Longitudinal Patterns and Economic Consequences of Emergency Department Visits among Medicaid Enrollees

Objective.;The objective of the dissertation was to examine the patient- and county-level factors associated with the Emergency Department (ED) visits and economic consequences associated with persistent ED use among adult fee-for-service (FFS) Medicaid beneficiaries. The first study examined the patient- and county-level factors associated with the number of ED visits and the second study examined the longitudinal patterns of ED visits among FFS Medicaid beneficiaries. Further, in both the studies ED visits due to primary care sensitive conditions were also examined. The third study examined the patient- and county- level factors associated with persistent ED use followed by an estimation of the excess healthcare expenditures associated with persistent ED use.;Methods.;Both cross-sectional and longitudinal study designs were implemented using a retrospective observational claims data of Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. Study population included adult, alive, FFS, not dually enrolled in Medicare, non-pregnant and continuously enrolled Medicaid beneficiaries. Data on patient-level factors were obtained from the Medicaid Analytic eXtract (MAX) files for the years 2006-2010. MAX files consisted of personal summary, other therapy, inpatient and prescription drugs claims. The personal summary file included demographics, Medicaid eligibility, county federal information processing standard (FIPS) codes, Medicaid managed care enrollment, and Medicare eligibility status. The inpatient claims file included information related to hospital stays, dates of service, Medicaid payment, and the International Classification of Disease, Ninth Revision, Clinical Modification codes (ICD-9-CM) and ICD-9-CM procedure codes. The other therapy claims file included information on dates of service, types of service, Medicaid payment, ICD-9-CM, and Current Procedural Terminology (CPT) codes. The prescription drugs claims file included information on the date of prescription filled, days supplied, Medicaid payment and national drug code (NDC). All these files were linked using encrypted identification numbers. Data on county-level factors such as socio economic status, healthcare resources, and obesity rates were obtained from the Area health resource and county health ranking files. Frequencies, means, inter-quartile range, and 90th percentile were used to examine the characteristics of the study population and distribution of ED visits. In the first study, unadjusted and adjusted negative binomial regressions (NBR) were conducted to examine the patient- and county-level factors associated with the number of ED visits. In the second study, multivariable hurdle models with logistic and NBRs were used to analyze ED visits over time, after adjusting for all other independent variables. In the third study, chi-square tests and logistic regression was conducted to examine the patient- and county-level factors associated with persistent ED use. Further, adjusted generalized linear models with log link function and gamma distribution were conducted to examine the excess expenditures. All analyses were conducted using STATA version 14.0.;Findings.;In the first study, it was observed that more than half of the study population had one or more ED visit. Patient-level factors such as complex chronic illness, fragmented primary care use, poly-pharmacy, and tobacco use were associated with higher number of ED visits. Residents in counties with higher number of urgent care centers had lower number of ED visits. Almost, half of the ED visits were preventable. In the second study, the likelihood of ED use did not change from year to year. However, among ED users, the estimated number of ED visits increased over time with a small magnitude. More than half of the ED visits were primary care sensitive in each panel year. In the third study, one in ten Medicaid beneficiary had persistent ED use i.e. they had 4 or more ED visits in both index and follow-up years. There were significant differences between persistent ED users and non-users in patient- and county-level characteristics. Individuals with complex chronic illnesses, fragmented primary care use, poly-pharmacy and tobacco use were more likely to be persistent ED users. In multivariable regression, persistent ED users had significantly higher total healthcare expenditures as compared to non-users.;Conclusions.;Adult FFS Medicaid beneficiaries with complex healthcare needs had higher number of ED visits. The number of ED visits increased over time with a small magnitude. Almost, half of the ED visits are preventable with timely care. Medicaid beneficiaries also had persistent ED use and had higher excess healthcare expenditures associated with persistent ED use. Taken together, these findings suggest that only access to primary care may not reduce ED visits. There is a need to have targeted interventions focused on this particular subgroup of the population who is consuming higher healthcare resources as compared to others. Cost containment may be achieved by providing comprehensive care management to individuals with complex healthcare needs. Access to county-level resources such as urgent care centers may contribute in reducing the number of ED visits and cost containment as care provided in these settings is less expensive as compared to ED

Depression treatment patterns among individuals with osteoarthritis: a cross sectional study

BACKGROUND: Arthritis and depression often co-occur; however, studies that describe patterns of depression treatment among individuals with arthritis are scant. The purpose of the study was to examine depression treatment patterns among individuals with osteoarthritis (OA) by predisposing, enabling, need factors, personal health practices and external health environment. METHODS: Retrospective cross-sectional design was used. Data were obtained from 2008 and 2010 Medical Expenditure Panel Survey (MEPS). The sample consisted of 647adults aged over 21 years with depression and OA. Depression treatment was categorized as: 1) No treatment;2) antidepressant use only and 3) both antidepressants and psychotherapy (combination therapy). Chi- square tests and multinomial logistic regressions were used to describe patterns of depression treatment. All analysis was performed using Statistical Analysis Software (SAS) version 9.3. RESULTS: Overall, 13.0% of the study sample reported no depression treatment, 67.8% used antidepressants only and 19.2% used combination therapy. Among individuals with OA significant subgroup differences in depression treatment were observed. For example, African Americans were less likely to report depression treatment compared to whites [antidepressants: AOR=0.33, 95% CI=0.21,0.51; combination therapy: AOR=0.39, 95% CI=0.23, 0.65]. Elderly adults were more likely to receive antidepressants and less likely to receive psychotherapy as compared to younger adults [AOR=0.53, 95% CI= 0.28,0.98]. Adults with anxiety were more likely to report depression treatment compared to those without anxiety [antidepressants: AOR=1.53, 95% CI=1.06, 2.22; combination therapy: AOR=3.52, 95% CI=2.40, 5.15]. CONCLUSION: Future research needs to examine the reason for low rates of combination therapy as well as subgroup differences in combination therapy among individuals with OA

Assessment of the iliolumbar artery: its structural variations and applied aspect

Background: The Iliolumbar artery normally arises from the posterior division of Internal iliac artery. The main artery and its two branches supply the iliacus and lumbar region and other vital structures in that area. However, various studies conducted depict the differences in the pattern of its origin and course. Thus, the goal of this study was to discover the various origins of the iliolumbar artery, as well as its relationships with other surgically significant anatomical structures; the importance of which can prevent any intraoperative hemorrhages during surgery.Methods: The study was conducted in Department of Anatomy Lady Hardinge Medical College between 2019-2021. Pelvis of 12 formalin fixed adult cadavers (8 females, 4 males) were dissected to observe the iliolumbar artery. Its origin, caliber and course were measured using a digital vernier caliper. The relationship of iliolumbar artery was established with obturator nerve, lumbosacral trunk and sympathetic chain.Results: Iliolumbar artery was originating from trunk of internal iliac artery in 70.83% cases in which the mean distance of origin and mean caliber was more on right side. In the remaining 29.17% cases where the Iliolumbar artery was arising from posterior division of internal iliac artery, the mean distance of origin and mean caliber was higher on left side. The truncal origin of iliolumbar artery was predominant in females.Conclusions: The variant origin of the iliolumbar artery and its clinic-anatomical relationships have been highlighted to reduce iatrogenic artery trauma during surgery.

Depression treatment patterns among individuals with osteoarthritis: a cross sectional study

Background Arthritis and depression often co-occur; however, studies that describe patterns of depression treatment among individuals with arthritis are scant. The purpose of the study was to examine depression treatment patterns among individuals with osteoarthritis (OA) by predisposing, enabling, need factors, personal health practices and external health environment. Methods Retrospective cross-sectional design was used. Data were obtained from 2008 and 2010 Medical Expenditure Panel Survey (MEPS). The sample consisted of 647adults aged over 21 years with depression and OA. Depression treatment was categorized as: 1) No treatment;2) antidepressant use only and 3) both antidepressants and psychotherapy (combination therapy). Chi- square tests and multinomial logistic regressions were used to describe patterns of depression treatment. All analysis was performed using Statistical Analysis Software (SAS) version 9.3. Results Overall, 13.0% of the study sample reported no depression treatment, 67.8% used antidepressants only and 19.2% used combination therapy. Among individuals with OA significant subgroup differences in depression treatment were observed. For example, African Americans were less likely to report depression treatment compared to whites [antidepressants: AOR=0.33, 95% CI=0.21,0.51; combination therapy: AOR=0.39, 95% CI=0.23, 0.65]. Elderly adults were more likely to receive antidepressants and less likely to receive psychotherapy as compared to younger adults [AOR=0.53, 95% CI= 0.28,0.98]. Adults with anxiety were more likely to report depression treatment compared to those without anxiety [antidepressants: AOR=1.53, 95% CI=1.06, 2.22; combination therapy: AOR=3.52, 95% CI=2.40, 5.15]. Conclusion Future research needs to examine the reason for low rates of combination therapy as well as subgroup differences in combination therapy among individuals with OA

Use of Selective-Serotonin Reuptake Inhibitors and Platelet Aggregation Inhibitors Among Individuals with Co-Occurring Atherosclerotic Cardiovascular Disease and Depression or Anxiety

Objective: Medications commonly used to treat heart disease, anxiety, and depression can interact resulting in an increased risk of bleeding, warranting a cautious approach in medical decision making. This retrospective, descriptive study examined the prevalence and the factors associated with the use of both selective-serotonin reuptake inhibitor and platelet aggregation inhibitor among individuals with co-occurring atherosclerotic cardiovascular disease and anxiety or depression. Methods: Respondents aged 22 years and older, alive throughout the study period, and diagnosed with co-occurring atherosclerotic cardiovascular disease and anxiety or depression (n=1507) in years 2007 through 2013 of the Medical Expenditures Panel Survey were included. The use of treatment was grouped as follows: selective-serotonin reuptake inhibitor and platelet aggregation inhibitor, selective-serotonin reuptake inhibitor or platelet aggregation inhibitor, and neither selective-serotonin reuptake inhibitor nor platelet aggregation inhibitor. Results: Overall, 16.5% used both selective-serotonin reuptake inhibitor and platelet aggregation inhibitor, 61.2% used selective-serotonin reuptake inhibitor or platelet aggregation inhibitor, and 22.3% used neither selective-serotonin reuptake inhibitor nor platelet aggregation inhibitor. Respondents aged over 65years (adjusted odds ratio=1.93 (95% confidence interval=1.08–3.45)) and having a diagnosis of diabetes (adjusted odds ratio=1.63 (95% confidence interval=1.15–2.31)) and hypertension (adjusted odds ratio=1.84 (95% confidence interval=1.04–3.27)) were more likely to be prescribed the combination. Conclusion: The drug interaction was prevalent in patients who are already at higher risk of health disparities and worse outcomes thus requiring vigilant evaluation

A Novel Approach for Speech to Text Recognition System Using Hidden Markov Model

Speech recognition is the application of sophisticated algorithms which involve the transforming of the human voice to text. Speech identification is essential as it utilizes by several biometric identification systems and voice-controlled automation systems. Variations in recording equipment, speakers, situations, and environments make speech recognition a tough undertaking. Three major phases comprise speech recognition: speech pre-processing, feature extraction, and speech categorization. This work presents a comprehensive study with the objectives of comprehending, analyzing, and enhancing these models and approaches, such as Hidden Markov Models and Artificial Neural Networks, employed in the voice recognition system for feature extraction and classification

The effect and safety of placental blood drainage as a part of active management of third stage of labour in spontaneous vaginal delivery

Background: In placental cord drainage facilitates placental delivery in both vaginal and caesarean section deliveries. The present study was done to evaluate the effect and safety of placental blood drainage as a part of active management of third stage of labour to reduce the duration and blood loss during third stage of labour.Methods: The study was conducted in department of Obstetrics and, SN Medical College, Agra, Uttar Pradesh, India on 400 term pregnant women, with single live intrauterine fetus in cephalic presentation, without any complication. They were randomly divided into to study and control group. Study group: It comprised of 200 Gynaecology cases, underwent active management of third stage of labour with placental blood drainage. Control group: It comprised of 200 cases, underwent active management of third stage of labour (AMTSL) alone. Duration and blood loss during third stage were noted.Results: The mean duration of third stage of labour was 3.61±0.972mins in study group and 8.15±1.711mins in control group. The mean blood loss during third stage of labour was 168.14±76.703ml and 287.40±85.808ml in study and control group respectively.Conclusions: Duration of third stage, blood loss during third stage, and hemoglobin deference between pre and post-delivery were reduced significantly in study group than control group

Endometrial histopathology patterns in women with abnormal uterine bleeding

Background: Abnormal uterine bleeding is the most common gynaecological condition for which many women seek medical opinion. Evaluation of these women requires careful investigation into the cause and nature of bleeding with a main focus to exclude organic pathology, especially genital malignancies. Endometrial biopsy is one such intervention which is of immense value in categorizing the conditions. Aims and objectives of current study were to analyse endometrial histology patterns in women with AUB.Methods: This was a retrospective study conducted on women with AUB who presented in the gynae OPD during the study period of one year and had endometrial biopsy as part of evaluation. Women between with AUB were included in the study after excluding pregnancy related bleeding. Detailed clinical history, examination findings, investigations and endometrial histopathology was noted.Results: A total of 97 women with AUB who had undergone dilatation and curettage with endometrial biopsy were studied. Majority of women were in age group of 40-45 years and heavy menstrual bleeding was the commonest complaint, AUB (P) 17% and AUB (L) 39%, accounted for most of the clinical presentations. Endometrial histology showed varied patterns 27 % had secretory endometrium, 11% proliferative endometrium. There were 7 cases of endometrial hyperplasia without atypia and three cases of endometrial malignancy. Conclusions: Histopathological evaluation of endometrium is the cornerstone of management of abnormal uterine bleeding. Endometrial patterns obtained can be useful in ruling out malignancy and help in formulating further management