep-inducing peptide (DSIP) (25 nmol/kg BW) or saline intravenously in a randomized cross-over, double-blind study. The concentrations of neuropeptides related to the hypothalamic pituitary-adrenal (HPA) axis and cortisol were examined in serial plasma samples. In addition, cortisol and monoamine metabolites were determined in urine. A significant reduction of ACTH-like immunoreactivity (ACTH-LI) in plasma was detected for at least 3 hr after the DSIP injection, compared to the control subjects, in whom a slightly elevated concentration of ACTH-LI occurred. Plasma cortisol levels were unaffected and followed the normal diurnal decline. No differences in urinary cortisol or monoamine metabolite concentrations occurred between the two groups. The results indicate an inhibitory action of DSIP on ACTH secretion in man, as previously suggested by animal experiments.

Pharmacist as a provider of oncology ambulatory care services

The services provided by a pharmacist to ambulatory oncology patients is described. The pharmacist takes drug histories, monitors drug therapy, gives patient discharge consultations and acts in cooperation with local physicians and the medical staff in providing chemotherapy to cancer patients for home administration. The pharmacist also provides inservice education and acts as a consultant to the medical, nursing and pharmacy staffs.