Medicare Payment and Hospital Provision of Outpatient Care to the Uninsured

Objective. To describe the amount of hospital outpatient care provided to the uninsured and its association with Medicare payment rate cuts following the implementation of Medicare\u27s Outpatient Prospective Payment System. Data Sources/Study Setting. We use hospital outpatient discharge records from Florida from 1997 through 2008. Study Design. We estimate multivariate regression models of hospital outpatient care provided to the uninsured in separate samples of nonprofit and for-profit hospitals. Principal Findings. Hospital outpatient departments provide significant amounts of care to the uninsured. As Medicare payment rates fall, total charges and the share of charges for outpatient visits by the uninsured decrease at nonprofit hospitals. At for-profit hospitals, the share of outpatient care provided to uninsured patients increases, but there is no significant change in the number of uninsured discharges. Conclusions. Nonprofit and for-profit hospitals respond differently to reductions in Medicare payments; thus, studies of the impact of legislated Medicare payment cuts on care of the uninsured should account for differences in hospital ownership in communities. Given that outpatient care to the uninsured includes preventive and diagnostic care procedures, reductions in this care following payment cuts may adversely affect long-run health and health care costs in communities dominated by nonprofit hospitals

Association of Environmental Cadmium Exposure with Periodontal Disease in U.S. Adults

Background: Periodontal disease is a complex, multifactorial, chronic inflammatory disease that involves degradation of periodontal structures, including alveolar bone. Cadmium adversely affects bone remodeling, and it is therefore possible that environmental Cd exposure may be a risk factor for periodontal-disease–related bone loss. Objective: We examined the relationship between environmental Cd exposure and periodontal disease in U.S. adults. Methods: We analyzed cross-sectional data from the third National Health and Nutrition Examination Survey (NHANES III). We defined periodontal disease as clinical attachment loss of at least 4 mm in > 10% of sites examined. We used multivariable-adjusted logistic regression analyses to estimate the association between creatinine-corrected urinary Cd levels and periodontal disease. Results: Of the 11,412 participants included in this study, 15.4% had periodontal disease. The age-adjusted geometric mean urine Cd concentration (micrograms per gram creatinine) was significantly higher among participants with periodontal disease [0.50; 95% confidence interval (CI), 0.45–0.56] than among those without periodontal disease (0.30; 95% CI, 0.28–0.31). Multivariable-adjusted analyses, which included extensive adjustments for tobacco exposure, showed that a 3-fold increase in creatinine-corrected urinary Cd concentrations [corresponding to an increment from the 25th (0.18 μg/g) to the 75th (0.63 μg/g) percentile] was associated with 54% greater odds of prevalent periodontal disease (odds ratio = 1.54; 95% CI, 1.26–1.87). We observed similar results among the subset of participants who had limited exposure to tobacco, but only after removing six influential observations. Conclusion: Environmental Cd exposure was associated with higher odds of periodontal disease

Serum selenium concentrations and diabetes in U.S. adults : National Health and Nutrition Examination Survey (NHANES) 2003–2004

Background: Increasing evidence suggests that high selenium levels are associated with diabetes and other cardiometabolic risk factors. Objectives: We evaluated the association of serum selenium concentrations with fasting plasma glucose, glycosylated hemoglobin levels, and diabetes in the most recently available representative sample of the U.S. population. Methods: We used a cross-sectional analysis of 917 adults ≥ 40 years of age who had a fasting morning blood sample in the National Health and Nutrition Examination Survey 2003–2004. We evaluated the association of serum selenium, measured by inductively coupled plasma-dynamic reaction cell-mass spectrometry, and diabetes, defined as a self-report of current use of hypoglycemic agents or insulin or as fasting plasma glucose ≥ 126 mg/dL. Results: Mean serum selenium was 137.1 μg/L. The multivariable adjusted odds ratio [95% confidence interval (CI)] for diabetes comparing the highest quartile of serum selenium (≥ 147 μg/L) with the lowest (< 124 μg/L) was 7.64 (3.34–17.46). The corresponding average differences (95% CI) in fasting plasma glucose and glycosylated hemoglobin were 9.5 mg/dL (3.4–15.6 mg/dL) and 0.30% (0.14–0.46%), respectively. In spline regression models, the prevalence of diabetes as well as glucose and glycosylated hemoglobin levels increased with increasing selenium concentrations up to 160 μg/L. Conclusions: In U.S. adults, high serum selenium concentrations were associated with higher prevalence of diabetes and higher fasting plasma glucose and glycosylated hemoglobin levels. Given high selenium intake in the U.S. population, further research is needed to determine the role of excess selenium levels in the development or the progression of diabetes

Cause-Specific Mortality in the Unionized U.S. Trucking Industry

Background: Occupational and population-based studies have related exposure to fine particulate air pollution, and specifically particulate matter from vehicle exhausts, to cardiovascular diseases and lung cancer. Objectives: We have established a large retrospective cohort to assess mortality in the unionized U.S. trucking industry. To provide insight into mortality patterns associated with job-specific exposures, we examined rates of cause-specific mortality compared with the general U.S. population. Methods: We used records from four national trucking companies to identify 54,319 male employees employed in 1985. Cause-specific mortality was assessed through 2000 using the National Death Index. Expected numbers of all and cause-specific deaths were calculated stratifying by race, 10-year age group, and calendar period using U.S. national reference rates. Standardized mortality ratios (SMRs) and 95% confidence intervals (CIs) were calculated for the entire cohort and by job title. Results: As expected in a working population, we found a deficit in overall and all-cancer mortality, likely due to the healthy worker effect. In contrast, compared with the general U.S. population, we observed elevated rates for lung cancer, ischemic heart disease, and transport-related accidents. Lung cancer rates were elevated among all drivers (SMR = 1.10; 95% CI, 1.02–1.19) and dockworkers (SMR = 1.10; 95% CI, 0.94–1.30); ischemic heart disease was also elevated among these groups of workers [drivers, SMR = 1.49 (95% CI, 1.40–1.59); dockworkers, SMR = 1.32 (95% CI, 1.15–1.52)], as well as among shop workers (SMR = 1.34; 95% CI, 1.05–1.72). Conclusions: In this detailed assessment of specific job categories in the U.S. trucking industry, we found an excess of mortality due to lung cancer and ischemic heart disease, particularly among drivers

Bypassing proximal health care facilities for acute care: a survey of patients in a Ghanaian Accident and Emergency Centre

Objective  To characterise the population that presents to the Accident and Emergency Centre (AEC) at Komfo Anokye Teaching Hospital (KATH) and to identify risk factors associated with bypassing proximal care facilities. Methods  A structured questionnaire was verbally administered to patients presenting to the AEC over 2 weeks. The questionnaire focused on the use of health care resources and characteristics of current illness or injury. Measures recorded include demographics, socioeconomic status, chief complaint, transportation and mobility, reasons for choosing KATH and health care service utilisation and cost. Results  The total rate of bypassing proximal care was 33.9%. On multivariate analysis, factors positively associated with bypassing included age older than 38 years (OR: 2.18, P 0.04) and prior visits to facility (OR 2.88, P 0.01). Bypassers were less likely to be insured (OR 0.31, P 0.01), to be seeking care due to injury (OR 0.42, P 0.03) and to have previously sought care for the problem (OR 0.10, P  <   0.001). Conclusions  Patients who bypass facilities near them to seek care at an urban AEC in Ghana do so for a combination of reasons including familiarity with the facility, chief complaint and insurance status. Understanding bypassing behaviour is important for guiding health care utilisation policy decisions and streamlining cost‐effective, appropriate access to care for all patients. Objectif:  Caractériser la population se présentant au Centre des Accidents et des Urgences à l’Hôpital Universitaire Komfo Anokye, et identifier les facteurs de risque associés au contournement des services de soins proximaux. Méthodes:  Un questionnaire structuré a été administréà des patients se présentant au Centre des Accidents et des Urgences durant deux semaines. Le questionnaire portait sur l’utilisation des ressources de soins de santé et les caractéristiques de la maladie ou la blessure en cours. Les mesures enregistrées comprenaient la démographie, le statut socioéconomique, la plainte principale, le transport et la mobilité, les raisons de choisir l’Hôpital Universitaire Komfo Anokye, l’utilisation et les coûts des services de soins de santé. Résultats:  La proportion totale des contournements des soins proximaux était de 33,9%. En analyse multivariée, les facteurs positivement associés au contournement comprenaient l’âge de plus de 38 ans (OR: 2,18; P = 0,04) et des visites préalables au service (OR: 2,88; P = 0,01). Les patients contournant étaient: moins susceptibles d’être assurés (OR: 0,31, P = 0,01), à la recherche de soins pour des blessures (OR: 0,42; P = 0,03) et d’avoir recherché des soins précédemment pour le même problème (OR: 0,10; P < 0,001). Conclusions:  Les patients qui contournent les services près d’eux pour rechercher des soins dans un centre urbain des accidents et des urgences au Ghana, le font pour une combinaison de raisons, y compris la familiarisation avec le service, la plainte principale et le statut d’assurance. Comprendre le comportement de contournement est important pour guider les décisions de la politique d’utilisation des soins de santé et la rationalisation du coût‐efficacité, pour l’accès approprié aux soins pour tous les patients. Objetivo:  Caracterizar la población que se presenta en el Centro para Accidentes y Emergencias del Hospital Universitario de Komfo Anokye, e identificar los factores de riesgo asociados con el pasar por alto los cuidados ofrecidos en centros cercanos. Métodos:  Se administró verbalmente, a lo largo de dos semanas, un cuestionario estructurado a los pacientes que se presentaron en el Centro para Accidentes y Emergencias. El cuestionario estaba enfocado al uso de recursos sanitarios y a las características de la enfermedad o lesión actual. Las medidas registradas incluían datos demográficos, estatus socioeconómico, principal motivo de consulta, transporte y movilidad, las razones para escoger el Hospital Universitario Komfo Anokye, y el uso de los servicios sanitarios y su coste. Resultado:  La tasa total de haber evitado los centros cercanos fue del 33.9%. En un análisis multivariado, los factores asociados de forma positiva con el haber pasado de utilizar un centro cercano incluían tener una edad mayor de 38 años (OR: 2.18, P 0.04) y haber realizado visitas anteriores al centro sanitario (OR 2.88, P 0.01). Los pacientes que evitaban un centro cercano tenían una mayor probabilidad de no estar asegurados (OR 0.31, P 0.01), de buscar ayuda por una lesión (OR 0.42, P 0.03), y de previamente haber buscado ayuda sanitaria para el problema (OR 0.10, P  <   0.001). Conclusiones:  Los pacientes que pasaban de utilizar centros cercanos y buscan ayuda en un centro urbano para accidentes y emergencias en Ghana lo hacen por una combinación de razones que incluyen el estar familiarizados con el centro, la causa por la que consultan, y el estar o no asegurados. Entender el comportamiento de pasar de un centro cercano es importante para tener en cuenta a la hora de realizar políticas sanitarias y ofrecer acceso a cuidados apropiados y coste‐efectivos para todos los pacientes.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/92092/1/j.1365-3156.2012.02984.x.pd

Medications as a Potential Source of Exposure to Phthalates in the U.S. Population

Background: Widespread human exposure to phthalates, some of which are developmental and reproductive toxicants in experimental animals, raises concerns about potential human health risks. Underappreciated sources of exposure include phthalates in the polymers coating some oral medications. Objective: The objective of this study was to evaluate whether users of phthalate-containing medications have higher urinary concentrations of phthalate metabolites than do nonusers. Methods: We used publically available files from the National Health and Nutrition Examination Survey for the years 1999–2004. For certain survey periods, participants were asked to recall use of prescription medication during the past 30 days, and for a subsample of individuals, the urinary concentrations of phthalate metabolites were measured. We a priori identified medications potentially containing phthalates as inactive ingredients and then compared the mean urinary concentration of phthalate metabolites between users and nonusers of those medications. Results: Of the 7,999 persons with information on urinary phthalate concentrations, 6 reported using mesalamine formulations, some of which may include dibutyl phthalate (DBP); the mean urinary concentration of monobutyl phthalate, the main DBP metabolite, among these mesalamine users was 50 times higher than the mean for nonusers (2,257 μg/L vs. 46 μg/L; p < 0.0001). Users of didanosine, omeprazole, and theophylline products, some of which may contain diethyl phthalate (DEP), had mean urinary concentrations of monoethyl phthalate, the main DEP metabolite, significantly higher than the mean for nonusers. Conclusion: Select medications might be a source of high exposure to some phthalates, one of which, DBP, shows adverse developmental and reproductive effects in laboratory animals. These results raise concern about potential human health risks, specifically among vulnerable segments of the general population and particularly pregnant women and children