Impact of COVID-19 on Perinatal Outcomes and Birth Locations in a Large US Metropolitan Area

This was a population-based study to determine the impact of COVID-19 on birth outcomes in the Chicago metropolitan area, comparing pre-pandemic (April-September 2019) versus pandemic (April-September 2020) births. Multivariable regression models that adjusted for demographic and neighborhood characteristics were used to estimate the marginal effects of COVID-19 on intrauterine fetal demise (IUFD)/stillbirth, preterm birth, birth hospital designation, and maternal and infant hospital length of stay (LOS). There were no differences in IUFD/stillbirths or preterm births between eras. Commercially insured preterm and term infants were 4.8 percentage points (2.3, 7.4) and 3.4 percentage points (2.5, 4.2) more likely to be born in an academic medical center during the pandemic, while Medicaid-insured preterm and term infants were 3.6 percentage points less likely (-6.5, -0.7) and 1.8 percentage points less likely (-2.8, -0.9) to be born in an academic medical center compared to the pre-pandemic era. Infant LOS decreased from 2.4 to 2.2 days (-0.35, -0.20), maternal LOS for indicated PTBs decreased from 5.6 to 5.0 days (-0.94, -0.19), and term births decreased from 2.5 to 2.3 days (-0.21, -0.17). The pandemic had a significant effect on the location of births that may have exacerbated health inequities that continue into childhood.

Where does the time go? Temporal patterns of pumping behaviors in mothers of very preterm infants vary by sociodemographic and clinical factors

Background

Mothers of very preterm (<32 weeks gestational age [GA]) infants are breast pump dependent and have shorter duration of milk provision than mothers of term infants. The opportunity (i.e., time) cost of pumping and transporting mother's own milk (MOM) from home to the NICU may be a barrier. There is a paucity of data regarding how much time mothers actually spend pumping.

Objective

To investigate the variation in pumping behavior by postpartum week, maternal characteristics, and infant GA.

Methods

Prospectively collected pump log data from mothers enrolled in ReDiMOM (Reducing Disparity in Mother's Own Milk) randomized, controlled trial included pumping date and start time and end time of each pumping session for the first 10 weeks postpartum or until the infant was discharged from the NICU, whichever occurred first. Outcomes included number of daily pumping sessions, number of minutes spent pumping per day, and pumping behaviors during 24-h periods, aggregated to the postpartum week. Medians (interquartile ranges) were used to describe outcomes overall, and by maternal characteristics and infant GA.

Results

Data included 13,994 pump sessions from 75 mothers. Maternal characteristics included 55% Black, 35% Hispanic, and 11% White and 44% <30 years old. The majority (56%) of infants were born at GA 28-31 weeks. Mothers pumped an average of less than 4 times per day, peaking in postpartum week 2. After accounting for mothers who stopped pumping, there was a gradual decrease in daily pumping minutes between postpartum weeks 2 (89 min) and 10 (46 min). Black mothers pumped fewer times daily than non-Black mothers after the first 2 weeks postpartum.

Conclusion

On average mothers pumped less intensively than the minimum recommendation of 8 times and 100 min per day. However, these pumping behaviors represent significant maternal opportunity costs that should be valued by the institution and society at large.

Impact of the COVID-19 pandemic on early intervention utilization and need for referral after NICU discharge in VLBW infants

OBJECTIVE

To examine the impact of COVID-19 pandemic on early intervention (EI) services in VLBW infants.

STUDY DESIGN

208 VLBW infants seen in NICU follow-up (FU) pre-COVID-19 were compared to 132 infants seen during COVID-19 at 4, 8 and 20 months corrected age (CA) in terms of enrollment in Child and Family Connections (CFC; intake agency for EI), EI therapies, need for CFC referral and Bayley scores.

RESULTS

Infants seen during COVID-19 at 4, 8 and 20 months CA were 3.4 (OR, 95% CI 1.64, 6.98), 4.0 (1.77, 8.95) and 4.8 (2.10, 11.08) times more likely to need CFC referral at FU based on severity of developmental delay. Infants followed during COVID-19 had significantly lower mean Bayley cognitive and language scores at 20 months CA.

CONCLUSIONS

VLBW infants seen during COVID-19 had significantly higher odds of needing EI and significantly lower cognitive and language scores at 20 months CA.

Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Preterm Infants: An Integrative Review

Background: Lack of mother's own milk (MOM) at discharge from the neonatal intensive care unit (NICU) is a global problem and is often attributable to inadequate MOM volume. Evidence suggests that the origins of this problem are during the first 14 days postpartum, a time period that includes secretory activation (SA; lactogenesis II, milk coming in). Objectives: To describe and summarize evidence regarding use of MOM biomarkers (MBMs) as a measure of SA in pump-dependent mothers of preterm infants in the NICU and to identify knowledge gaps requiring further investigation. Methods: An integrative review was conducted using Whittemore and Knafl methodology incorporating the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. A search using electronic databases MEDLINE (through PubMed) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) and reference lists of included articles was conducted. Results: Of the 40 articles retrieved, 6 met the criteria for inclusion. Results revealed the following five findings: (1) Achievement of SA defined by MBMs is delayed and/or impaired in mothers of preterm infants. (2) MBMs are associated with pumped MOM volume. (3) Achievement of SA defined by MBMs is associated with pumping frequency. (4) Delayed and/or impaired achievement of SA defined by MBMs may be exacerbated by maternal comorbidities. (5) There is a lack of consensus as to which MBM(s) and analysis techniques should be used in research and practice. Conclusions: MBMs hold tremendous potential to document and monitor achievement of SA in mothers of preterm infants, with multiple implications for research and clinical practice.

Racial, socioeconomic, and neighborhood characteristics in relation to COVID-19 severity of illness for adolescents and young adults

This study tests the hypotheses that insurance status, race and ethnicity, and neighborhood characteristics are associated with hospital admission and severe health outcomes (Intensive Care Unit [ICU] admission and oxygen assistance) for youth and young adults who present to the emergency department (ED) with COVID-19 in a single, academic health system in Illinois, Rush University System for Health (RUSH). Demographic and clinical data from the electronic health record were collected for all 13- to 24-y-old patients seen at RUSH who tested positive for COVID-19 between March 2020 and 2021. Individual-level and neighborhood characteristics were analyzed to determine their association with hospital admission and severe health outcomes through generalized estimating equations. As of March 2021, 1,057 patients were seen in the ED within RUSH in which non-Hispanic White (odds ratio [OR], 2.96; 95% CI, 1.61-5.46; P = 0.001) and Hispanic (OR, 3.34; 95% CI, 1.84-6.10; P < 0.001) adolescents and youth were more likely to be admitted to the hospital compared with non-Hispanic Black/other adolescents and youth. Patients with public insurance or who were uninsured were less likely to be admitted to the ICU compared with those with private insurance (OR, 0.24; 95% CI, 0.09-0.64; P = 0.004). None of the neighborhood characteristics were significantly associated with hospital admission or severe health outcomes after adjusting for covariates. Our findings demonstrated that race and ethnicity were related to hospitalization, while insurance was associated with presentation severity due to COVID-19 for adolescents and young adults. These findings can aid public health investigators in understanding COVID-19 disparities among adolescents and young adults.

Experiences With Kidney Transplant Among Undocumented Immigrants in Illinois: A Qualitative Study

Rationale & Objective

Noncitizen, undocumented patients with kidney failure have few treatment options in many states, although Illinois allows for patients to receive a transplant regardless of citizenship status. Little information exists about the experiences of noncitizen patients pursuing kidney transplantation. We sought to understand how access to kidney transplantation affects patients, their family, health care providers, and the health care system.

Study Design

A qualitative study with virtually conducted semistructured interviews.

Setting & Participants

Participants were transplant and immigration stakeholders (physicians, transplant center and community outreach professionals), and patients who have received assistance through the Illinois Transplant Fund (listed for or received transplant; patients could complete the interview with a family member).

Analytical Approach

Interview transcripts were coded using open coding and were analyzed using thematic analysis methods with an inductive approach.

Results

We interviewed 36 participants: 13 stakeholders (5 physicians, 4 community outreach stakeholders, and 4 transplant center professionals), 16 patients, and 7 partners. The following seven themes were identified: (1) devastation from kidney failure diagnosis, (2) resource needs for care, (3) communication barriers to care, (4) importance of culturally competent health care providers, (5) negative impacts of policy gaps, (6) new chance at life after transplant, and (7) recommendations for improving care.

Limitations

The patients we interviewed were not representative of noncitizen patients with kidney failure overall or in other states. The stakeholders were also not representative of health care providers because they were generally well informed on kidney failure and immigration issues.

Conclusions

Although patients in Illinois can access kidney transplants regardless of citizenship status, access barriers, and health care policy gaps continue to negatively affect patients, families, health care professionals, and the health care system. Necessary changes for promoting equitable care include comprehensive policies to increase access, diversifying the health care workforce, and improving communication with patients. These solutions would benefit patients with kidney failure regardless of citizenship.

The Role of Work as a Social Determinant of Health in Mother's Own Milk Feeding Decisions for Preterm Infants: A State of the Science Review

In the United States, 10% of infants are born preterm (PT; <37 weeks gestational age) each year and are at higher risk of complications compared to full term infants. The burden of PT birth is borne disproportionately by Black versus non-Black families, with Black mothers significantly more likely to give birth to a PT infant. One proven strategy to improve short- and long-term health outcomes in PT infants is to feed mother's own milk (MOM; breast milk from the mother). However, mothers must make decisions about work and MOM provision following PT birth, and more time spent in paid work may reduce time spent in unpaid activities, including MOM provision. Non-Black PT infants are substantially more likely than Black PT infants to receive MOM during the birth hospitalization, and this disparity is likely to be influenced by the complex decisions mothers of PT infants make about allocating their time between paid and unpaid work. Work is a social determinant of health that provides a source of income and health insurance coverage, and at the same time, has been shown to create disparities through poorer job quality, lower earnings, and more precarious employment in racial and ethnic minority populations. However, little is known about the relationship between work and disparities in MOM provision by mothers of PT infants. This State of the Science review synthesizes the literature on paid and unpaid work and MOM provision, including: (1) the complex decisions that mothers of PT infants make about returning to work, (2) racial and ethnic disparities in paid and unpaid workloads of mothers, and (3) the relationship between components of job quality and duration of MOM provision. Important gaps in the literature and opportunities for future research are summarized, including the generalizability of findings to other countries.

Estimating biofuel contaminant concentration from 4D ERT with mixing models

We present the results of a lab-scaled feasibility study to assess the performance of electrical resistivity tomography for detection, characterization, and monitoring of fuel grade ethanol releases to the subsurface. Further, we attempt to determine the concentration distribution of the ethanol from the electrical resistivity tomography data using mixing-models. Ethanol is a renewable fuel source as well as an oxygenate fuel additive currently used to replace the known carcinogen methyl tert-butyl ether; however, ethanol is preferentially biodegraded and a cosolvent. When introduced to areas previously impacted by nonethanol-based fuels, it will facilitate the persistence of carcinogenic fuel compounds like benzene and ethylbenzene, as well as remobilize them to the ground water. These compounds would otherwise be retained in the soil column undergoing active or passive remediation processes such as soil vapor extraction or natural attenuation. Here, we introduce ethanol to a saturated Ottawa sand in a tank instrumented for four-dimensional geoelectrical measurements. Forward model results suggest pure phase ethanol released into a water saturated silica sand should present a detectable target for electrical resistivity tomography relative to a saturated silica sand only. We observe the introduction of ethanol to the closed hydraulic system and subsequent migration over the duration of the experiment. One-dimensional and three-dimensional temporal data are assessed for the detection, characterization, and monitoring of the ethanol release. Results suggest one-dimensional geoelectrical measurements may be useful for monitoring a release, while three-dimensional geoelectrical field imaging would be useful to characterize, monitor, and design effective remediation approaches for an ethanol release, assuming field conditions do not preclude the application of geoelectrical methods. We then attempt to use predictive mixing models to calculate the distribution of ethanol concentration within the measurement domain. For this study we examine four different models: a nested parallel mixing model, a nested cubic mixing model, the complex refractive index model (CRIM), and the Lichtenecker-Rother (L-R) model. The L-R model, modified to include an electrical formation factor geometry term, provided the best agreement with expected EtOH concentrations.

Are We Ready for a New Approach to Comparing Coverage and Reimbursement Policies for Medical Nutrition in Key Markets: An ISPOR Special Interest Group Report

OBJECTIVES

Healthcare policy makers should ensure optimal patient access to medical nutrition (MN) as part of the management of nutrition-related disorders and conditions. Questions remain whether current healthcare policies reflect the clinical and economic benefits of MN. The objective of this article is to characterize coverage and reimbursement of MN, defined as food for special medical purposes/medical food for a diverse set of countries, including Australia, Belgium, Brazil, Canada, China, France, Germany, Hong Kong, Italy, Japan, The Netherlands, Singapore, Spain, United Kingdom, and United States.

METHODS

Data sources included published literature and online sources. ISPOR's Nutrition Economics Special Interest Group developed a data collection form to guide data extraction that included reimbursement coverage, years that reimbursement policies were established, and presence of a formal health technology assessment (HTA) for MN technologies.

RESULTS

Reimbursement coverage of MN technologies varied across the countries that were reviewed. All but 3 countries limited coverage to specific formulations of products, regardless of demonstrated clinical benefit. The year that reimbursement policies were established varied across countries (ranging from 1984 to 2017), and only 4 countries regularly update policies. France and Brazil are the only countries with a formal HTA process for MN technologies.

CONCLUSIONS

Most countries have limited MN reimbursement, have not updated reimbursement policies, and lack HTA for MN technologies. These limitations may lead to suboptimal access to MN technologies where they are indicated to manage nutrition-related disorders and conditions, with the potential of negatively affecting patient and healthcare system outcomes.

Cost Savings of Mother's Own Milk for Very Low Birth Weight Infants in the Neonatal Intensive Care Unit

OBJECTIVE

The study aim was to determine the relationship between hospitalization costs and mother's own milk (MOM) dose for very low birth weight (VLBW; < 1500 g) infants during the initial neonatal intensive care unit (NICU) stay. Additionally, because MOM intake during the NICU hospitalization is associated with a reduction in the risk of late-onset sepsis, necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia (BPD), we aimed to quantify the incremental cost of these potentially preventable complications of prematurity.

METHODS

The study included 430 VLBW infants enrolled in the Longitudinal Outcomes of Very Low Birthweight Infants Exposed to Mothers' Own Milk prospective cohort study between 2008 and 2012 at Rush University Medical Center in Chicago, IL, USA. NICU hospitalization costs included hospital, feeding, and physician costs. The average marginal effect of MOM dose and prematurity-related complications known to be reduced by MOM intake on NICU hospitalization costs were estimated using generalized linear regression.

RESULTS

The mean NICU hospitalization cost was $190,586 (standard deviation $119,235). The marginal cost of sepsis was $27,890 (95% confidence interval [CI] $2934-$52,646), of NEC was $46,103 (95% CI $16,829-$75,377), and of BPD was $41,976 (95% CI $24,660-59,292). The cumulative proportion of MOM during the NICU hospitalization was not significantly associated with cost.

CONCLUSIONS

A reduction in the incidence of complications that are potentially preventable with MOM intake has significant cost implications. Hospitals should prioritize investments in initiatives to support MOM feedings in the NICU.

Study protocol for reducing disparity in receipt of mother's own milk in very low birth weight infants (ReDiMOM): a randomized trial to improve adherence to sustained maternal breast pump use

BACKGROUND

Black very low birth weight (VLBW; < 1500 g birth weight) and very preterm (VP, < 32 weeks gestational age, inclusive of extremely preterm, < 28 weeks gestational age) infants are significantly less likely than other VLBW and VP infants to receive mother's own milk (MOM) through to discharge from the neonatal intensive care unit (NICU). The costs associated with adhering to pumping maternal breast milk are borne by mothers and contribute to this disparity. This randomized controlled trial tests the effectiveness and cost-effectiveness of an intervention to offset maternal costs associated with pumping.

METHODS

This randomized control trial will enroll 284 mothers and their VP infants to test an intervention (NICU acquires MOM) developed to facilitate maternal adherence to breast pump use by offsetting maternal costs that serve as barriers to sustaining MOM feedings and the receipt of MOM at NICU discharge. Compared to current standard of care (mother provides MOM), the intervention bundle includes three components: a) free hospital-grade electric breast pump, b) pickup of MOM, and c) payment for opportunity costs. The primary outcome is infant receipt of MOM at the time of NICU discharge, and secondary outcomes include infant receipt of any MOM during the NICU hospitalization, duration of MOM feedings (days), and cumulative dose of MOM feedings (total mL/kg of MOM) received by the infant during the NICU hospitalization; maternal duration of MOM pumping (days) and volume of MOM pumped (mLs); and total cost of NICU care. Additionally, we will compare the cost of the NICU acquiring MOM versus NICU acquiring donor human milk if MOM is not available and the cost-effectiveness of the intervention (NICU acquires MOM) versus standard of care (mother provides MOM).

DISCUSSION

This trial will determine the effectiveness of an economic intervention that transfers the costs of feeding VLBWand VP infants from mothers to the NICU to address the disparity in the receipt of MOM feedings at NICU discharge by Black infants. The cost-effectiveness analysis will provide data that inform the adoption and scalability of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04540575 , registered September 7, 2020.

End Stage Kidney Disease in Non-citizen Patients: Epidemiology, Treatment, and an Update to Policy in Illinois

End-stage kidney disease (ESKD) is common in the U.S. There is no cure, and survival requires either dialysis or kidney transplant. Medicare provides coverage for most ESKD patients in the U.S., though non-citizens are excluded from most current policies providing standard ESKD care, especially regarding kidney transplants. Despite being eligible to be organ donors, non-citizens often have few avenues to be organ recipients-a major equity problem. Overall, transplants are cost-saving compared to dialysis, and non-citizens have comparable outcomes to the general population. We reviewed the literature regarding the vastly different policies across the U.S., with a focus on current Illinois policy, including updates regarding Illinois legislation which passed in 2014 providing non-citizens to receive coverage for transplants. Unfortunately, despite legislation providing avenues for transplants, funds were not allocated, and the bill has not had the impact that was expected when initially passed. We outline opportunities for improving current policies.

The Financial Impact of a Partnership Between an Academic Medical Center and a Free Clinic

PURPOSE

The objective of this study is to examine the association between an academic medical center and free clinic referral partnership and subsequent hospital utilization and costs for uninsured patients discharged from the academic medical center's emergency department (ED) or inpatient hospital.

METHODS

This retrospective, cross-sectional study included 6014 uninsured patients age 18 and older who were discharged from the academic medical center's ED or inpatient hospital between July 2016 and June 2017 and were followed for 90 days in the organization's electronic medical record to identify the occurrence and cost of subsequent same-hospital ED visits and hospital admissions. The occurrence of any subsequent ED visits or hospital admissions and the cost of subsequent hospital care were compared by free clinic referral status after inverse probability of treatment weighting.

RESULTS

Overall, 330 (5.5%) of uninsured patients were referred to the free clinic. Compared with patients referred to the free clinic, patients not referred had greater odds of any subsequent ED visits or hospital admissions within 90 days (odds ratio, 1.8; 95% confidence interval: 1.7-2.0). For patients with any subsequent ED visits or hospital admissions, the mean cost of care for those who were not referred to the free clinic was 2.3 times higher (95% confidence interval: 2.0-2.7) compared to referred patients.

CONCLUSION

An academic medical center-free clinic partnership for follow-up care after discharge from the ED or hospital admission is a promising approach for improving access to care for uninsured patients.

Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units

Very low birth weight (VLBW; <1500 g birth weight) infants are substantially more likely to be born to black than to non-black mothers, predisposing them to potentially preventable morbidities that increase the risk for costly lifelong health problems. Mothers' own milk (MOM) may be considered the ultimate "personalized medicine" since milk composition and bioactive components vary among mothers and multiple milk constituents provide specific protection based on shared exposures between mother and infant. MOM feedings reduce the risks and associated costs of prematurity-associated morbidities, with the greatest reduction afforded by MOM through to NICU discharge. Although black and non-black mothers have similar lactation goals and initiation rates, black VLBW infants are half as likely to receive MOM at NICU discharge in the United States. Black mothers are significantly more likely to be low-income, single heads of household and have more children in the home, increasing the burden of MOM provision. Although rarely considered, the out-of-pocket and opportunity costs associated with providing MOM for VLBW infants are especially onerous for black mothers. When MOM is not available, the NICU assumes the costs of inferior substitutes for MOM, contributing further to disparate outcomes. Novel strategies to mitigate these disparities are urgently needed. IMPACT: Mother's own milk exemplifies personalized medicine through its unique biologic activity. Hospital factors and social determinants of health are associated with mother's own milk feedings for very low-birth-weight infants in the neonatal intensive care unit. Notably, out-of-pocket and opportunity costs associated with providing mother's own milk are borne by mothers. Conceptualizing mother's own milk feedings as an integral part of NICU care requires consideration of who bears the costs of MOM provision-the mother or the NICU?

Effect of supplementation of a dairy-originated probiotic bacterium, Propionibacterium freudenreichii subsp. freudenreichii, on the cecal microbiome of turkeys challenged with multidrug-resistant Salmonella Heidelberg

A dairy-originated probiotic bacterium, Propionibacterium freudenreichii subsp. freudenreichii B3523 (PF) was found to be effective in reducing multidrug-resistant Salmonella Heidelberg (MDR SH) colonization in turkey poults (2-week-old) and growing (7-week-old) and finishing (12-week-old) turkeys. In this study, we explored the potential for microbiome modulation in the cecum of turkeys of different age groups due to PF supplementation in conjunction with MDR SH challenge. One-day-old commercial turkey poults were allocated to 3 treatment groups: negative control (N; turkeys without PF supplementation or SH challenge), SH control (S; turkeys challenged with SH without PF supplementation), and test group (P; turkeys supplemented with PF and challenged with SH). Turkeys were supplemented with 10¹⁰ CFU PF in 5-gallon (18.9 L) water until 7 or 12 week of age. At the 6th or 11^th wk, turkeys were challenged with SH at 10⁶ and 10⁸ CFU/bird by crop gavage, respectively. After 2 and 7 d of challenge (2-d postinoculation [PI] and 7-d PI, respectively), cecal samples were collected and microbiome analysis was conducted using Illumina MiSeq. The experiments were repeated twice with 8 and 10 turkeys/group for 7- and 12-wk studies, respectively. Results indicated that the species richness and abundance (Shannon diversity index) was similar among the treatment groups. However, treatments caused apparent clustering of the samples among each other (P < 0.05). Firmicutes was the predominant phylum in the growing and finishing turkey cecum which was evenly distributed among the treatments except on wk 12 where the relative abundance of Firmicutes was significantly higher in P than in N (P = 0.02). The MDR SH challenge resulted in modulation of microflora such as Streptococcus, Gordonibacter, and Turicibacter (P < 0.05) in the S groups compared with the P and N groups, known to be associated with inflammatory responses in birds and mammals. The supplementation of PF increased the relative abundance of carbohydrate-fermenting and short-chain fatty acid–producing genera in the P group compared with the S group (P < 0.05). Moreover, the results revealed that PF supplementation potentially modulated the beneficial microbiota in the P group, which could mitigate SH carriage in turkeys.

The Economic Impact of Donor Milk in the Neonatal Intensive Care Unit

OBJECTIVE

To assess the cost-effectiveness of mother's own milk supplemented with donor milk vs mother's own milk supplemented with formula for infants of very low birth weight in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective analysis of 319 infants with very low birth weight born before (January 2011-December 2012, mother's own milk + formula, n = 150) and after (April 2013-March 2015, mother's own milk + donor milk, n = 169) a donor milk program was implemented in the NICU. Data were retrieved from a prospectively collected research database, the hospital's electronic medical record, and the hospital's cost accounting system. Costs included feedings and other NICU costs incurred by the hospital. A generalized linear regression model was constructed to evaluate the impact of feeding era on NICU total costs, controlling for neonatal and sociodemographic risk factors and morbidities. An incremental cost-effectiveness ratio was calculated for each morbidity that differed significantly between feeding eras.

RESULTS

Infants receiving mother's own milk + donor milk had a lower incidence of necrotizing enterocolitis (NEC) than infants receiving mother's own milk + formula (1.8% vs 6.0%, P = .048). Total (hospital + feeding) median costs (2016 USD) were $169 555 for mother's own milk + donor milk and $185 740 for mother's own milk + formula (P = .331), with median feeding costs of $1317 and $936, respectively (P < .001). Mother's own milk + donor milk was associated with $15 555 lower costs per infant (P = .045) and saved $1812 per percentage point decrease in NEC incidence.

CONCLUSIONS

The additional cost of a donor milk program was small compared with the cost of a NICU hospitalization. After its introduction, the NEC incidence was significantly lower with small cost savings per case. We speculate that NICUs with greater NEC rates may have greater cost savings.

In-situ measurement of pyrolysis and combustion gases from biomass burning using swept wavelength external cavity quantum cascade lasers

Broadband high-speed absorption spectroscopy using swept-wavelength external cavity quantum cascade lasers (ECQCLs) is applied to measure multiple pyrolysis and combustion gases in biomass burning experiments. Two broadly-tunable swept-ECQCL systems were used, with the first tuned over a range of 2089-2262 cm^-1 (4.42-4.79 µm) to measure spectra of CO₂, H₂O, and CO. The second was tuned over a range of 920-1150 cm^-1 (8.70-10.9 µm) to measure spectra of ammonia (NH₃), ethene (C₂H₄), and methanol (MeOH). Absorption spectra were measured continuously at a 100 Hz rate throughout the burn process, including inhomogeneous flame regions, and analyzed to determine time-resolved gas concentrations and temperature. The results provide in-situ, dynamic information regarding gas-phase species as they are generated, close to the biomass fuel source.

Understanding Student Preferences in the Selection of a Graduate Allied Health Program: A Conjoint Analysis Study

ISSUE

As the healthcare landscape rapidly changes, graduate allied health programs must position themselves to educate the next generation of healthcare professionals in a highly competitive landscape. No studies have directly measured the relative importance of attributes in program selection by prospective healthcare students.

METHODS

We surveyed graduate healthcare management program applicants in the 2018 admissions cycle (n=512) to determine which attributes were most important in program choice. We utilized conjoint analysis to estimate utilities and importance scores of six attributes: program ranking, cost, work experience, geography, distance to home, and salary. We then conducted a market simulation to predict relative market share of academic programs.

OUTCOMES

The most important attribute to prospective students was the projected starting salary, with US News and World Report ranking and tuition cost the second and third most important attributes, respectively. Each attribute was relatively inelastic respective to tuition cost.

CONCLUSION

While future leaders placed the most value on earnings when selecting a program, they also valued rankings and cost. By focusing on these factors, programs can target their marketing efforts to recruit the best potential future healthcare leaders, while this method can be replicated to gauge the most important relative attributes for a variety of healthcare professions.

Evaluation of Factors Related to Prolonged Lengths of Stay for Patients With Autism With or Without Intellectual Disability

Patients with autism spectrum disorder and/or intellectual disability (ASD/ID) face unique health care challenges. In addition to hospital experiences characterized by fear and insufficient staff training, these patients have 1.5-times longer lengths of stay (LOS) than patients without ASD/ID, and 3.4% of patients with ASD/ID have prolonged LOS (i.e., ≥30 days). Little research exists on factors related to prolonged LOS of patients with ASD/ID, hindering efforts to develop and implement evidence-based practices to improve care and reduce prolonged LOS. The purpose of the current study was to describe factors related to prolonged LOS of adult patients with ASD/ID in acute care settings using a retrospective chart review of 10 patients discharged from one academic medical center. Findings indicate that health care institutions should evaluate performance with this patient population and identify evidence-based strategies to provide a safe environment for care and reduce LOS that is due to non-health care needs. [Journal of Psychosocial Nursing and Mental Health Services, 57(7), 17-22.].

The return on investment from international patient programs in American hospitals

Purpose

Hospitals catering to the unique needs of international patients often make substantial investments in their international program. Research has yet to evaluate the return on investment (ROI) of establishing these programs. The purpose of this paper is to quantify the economic benefits and costs of international patient programs and evaluate the ROI of international patients for US hospitals by program maturity and size.

Design/methodology/approach

Operational information about 29 health systems with international patient programs in the USA was obtained from the US Cooperative for International Patient Programs (USCIPP) Annual Benchmarking Survey. A Spearman correlation coefficient was used to test the association between international program investments and revenue. Mann–Whitney U tests were used to test whether ROI differs significantly by program maturity and size.

Findings

It was found that 14 (48.3 per cent) international programs were established and 10 (34.5 per cent) programs were large in size. The median estimated organizational total gross revenue less operating expense for all programs was positive ($15.6m). Total gross revenue less operating expense was higher for large programs ($105.6m) than for small programs ($9.2m) (p < 0.001) and higher for established programs ($40.2m) than for new programs ($8.5m) (p < 0.001).

Originality/value

The results suggest that hospital investment in international programs yields substantial returns for the health systems studied. New programs rely on staff from other areas of the organization while developing operational processes and relationships with providers and payers abroad. Examining the ROI can help hospitals develop a business case for an international program and understand any economies of scale from increased investment.

Efficacy of a Transition Clinic on Hospital Readmissions

BACKGROUND

A primary care-staffed transition clinic is one potential strategy for reducing 30-day re-admissions for patients without an established primary care physician, but the effectiveness has not been studied. The objective was to test whether patients who completed a postdischarge transition clinic appointment were less likely to be readmitted within 30 days.

METHODS

This retrospective cross-sectional study included adults with Medicare or Medicaid coverage who were discharged from general medicine units at Rush University Medical Center between October 2013 and October 2014. All patients had a follow-up appointment scheduled within 30 days of discharge in the transition clinic or with their primary care physician. A binary logistic regression model was constructed to test the relationship between 30-day readmission and follow-up appointment status, controlling for patient factors.

RESULTS

The sample included 1149 patients with scheduled follow-up appointments (24% in the transition clinic and 76% with their primary care physician). After controlling for patient demographic characteristics and clinical factors, patients who did not complete a scheduled transition clinic appointment had approximately 3 times higher odds of readmission compared with patients who completed a transition clinic appointment (adjusted odds ratio, 2.80; P = .004). There was no significant difference in the likelihood of 30-day readmission between patients completing a transition clinic appointment and those who were scheduled with their primary care physician.

CONCLUSIONS

A primary care-staffed transition clinic is a promising strategy for providing access after a recent hospitalization and effectively managing the initial posthospital discharge needs of vulnerable populations.

Practice Innovation, Health Care Utilization and Costs in a Network of Federally Qualified Health Centers and Hospitals for Medicaid Enrollees

State Medicaid programs need cost-effective strategies to provide high-quality care that is accessible to individuals with low incomes and limited resources. Integrated delivery systems have been formed to provide care across the continuum, but creating a shared vision for improving community health can be challenging. Medical Home Network was created as a network of primary care providers and hospital systems providing care to Medicaid enrollees, guided by the principles of egalitarian governance, practice-level care coordination, real-time electronic alerts, and pay-for-performance incentives. This analysis of health care utilization and costs included 1,189,195 Medicaid enrollees. After implementation of Medical Home Network, a risk-adjusted increase of $9.07 or 4.3% per member per month was found over the 2 years of implementation compared with an increase of $17.25 or 9.3% per member per month, before accounting for the cost of care management fees and other financial incentives, for Medicaid enrollees within the same geographic area with a primary care provider outside of Medical Home Network. After accounting for care coordination fees paid to providers, the net risk-adjusted cost reduction was $11.0 million.

What is appropriate care? An integrative review of emerging themes in the literature

Background

Health care improvement efforts should be aligned in order to make a meaningful impact on health systems. Appropriate care delivery could be a unifying goal to help coordinate efforts to improve health outcomes and ensure system sustainability. A more complete understanding of how appropriate care is currently conceived in research and clinical practice could help inform a more integrated and holistic concept of appropriate care that could guide health care policy and delivery practices. We examined the current understanding of appropriate care by identifying its use and definitions in recently published literature.

Methods

An integrated review of the practices, goals and perspectives of appropriate care in English language peer-reviewed articles published from 2011 to 2016. Inductive content analysis was used to describe emerging themes of appropriate care in articles meeting inclusion criteria.

Results

This integrative review included empirical studies, reviews, and commentaries with various health care settings, cultural contexts, and perspectives. Conceptualizations of appropriate care varied, however most descriptions fell into five main categories: evidence-based care, clinical expertise, patient-centeredness, resource use, and equity. These categories were often used in combination, indicating an integrated understanding of appropriate care.

Conclusions

An understanding of how appropriate care is conceptualized in research and policy can help inform an integrated approach to appropriate care delivery in policy and practice according to the relevant priorities and circumstances.

Influence of own mother's milk on bronchopulmonary dysplasia and costs

BACKGROUND

Human milk from the infant's mother (own mother's milk; OMM) feedings reduces the risk of several morbidities in very low birthweight (VLBW) infants, but limited data exist regarding its impact on bronchopulmonary dysplasia (BPD).

OBJECTIVE

To prospectively study the impact of OMM received in the neonatal intensive care unit (NICU) on the risk of BPD and associated costs.

DESIGN/METHODS

A 5-year prospective cohort study of the impact of OMM dose on growth, morbidity and NICU costs in VLBW infants. OMM dose was the proportion of enteral intake that consisted of OMM from birth to 36 weeks postmenstrual age (PMA) or discharge, whichever occurred first. BPD was defined as the receipt of oxygen and/or positive pressure ventilation at 36 weeks PMA. NICU costs included hospital and physician costs.

RESULTS

The cohort consisted of 254 VLBW infants with mean birth weight 1027±257 g and gestational age 27.8±2.5 weeks. Multivariable logistic regression demonstrated a 9.5% reduction in the odds of BPD for every 10% increase in OMM dose (OR 0.905 (0.824 to 0.995)). After controlling for demographic and clinical factors, BPD was associated with an increase of US$41 929 in NICU costs.

CONCLUSIONS

Increased dose of OMM feedings from birth to 36 weeks PMA was associated with a reduction in the odds of BPD in VLBW infants. Thus, high-dose OMM feeding may be an inexpensive, effective strategy to help reduce the risk of this costly multifactorial morbidity.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

Care provider perspectives on medical travel: A three-country study of destination hospitals

Despite growing interest in the current and potential role of medical travel in U.S. patient care, very little research has been conducted on clinician and other provider organizations' perspectives on providing international patient care. The present study sought to gain formative insights about medical travel from the providers' perspectives, by conducting structured interviews and focus groups in six hospitals from three countries catering to patients traveling from the United States. Findings highlighted the surprising role of international events and policies in the evolution of medical travel, as well as both the desire and need for more transparent quality standards.

NICU Human Milk Dose and 20-Month Neurodevelopmental Outcome in Very Low Birth Weight Infants

BACKGROUND

The association between human milk (HM) feeding in the NICU and neurodevelopmental (ND) outcome in very low birth weight (VLBW) infants is unclear. Limitations of previous studies include a lack of exact estimates of HM dose and of generalizability to minority populations.

OBJECTIVE

To determine the impact on ND outcome of an exact dose of HM received in the NICU in a diverse, contemporary cohort of VLBW infants.

METHODS

We included 430 VLBW infants born in the period 2008-2012 for whom the mean daily dose (DD) of HM received during the stay in the NICU (NICU HM-DD) was calculated prospectively from the daily nutritional intake from admission to discharge. Outcomes included Bayley-III index scores at 20 months' corrected age (CA) as assessed upon ND follow-up, which were collected retrospectively. Multivariable linear regression analyses controlled for neonatal and social risk factors.

RESULTS

Each 10 mL/kg/day increase in NICU HM-DD was associated with a 0.35 increase in cognitive index score (95% CI [0.03-0.66], p = 0.03), but no significant associations were detected for the language or motor indices.

CONCLUSIONS

There is a significant dose-dependent association between NICU HM intake and cognitive scores at 20 months' CA. Further follow-up will determine whether these findings persist at school age, and could help alleviate the special-education and health-care burden in this population.

Palliative Workforce Development and a Regional Training Program

Aims:

Our primary aims were to assess growth in the local hospital based workforce, changes in the composition of the workforce and use of an interdisciplinary team, and sources of support for palliative medicine teams in hospitals participating in a regional palliative training program in Chicago.

Methods:

PC program directors and administrators at 16 sites were sent an electronic survey on institutional and PC program characteristics such as: hospital type, number of beds, PC staffing composition, PC programs offered, start-up years, PC service utilization and sources of financial support for fiscal years 2012 and 2014.

Results:

The median number of consultations reported for existing programs in 2012 was 345 (IQR 109 – 2168) compared with 840 (IQR 320 – 4268) in 2014. At the same time there were small increases in the overall team size from a median of 3.2 full time equivalent positions (FTE) in 2012 to 3.3 FTE in 2013, with a median increase of 0.4 (IQR 0-1.0). Discharge to hospice was more common than deaths in the acute care setting in hospitals with palliative medicine teams that included both social workers and advanced practice nurses ( p < .0001).

Conclusions:

Given the shortage of palliative medicine specialist providers more emphasis should be placed on training other clinicians to provide primary level palliative care while addressing the need to hire sufficient workforce to care for seriously ill patients.

Patient safety intervention to reduce unnecessary red blood cell utilization

OBJECTIVES

To measure the impact of a local patient safety intervention and a national guideline to reduce unnecessary red blood cell (RBC) transfusions in the Department of Medicine of an academic medical center.

STUDY DESIGN

This was a retrospective, pre-post study.

METHODS

In May 2013, a clinical practice guideline, modeled after the 2012 AABB recommendations for RBC use, was implemented with the goal of decreasing unnecessary RBC transfusions. This was done using a previously developed model for change management in the Department of Medicine that included academic safety conferences, e-mail safety alerts, and feedback to providers on global blood product utilization. Data regarding the utilization of RBC products were obtained for the time before the AABB guideline, after the AABB guideline but before the local intervention, and after the local intervention (January 2011 through March 2014).

RESULTS

Blood product use started to decline after the AABB guideline, but dropped much further after the focused, local interventions were implemented. The proportion of patients receiving a transfusion decreased from 12.6% prior to the AABB guideline to 8.8% after the intervention (P < .001). The percent of total blood use with a hemoglobin level above 8 g/dL decreased from 20.2% to 12.4%; the total units of RBCs transfused per 100 discharges also decreased from 33.4 to 21.7. The direct RBC costs per discharge dropped from $61.60 to $39.70.

CONCLUSIONS

Passive adoption of restrictive transfusion guidelines was shown to reduce blood product use on general medicine floors of an academic medical center, but the effect was greatly improved after a local, targeted intervention to improve patient safety was implemented.

Integration of Palliative Care Advanced Practice Nurses Into Intensive Care Unit Teams

Background:

Referrals to palliative care for patients at the end of life in the intensive care unit (ICU) often happen late in the ICU stay, if at all. The integration of a palliative medicine advanced practice nurse (APN) is one potential strategy for proactively identifying patients who could benefit from this service.

Objective:

To evaluate the association between the integration of palliative medicine APNs into the routine operations of ICUs and hospital costs at 2 different institutions, Montefiore Medical Center (MMC) and Rush University Medical Center.

Methods:

The association between collaborative palliative care consultation service programs and hospital costs per patient was evaluated for the 2 institutions. Hospital costs were compared for patients with and without a referral to palliative care using Mann-Whitney U tests.

Results:

Hospital nonroom and board costs at the Weiler campus of MMC were significantly lower for patients with palliative care compared with those who did not receive palliative care (Median = US$6643 vs US$12 399, P < .001). Cost differences for ICU patients with and without palliative care at Rush University Medical Center were not significantly different.

Conclusion:

Our evaluation suggests that the integration of APNs into a palliative care team for case finding may be a promising strategy, but more work is needed to determine whether reductions in cost are significant.

The Cost of Increasing Physical Activity and Maintaining Weight for Midlife Sedentary African American Women

OBJECTIVE

To evaluate the marginal costs of increasing physical activity and maintaining weight for a lifestyle physical activity program targeting sedentary African American women.

METHODS

Outcomes included change in minutes of total moderate to vigorous physical activity, leisure-time moderate to vigorous physical activity and walking per week, and weight stability between baseline and maintenance at 48 weeks. Marginal cost-effectiveness ratios (MCERs) were calculated for each outcome, and 95% confidence intervals (CIs) were computed using a bootstrap method. The analysis was carried out from the societal perspective and calculated in 2013 US dollars.

RESULTS

For the 260 participants in the analysis, program costs were $165 ± $19, and participant costs were $164 ± $35, for a total cost of $329 ± $49. The MCER for change in walking was $1.50/min/wk (95% CI 1.28-1.87), for change in moderate to vigorous physical activity was $1.73/min/wk (95% CI 1.41-2.18), and for leisure-time moderate to vigorous physical activity was $1.94/min/wk (95% CI 1.58-2.40). The MCER for steps based on the accelerometer was $0.46 per step (95% CI 0.30-0.85) and weight stability was $412 (95% CI 399-456).

CONCLUSIONS

The Women's Lifestyle Physical Activity Program is a relatively low-cost strategy for increasing physical activity. The marginal cost of increasing physical activity is lower than for weight stability. The participant costs related to time in the program were nearly half the total costs, suggesting that practitioners and policymakers should consider the participant cost when disseminating a lifestyle physical activity program into practice.

Medicaid beneficiaries who continue to use the ED: a focus on the Illinois Medical Home Network

OBJECTIVES

Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities.

METHODS

We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data.

RESULTS

Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients.

CONCLUSIONS

This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

Factors influencing medical travel into the United States

Purpose

– This paper aims to evaluate the potential of 24 country-level measures for predicting the number of outbound international medical travelers into the USA, including health and healthcare system, economic, social and diplomatic and travel pattern factors. Medical travel is recognized as a growing global market and is an important subject of inquiry for US academic medical centers, hospitals and policy makers. Few data-driven studies exist to shed light on efficient and effective strategies for attracting international medical travelers.

Design/methodology/approach

– This was a retrospective, cross-sectional study of the 194 member and/or observer countries of the United Nations. Data for medical traveler volume into the USA between 2008 and 2010 were obtained from the USA Department of Commerce, Office of Travel and Tourism Industries, Survey of International Air Travelers. Data on country-level factors were collected from publicly available databases, including the United Nations, World Bank and World Health Organization. Linear regression models with a negative binomial distribution and log link function were fit to test the association between each independent variable and the number of inbound medical travelers to the USA.

Findings

– Seven of the 24 country-level factors were significantly associated with the number of outbound medical travelers to the USA These factors included imports as a per cent of gross domestic product, trade in services as a per cent of gross domestic product, per cent of population living in urban areas, life expectancy, childhood mortality, incidence of tuberculosis and prevalence of human immunodeficiency virus.

Practical implications

– Results of this model provide evidence for a data-driven approach to strategic outreach and business development for hospitals and policy makers for attracting international patients to the USA for medical care.

Originality/value

– The model developed in this paper can assist US hospitals in promoting their services to international patients as well as national efforts in identifying “high potential” medical travel markets. Other countries could also adapt this methodology for targeting the international patient market.

Factors related to complications among adult patients with intellectual disabilities hospitalized at an academic medical center

People with intellectual disabilities (ID) represent a small but important group of hospitalized patients who have higher rates of complications than do patients without ID hospitalized for the same reasons. Complications are potentially avoidable conditions, such as healthcare-acquired infections, healthcare-acquired skin breakdown, falls, and medication errors and reactions. Addressing factors related to complications can focus efforts to improve hospital care. The purpose of this exploratory study was to analyze data from reviews of academic medical center charts (N  =  70) about complications and to examine patient and hospitalization characteristics in relation to complications among adult patients (age ≥ 18 years) with ID hospitalized for nonpsychiatric reasons. Adults with ID tended to be twice as likely to have complications (χ2  =  2.893, df  =  1, p  =  .09) if they had a surgical procedure and were nearly four times as likely to have complications (χ2  =  6.836, df  =  1, p  =  .009) if they had multiple chronic health conditions (three of the following: history of cerebral palsy, autism spectrum symptoms, aggressive behavior, respiratory disorder, and admission through the emergency department). Findings suggest preliminary criteria for assessing risk for complications among hospitalized people with ID and the need for attention to their specific needs when hospitalized.

Cost savings of human milk as a strategy to reduce the incidence of necrotizing enterocolitis in very low birth weight infants

BACKGROUND

Necrotizing enterocolitis (NEC) is a costly morbidity in very low birth weight (VLBW; <1,500 g birth weight) infants that increases hospital length of stay and requires expensive treatments.

OBJECTIVES

To evaluate the cost of NEC as a function of dose and exposure period of human milk (HM) feedings received by VLBW infants during the neonatal intensive care unit (NICU) hospitalization and determine the drivers of differences in NICU hospitalization costs for infants with and without NEC.

METHODS

This study included 291 VLBW infants enrolled in an NIH-funded prospective observational cohort study between February 2008 and July 2012. We examined the incidence of NEC, NICU hospitalization cost, and cost of individual resources used during the NICU hospitalization.

RESULTS

Twenty-nine (10.0%) infants developed NEC. The average total NICU hospitalization cost (in 2012 USD) was USD 180,163 for infants with NEC and USD 134,494 for infants without NEC (p = 0.024). NEC was associated with a marginal increase in costs of USD 43,818, after controlling for demographic characteristics, risk of NEC, and average daily dose of HM during days 1-14 (p < 0.001). Each additional ml/kg/day of HM during days 1-14 decreased non-NEC-related NICU costs by USD 534 (p < 0.001).

CONCLUSIONS

Avoidance of formula and use of exclusive HM feedings during the first 14 days of life is an effective strategy to reduce the risk of NEC and resulting NICU costs in VLBW infants. Hospitals investing in initiatives to feed exclusive HM during the first 14 days of life could substantially reduce NEC-related NICU hospitalization costs.

Economic benefits and costs of human milk feedings: a strategy to reduce the risk of prematurity-related morbidities in very-low-birth-weight infants

Infants born at very low birth weight (VLBW; birth weight <1500 g) are at high risk of mortality and are some of the most expensive patients in the hospital. Additionally, VLBW infants are susceptible to prematurity-related morbidities, including late-onset sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, and retinopathy of prematurity, which have short- and long-term economic consequences. The incremental cost of these morbidities during the neonatal intensive care unit (NICU) hospitalization is high, ranging from $10,055 (in 2009 US$) for late-onset sepsis to $31,565 for BPD. Human milk has been shown to reduce both the incidence and severity of some of these morbidities and, therefore, has an indirect impact on the cost of the NICU hospitalization. Furthermore, human milk may also directly reduce NICU hospitalization costs, independent of the indirect impact on the incidence and/or severity of these morbidities. Although there is an economic cost to both the mother and institution for providing human milk during the NICU hospitalization, these costs are relatively low. This review describes the total cost of the initial NICU hospitalization, the incremental cost associated with these prematurity-related morbidities, and the incremental benefits and costs of human milk feedings during critical periods of the NICU hospitalization as a strategy to reduce the incidence and severity of these morbidities.

Effectiveness, efficiency, duration, and costs of recruiting for an African American women's lifestyle physical activity program

In a 48-week lifestyle physical activity controlled trial in African American women, we analyzed recruitment effectiveness, efficiency, duration, and costs. Social networking was the most effective approach for inviting women to the trial. Of the 609 who responded to invitations, 514 completed telephone screening; of these, 409 (80%) were found eligible. The health assessment screening was completed by 337 women; of these, 297 (88%) were found eligible. The mean number of days from completion of the telephone and health assessment screenings to beginning the intervention was 23.01, and the mean cost was $74.57 per person. Results suggest that provision of health assessment screening by study staff as part of recruitment is effective for minimizing attrition and also might be cost-effective.

Empirical analysis of domestic medical travel for elective cardiovascular procedures

OBJECTIVES

To investigate whether domestic medical travel (DMT; traveling outside of one's home region but within the United States for medical care) and surgeon volume affect clinical outcomes and costs for patients undergoing elective cardiovascular procedures.

STUDY DESIGN

Retrospective, cross-sectional analysis of patient discharge data from US academic medical centers.

METHODS

Patients were classified as medical travelers if they received elective, nonemergent care more than 250 miles from home. High-volume surgeons (HVSs) were those above the 75th percentile compared with other study surgeons in the annual number of cardiovascular surgeries performed. Multivariable regression models were fit to test the relationships among complications, mortality, length of stay (LOS), cost, DMT status, and surgeon volume, controlling for sociodemographic and clinical factors.

RESULTS

Patients who traveled to HVSs were more likely to be male, white, have lower severity of illness, and have health insurance through an indemnity plan or preferred provider organization with coverage outside of the patient's home region. Patients who traveled to HVSs had shorter LOS and fewer complications than those who received care from local, low-volume surgeons. There was no significant difference in mortality between travelers and nontravelers.

CONCLUSIONS

Patients who travelled to HVSs for elective cardiovascular procedures had outcomes similar to or better than those of patients who received care locally from low-volume surgeons. We found no increase in complications or LOS, despite potentially complex logistical arrangements required by travelers. More work is needed to evaluate the potential of DMT to improve the value of care provided for selected procedures.

Impact of a combined pharmacist and social worker program to reduce hospital readmissions

BACKGROUND

The Patient Protection and Affordable Care Act (2010) directed the Centers for Medicare and Medicaid Services to implement a hospital readmissions reduction program that reduces payments to hospitals for excess readmissions that began in October 2012. As such, hospitals across the country have been trying to identify and implement successful strategies for reducing hospitalizations.

OBJECTIVE

To evaluate the impact of a combined pharmacist and social worker program on reducing 30-day, all-cause readmission rates to the same hospital.

METHODS

Our study design was a retrospective, cross-sectional study that included 100 inpatients discharged from a large academic medical center. Fifty patients were enrolled in the combined pharmacist and social worker program, and 50 received usual care; all were deemed high risk for readmission due to clinical or social factors. In the program group, a pharmacist performed a thorough medication history and review of discharge medications and, in some cases, communicated with the patient after discharge. The program group was also followed by a social worker team in the hospital and after discharge; as necessary, psychosocial interventions were performed.

RESULTS

The 2 patient cohorts had similar demographic and clinical characteristics. Ten percent of patients enrolled in the combined pharmacist and social worker program were readmitted to the hospital for any reason within 30 days of discharge, compared with 30% of patients in the usual care group (P = 0.012).

CONCLUSION

The combined pharmacist and social worker program demonstrated a significant reduction in 30-day, all-cause readmission rates to the same hospital.

The institutional cost of acquiring 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit

BACKGROUND

Human milk from the biologic mother (HM) reduces disease burden and associated costs of care during and after neonatal intensive care unit (NICU) hospitalization for very low birth weight (VLBW; birth weight < 1500 g) infants, when compared to feedings of donor human milk (DHM) or commercial formula (CF). However, compared to DHM and CF, little is known about the institutional cost to acquire HM from the biologic mother.

OBJECTIVE

This study aimed to determine the institutional cost of acquiring HM for VLBW infant feedings during the NICU hospitalization.

METHODS

This analysis examined 157 maternal pumping records from a prospective cohort study evaluating health outcomes and cost of HM feedings for VLBW infants. The costs for the breast pump rental fee, 1-time pump kit purchase, and disposable food-grade containers for storing expressed HM were evaluated using standard cost analysis techniques.

RESULTS

The median cost of acquiring 100 mL of HM varied from $0.51 when mothers pumped ≥ 700 mL daily to $7.93 for those who pumped < 100 mL daily. Mothers who pumped ≥ 100 mL daily had lower acquisition cost compared to both DHM ($14.84/100 mL) and CF ($3.18/100 mL). For mothers who pumped > 100 mL daily, the exact day of pumping where the cost of HM was less expensive than DHM or CF was 4 to 7 days and 6 to 19 days, respectively.

CONCLUSION

Human milk from the biologic mother has lower acquisition cost than DHM and CF when mothers provided ≥ 100 mL daily and pumped for a sufficient number of days (range, 4-19). Neonatal intensive care units should prioritize resources to ensure that mothers achieve this daily milk volume.

Impact of early human milk on sepsis and health-care costs in very low birth weight infants

OBJECTIVE

To study the incidence of sepsis and neonatal intensive care unit (NICU) costs as a function of the human milk (HM) dose received during the first 28 days post birth for very low birth weight (VLBW) infants.

STUDY DESIGN

Prospective cohort study of 175 VLBW infants. The average daily dose of HM (ADDHM) was calculated from daily nutritional data for the first 28 days post birth (ADDHM-Days 1-28). Other covariates associated with sepsis were used to create a propensity score, combining multiple risk factors into a single metric.

RESULT

The mean gestational age and birth weight were 28.1 ± 2.4 weeks and 1087 ± 252 g, respectively. The mean ADDHM-Days 1-28 was 54 ± 39 ml kg(-1) day(-1) (range 0-135). Binary logistic regression analysis controlling for propensity score revealed that increasing ADDHM-Days 1-28 was associated with lower odds of sepsis (odds ratio 0.981, 95% confidence interval 0.967-0.995, P=0.008). Increasing ADDHM-Days 1-28 was associated with significantly lower NICU costs.

CONCLUSION

A dose-response relationship was demonstrated between ADDHM-Days 1-28 and a reduction in the odds of sepsis and associated NICU costs after controlling for propensity score. For every HM dose increase of 10 ml kg(-1) day(-1), the odds of sepsis decreased by 19%. NICU costs were lowest in the VLBW infants who received the highest ADDHM-Days 1-28.

Cost of morbidities in very low birth weight infants

OBJECTIVE

To determine the association between direct costs for the initial neonatal intensive care unit hospitalization and 4 potentially preventable morbidities in a retrospective cohort of very low birth weight (VLBW) infants (birth weight <1500 g).

STUDY DESIGN

The sample included 425 VLBW infants born alive between July 2005 and June 2009 at Rush University Medical Center. Morbidities included brain injury, necrotizing enterocolitis, bronchopulmonary dysplasia, and late-onset sepsis. Clinical and economic data were retrieved from the institution's system-wide data and cost accounting system. A general linear regression model was fit to determine incremental direct costs associated with each morbidity.

RESULTS

After controlling for birth weight, gestational age, and sociodemographic characteristics, the presence of brain injury was associated with a $12048 (P = .005) increase in direct costs; necrotizing enterocolitis, with a $15 440 (P = .005) increase; bronchopulmonary dysplasia, with a $31565 (P < .001) increase; and late-onset sepsis, with a $10055 (P < .001) increase. The absolute number of morbidities was also associated with significantly higher costs.

CONCLUSION

This study provides collective estimates of the direct costs incurred during neonatal intensive care unit hospitalization for these 4 morbidities in VLBW infants. The incremental costs associated with these morbidities are high, and these data can inform future studies evaluating interventions aimed at preventing or reducing these costly morbidities.

Electronic quality measurement predicts outcomes in community acquired pneumonia

Using electronic medical data, we calculated emergency department physician performance and subsequent outcomes on a measure used in the Centers for Medicare & Medicaid Services' Physician Quality Reporting System. The measure assesses use of guideline recommended antibiotics for community acquired pneumonia. Physicians met measure criteria in 70.6% of cases at one institution. Among patients admitted to the hospital, measure compliant cases had a significantly shorter length of stay, lower costs and lower intensive care utilization than measure failures. For measure failures admitted to the hospital, antibiotic treatment was adjusted to be measure compliant within 48 hours in 57.1% of cases. Use of electronic performance measurement for antibiotic treatment of community acquired pneumonia identified variations in physician performance. Measure compliance correlated with significantly improved patient outcomes and lower costs.

Comparative faecal microbiota of dogs with and without calcium oxalate stones

AIMS

The absence of enteric oxalate-metabolizing bacterial species (OMBS) increases the likelihood of calcium oxalate (CaOx) urolithiasis in humans and dogs. The goal of this study was to compare the gut microbiota of healthy dogs and CaOx stone formed dogs (CaOx-dogs), especially with respect to OMBS.

METHODS AND RESULTS

Faecal samples from healthy and CaOx-dogs were obtained to analyse the hindgut microbiota by sequencing the V3 region of bacterial 16S rDNA. In total, 1223 operational taxonomic units (OTUs) were identified at 97% identity. Only 38% of these OTUs were shared by both groups. Significant differences in the relative abundance of 152 OTUs and 36 genera were observed between the two groups of dogs.

CONCLUSIONS

The faecal microbiota of healthy dogs is distinct from that of CaOx-dogs, indicating that the microbiota is altered in CaOx-dogs.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first study that has compared the gut microbial diversity in healthy and CaOx-dogs. Results of this study indicate the future need for functional and comparative analyses of the total array of oxalate-metabolizing genes between healthy and CaOx stone formers, rather than focusing on specific bacterial species, to understand the critical role of OMBS in CaOx urolithiasis.

Socioeconomic status, energy cost, and nutrient content of supermarket food purchases

BACKGROUND

The relative affordability of energy-dense versus nutrient-rich foods may promote socioeconomic disparities in dietary quality and obesity. Although supermarkets are the largest food source in the American diet, the associations between SES and the cost and nutrient content of freely chosen food purchases have not been described.

PURPOSE

To investigate relationships of SES with the energy cost ($/1000 kcal) and nutrient content of freely chosen supermarket purchases.

METHODS

Supermarket shoppers (n=69) were recruited at a Phoenix AZ supermarket in 2009. The energy cost and nutrient content of participants' purchases were calculated from photographs of food packaging and nutrition labels using dietary analysis software. Data were analyzed in 2010-2011.

RESULTS

Two SES indicators, education and household income as a percentage of the federal poverty guideline (FPG), were associated with the energy cost of purchased foods. Adjusting for covariates, the amount spent on 1000 kcal of food was $0.26 greater for every multiple of the FPG, and those with a baccalaureate or postbaccalaureate degree spent an additional $1.05 for every 1000 kcal of food compared to those with no college education. Lower energy cost was associated with higher total fat and less protein, dietary fiber, and vegetables per 1000 kcal purchased.

CONCLUSIONS

Low-SES supermarket shoppers purchase calories in inexpensive forms that are higher in fat and less nutrient-rich.