Infants Exposed To Homelessness: Health, Health Care Use, And Health Spending From Birth To Age Six

Homeless infants are known to have poor birth outcomes, but the longitudinal impact of homelessness on health, health care use, and health spending during the early years of life has received little attention. Linking Massachusetts emergency shelter enrollment records for the period 2008-15 with Medicaid claims, we compared 5,762 infants who experienced a homeless episode with a group of 5,553 infants matched on sex, race/ethnicity, location, and birth month. Infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions; longer neonatal intensive care unit stays; more emergency department visits; and higher annual spending. Differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age six. While screening and access to health care can be improved for homeless infants, long-term solutions require a broader focus on housing and income

The Effect of Oral Antibiotics on the Development of Community Acquired Clostridium Difficile Colitis in Medicare Beneficiaries

Clostridium difficile infection (CDI) is increasingly prevalent among community dwelling Americans. Older Americans are particularly vulnerable to community-acquired Clostridium difficile (CACD), in part to increasing use of antibiotics. We studied the association between outpatient antibiotics and CACD among Medicare beneficiaries. Case-control study utilizing a 5% sample of Medicare beneficiaries (2009-2011). Patients with CACD severe enough to warrant hospitalization were identified by a primary diagnosis code for CDI and no exposure to a healthcare environment within 90-days of admission. 1,514 CACD cases were matched to ten controls each on birth year and sex. Potential controls with exposure to healthcare environment were excluded. Outpatient oral antibiotic exposure was classified into three groups: ≤30 days, 31-60 days, or 61-90 days prior to case subject’s index admission. Metronidazole and Vancomycin were excluded because they are used to treat CDI. Multivariable models were utilized to determine the independent effect of antibiotics on the development of CACD while controlling for several patient associated characteristics. Cases of CACD had more outpatient antibiotic exposure in each time period examined: ≤30 days = 40.0% vs 8.4%; 31-60 = 10.7% vs 5.0%; and 61-90 = 5.5% vs 4.4% (all p-values \u3c 0.05). Subjects exposed to antibiotics ≤30 days prior to admission had a markedly higher risk of being admitted with CACD compared with those not exposed (OR 8.09, 95% CI 7.13, 9.19). Similarly, subjects taking antibiotics 31-60 days and 61-90 days prior to admission had increased risk of CDI admission (OR 3.65, 95% CI 3.02, 4.41) and (OR 2.06, 95% CI 1.61, 2.63) respectively. Recent exposure to outpatient oral antibiotics increases the risk of CACD among community dwelling elderly with the risk persisting as long as 90 days after exposure. Inappropriate antibiotic usage must be minimized and older Americans who require outpatient antibiotic treatment may warrant close observation for signs of CDI

The contributions of focused attention and open monitoring in mindfulness-based cognitive therapy for affective disturbances: A 3-armed randomized dismantling trial

OBJECTIVE: Mindfulness-based cognitive therapy (MBCT) includes a combination of focused attention (FA) and open monitoring (OM) meditation practices. The aim of this study was to assess both short- and long-term between- and within-group differences in affective disturbance among FA, OM and their combination (MBCT) in the context of a randomized controlled trial. METHOD: One hundred and four participants with mild to severe depression and anxiety were randomized into one of three 8-week interventions: MBCT (n = 32), FA (n = 36) and OM (n = 36). Outcome measures included the Inventory of Depressive Symptomatology (IDS), and the Depression Anxiety Stress Scales (DASS). Mixed effects regression models were used to assess differential treatment effects during treatment, post-treatment (8 weeks) and long-term (20 weeks). The Reliable Change Index (RCI) was used to translate statistical findings into clinically meaningful improvements or deteriorations. RESULTS: All treatments demonstrated medium to large improvements (ds = 0.42-1.65) for almost all outcomes. While all treatments were largely comparable in their effects at post-treatment (week 8), the treatments showed meaningful differences in rapidity of response and pattern of deteriorations. FA showed the fastest rate of improvement and the fewest deteriorations on stress, anxiety and depression during treatment, but a loss of treatment-related gains and lasting deteriorations in depression at week 20. OM showed the slowest rate of improvement and lost treatment-related gains for anxiety, resulting in higher anxiety in OM at week 20 than MBCT (d = 0.40) and FA (d = 0.36), though these differences did not reach statistical significance after correcting for multiple comparisons (p\u27s = .06). MBCT and OM showed deteriorations in stress, anxiety and depression at multiple timepoints during treatment, with lasting deteriorations in stress and depression. MBCT showed the most favorable pattern for long-term treatment of depression. CONCLUSIONS: FA, OM and MBCT show different patterns of response for different dimensions of affective disturbance. TRIAL REGISTRATION: This trial is registered at (v NCT01831362); www.clinicaltrials.gov

Impact of Pre-Injury Warfarin Use Among Medicare Beneficiaries With Head Trauma

Introduction: The effect of warfarin on outcomes of head injured patients remains controversial. Yet more than 2 million Americans, many of them elderly, are started on warfarin annually. Meanwhile, with the aging US population, elderly Americans are becoming an increasingly large proportion of head injured patients. We studied a national cohort of Medicare beneficiaries with head injuries to determine the effects of pre-injury warfarin on outcomes. Methods: A retrospective review of a 5% random sample of Medicare claims data (2009-2010) was performed for enrollees with at least 1 year of Medicare eligibility. Head injury cases were identified using ICD-9 codes for intracranial hemorrhage with or without accompanying skull fractures. Using Part D prescription drug claims, warfarin exposure was defined as \u3e2 warfarin prescriptions filled within 60 days prior to injury. Characteristics and outcomes (mortality, length of stay (LOS), ICU LOS) between warfarin users and patients not on warfarin (non-users) were compared using univariate tests of association. Multivariable models adjusting for patient characteristics, concomitant torso injuries/long-bone fractures, and need for ICU care were conducted to measure the independent effect of warfarin on in-hospital mortality. Results: We identified 3,420 head injured patients,6.6% of whom were treated with warfarin. Warfarin users were more likely to be female (74.2%vs.65.6%, p Conclusion: Anticoagulation with warfarin increases risk of mortality after head injury nearly two fold in Medicare beneficiaries even after adjusting for other risk factors. As new, more difficult to reverse, agents are introduced for chronic anticoagulation this problem may be exacerbated. Physicians should exercise caution when initiating chronic anticoagulation in patients over the age of 65

Quadrimodal Distribution of Death after Trauma: Predictors of Death in the Fourth Peak

Introduction: Patterns of death after trauma are changing due to diagnostic and treatment advances. We examined mortality in critically injured patients at risk of death after discharge. Methods: We reviewed all critically injured (Injury Severity Score≥25 AND death in Emergency Room , death within 24hrs, OR ICU admission\u3e24hrs) adults (age≥18) admitted to a Level 1 trauma center (01/01/2000-12/31/2010) and determined death post-discharge (Social Security Death Index) of patients discharged alive. We compared demographics, injury data, and critical care resource utilization between those who died during follow-up and survivors using univariate tests and Cox proportional hazards models. Results: Of 1,695 critically injured patients, 1135 (67%) were discharged alive. As of 05/1/2012, 977 (58%) index survivors were alive (median follow-up 62mos (IQR35,96)). Of 158 deaths post-discharge, 75 (47%) occurred within the first year. Patients who died post-discharge had longer hospital (24dys (IQR13,38) vs. 17dys (IQR10,27)) and ICU LOS (17dys (IQR6,29) vs. 8dys (IQR4,19)) and were more likely to undergo tracheostomies (36.1% vs. 15.6%, p16dys increased risk of death at one year (HR1.94 (1.22,3.06)) and by the end of follow-up (HR2.19 (1.58,3.04)) compared to shorter ICU stays. Conclusion: We propose the first year after discharge as the fourth peak of trauma related mortality. Duration of ICU LOS during index hospitalization is associated with post-discharge mortality

Rates of Insurance for Injured Patients before and after Health Care Reform in Massachusetts: Another Case of Double Jeopardy?

Background: As a result of healthcare reform (HCR), insurance rates among Massachusetts (MA) residents increased from 86.6% (2006) to 94.4% (2010) and conferred a 7.6% higher probability of being insured compared to neighboring states. The effect of an individual mandate on insurance rates among trauma patients is unknown. Methods: This was retrospective analysis of adult (18-64yrs) trauma patients from MA and surrounding states (NH, RI, CT, NY, VT) treated at our level 1 trauma center in central MA before (2004-2005) and after (2009-2010) MA-HCR. We estimated changes in insurance rates across time-periods and state-residence. Results: Before MA-HCR, 76.7% (1647/2,148) of injured MA residents had insurance compared to 84.3% (2088/2477) post-HCR (p Conclusions: In this single center study, time rather than HCR resulted in modest increases in insurance rates. However, MA-HCR was ineffectual at increasing insurance among trauma patients to levels comparable to the general public, suggesting certain factors may place certain subgroups in “double jeopardy” by simultaneously increasing risk of injury and precluding compliance with an individual mandate

Clinical and Financial Impact of Readmissions Following Colorectal Resection: An Analysis of Predictors, Outcomes, and Cost

Background: Following passage of the Affordable Care Act, 30day readmissions have come under greater scrutiny, with penalties levied for higher than expected readmission rates. We examined risk factors for 30day readmission following colorectal resection and evaluated the financial impact of readmissions on the healthcare system. Methods: The University HealthSystem Consortium Clinical Database was queried for adults undergoing colorectal surgery for cancer, diverticular disease, inflammatory bowel disease, or benign tumors from 2008-2012. Predictors of 30day readmission were assessed with multivariable logistic regression. Additional endpoints included time to readmission, readmission diagnosis, readmission length of stay (LOS), and readmission cost. Results: A total of 70,484 patients met study inclusion criteria, 13.7% (9,632) of which were readmitted within 30 days of discharge. The strongest independent predictors of readmission were: LOS ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and non-home discharge (OR 1.68; 95% CI 1.57-1.81). Of those readmitted, half occurred within 7 days, 13% required ICU care, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was over two times higher ($26,917 v.$13,817; p\u3c0.001) than non-readmitted patients. Compared with late readmissions, those readmitted within 7 days were more likely to have a reoperation (8% v. 4%, p\u3c0.001), be admitted to the ICU (14% vs. 12%, p\u3c0.001), and had a longer median readmission LOS (5d vs. 4d, p\u3c0.001). CONCLUSIONS: 30-day readmissions following colorectal resection occur frequently and incur a significant financial burden on the healthcare system. Highest-risk patients include those with longer LOS, stoma, and non-home discharge. Future studies aimed at targeted interventions may reduce readmissions and curb escalating healthcare costs

A New Look at the Volume and Outcome Relationship in Surgery for Colorectal Cancer

Purpose: Surgeon and hospital factors have a significant impact on treatment outcomes for colorectal cancer (CRC). Limited research has been done to assess cost and quality of treatment by surgeon-volume. We aim to identify the surgeon factors impacting cost and quality of surgical care for CRC. Methods: The University HealthSystem Consortium database was queried for patients who underwent colon resection for cancer from 2008 to 2012. Patients were grouped by surgeon-volume. Outcomes of interest were postoperative complications, ICU admission, readmission rate, inpatient hospital length of stay (LOS) and direct hospital cost. Average surgeon-volume per year was categorized as high (\u3e6) or low (16) based on the distribution of surgeon-volume. Results: 29,972 patients over age 18 were identified for inclusion. 25,426 underwent resection by high-volume surgeons (HVS) and 4,547 by low-volume surgeons (LVS). LVS were more likely to admit patients to the ICU than HVS (21% v 33%, p Conclusions: Surgeons who perform greater than 6 colectomies per year for colon cancer are more likely to use laparoscopy, less likely to admit patients to the ICU, have lower complication and readmission rates, and shorter LOS. Hospital cost is significantly lower in patients operated on by high volume surgeons. As health care costs continue to escalate and health care reform efforts gain momentum, factors leading to high-quality, cost-effective care need to be identified

International genome-wide meta-analysis identifies new primary biliary cirrhosis risk loci and targetable pathogenic pathways.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist