A medicare benefit expansion: inpatient clinical and economic outcomes in deep brain stimulation for Parkinson's Disease

Dissertation advisor: Rafia RasuVitaIncludes bibliographical references (p. 128- 134)Thesis (Ph.D.)--Dept. of Public Affairs and Administration and Dept. of Economics. University of Missouri-Kansas City, 2011Title from PDF of title page, viewed on July 11, 2011Background: The Centers for Medicare and Medicaid Services, (CMS) implements National Coverage Decisions (NCD) to expand access or eliminate regional reimbursement differences. Policymakers may estimate clinical and economic consequences through short term pilots or demonstration projects. Objective: Examined whether short term outcomes mirror longer term outcomes for a CMS NCD for Deep Brain Stimulation (DBS) in Parkinson's Disease (PD). Methods: This observational study examined the inpatient clinical and economic outcomes associated with a CMS NCD for DBS in PD using Health Care Utilization Project (HCUP) retrospective data from 1999 through 2007. The Healthcare Utilization Project (HCUP) data, is supported by CMS. HCUP is the largest collection of all-payer, uniform, state-based inpatient surgery administrative data and covers the years of interest. Short-term cross-sectional analysis examined 12 months pre NCD (January 1, 1999 to March 31, 2003); and 12 months post NCD (April 1, 2003 to March 30, 2004). Long-term, cross-sectional analysis examined the three years, three months prior to the the short term pre period (January 1, 1999 to March 31, 2002); and the three years, nine months after the short term post period (April 1 2004 to December 31, 2007). Results: A patient who had DBS surgery in the 12 months post NCD is more likely to be discharged to long or short term care rather than home (OR 3.671, p=0.0249); is associated with longer lengths of stay (0.2888, p=0.0001); and is positively associated with the log of total charges (0.19985, p=0.0240). A patient who has DBS surgery more than 12 months post NCD compared surgery more than 12 months pre NCD, was less likely to have complications (OR 0.376, 0.0004) , was associated with a shorter length of stay (-0.2857, p=0.0093), and is positively associated with the log of total charges (0.33875, p<0.001). Conclusions: These results suggest that after the benefit expansion, outcomes worsened in the short term, and improved in the long term. Policymakers may benefit from a longer term view when forecasting before--or interpreting outcomes after--a benefit design change. Differences in populations served may cause temporary or long term shifts in health outcomes and resource utilization.Introduction and problem statement -- Literature review -- Methods and hypotheses -- Results -- Hierarchical specification -- Discussion and implication -- Conclusions -- Appendix A. Data dictionary -- Appendix B. Complications - long run without physician variable -- Appendix C. Complications - long run with physician influence -- Appendix D. Non death disposition - long run full sample -- Appendix E. Non death disposition - long run with physician influence -- Appendix F. Length of stay - long run without physician influence -- Appendix G. Length of stay - long run with physican influence -- Appendix H. Log total charges - long run full sample -- Appendix L. Log total charges - long run subsample -- Appendix J. Complications -- short run full sample hierarchical logistic multivariate model -- Appendix K. Complications - short run subsample hierarchical logistic multivariate model -- Appendix L. Non death disposition - short run full sample hierarchical logistic multivariate model -- Appendix M. Non death disposition - short run subsample hierarchical logistic multivariate model -- Appendix N. Length of stay - short run full sample hierarchical negative binomial multivariate model -- Appendix O. Length of stay - short run subsample hierarchical negative binomial multivariate -- Appendix P. Log total charges - short run full sample hierarchical ordinary least squares multivariate model -- Appendix Q. Log total charges - short run subsample hierarchical ordinary least squares multivariate mode

Psychometric validation of the revised SCOPA-Diary Card: expanding the measurement of non-motor symptoms in parkinson's disease

<p>Abstract</p> <p>Background</p> <p>To identify key non-motor symptoms of Parkinson's disease (PD) to include in a daily diary assessment for off-time, revise the Scales for Outcomes of Parkinson's disease Diary Card (SCOPA-DC) to include these non-motor symptoms, and investigate the validity, reliability and predictive utility of the Revised SCOPA-DC in a U.S. population.</p> <p>Methods</p> <p>A convenience sample was used to recruit four focus groups of PD patients. Based on findings from focus groups, the SCOPA-DC was revised and administered to a sample of 101 PD patients. Confirmatory factor analysis was conducted to test the domain structure of the Revised SCOPA-DC. The reliability, convergent and discriminant validity, and ability to predict off-time of the Revised SCOPA-DC were then assessed.</p> <p>Results</p> <p>Based on input from PD patients, the Revised SCOPA-DC included several format changes and the addition of non-motor symptoms. The Revised SCOPA-DC was best represented by a three-factor structure: Mobility, Physical Functioning and Psychological Functioning. Correlations between the Revised SCOPA-DC and other Health-Related Quality of Life scores were supportive of convergent validity. Known-groups validity analyses indicated that scores on the Revised SCOPA-DC were lower among patients who reported experiencing off-time when compared to those without off-time. The three subscales had satisfactory predictive utility, correctly predicting off-time slightly over two-thirds of the time.</p> <p>Conclusions</p> <p>These findings provide evidence of content validity of the Revised SCOPA-DC and suggest that a three-factor structure is an appropriate model that provides reliable and valid scores to assess symptom severity among PD patients with symptom fluctuations in the U.S.</p

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice