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Wilner A.N.,Lawrence and Memorial Hospital | Sharma B.K.,Accordant Health Services | Thompson A.,Accordant Health Services | Soucy A.,Accordant Health Services | Krueger A.,Accordant Health Services
Epilepsy and Behavior

Our objective was to identify the top MD-office, inpatient and outpatient diagnoses, procedures, drug classes, comorbidities, and cost of health care for people with epilepsy. We examined health insurance claims for 8388 persons with epilepsy (females. =. 52%, males. =. 48%; average age. =. 35. years; privately insured. =. 78%, and Medicaid-insured. =. 22%) from eight health insurance plans for the year 2012. All of the top three diagnoses for MD-office place of service were either for other convulsions (780.39) or for epilepsy (345.90 and 345.40). Two of the top three primary diagnosis codes from the inpatient hospital and emergency department places of service were 780.39 and 345.90 for convulsions and epilepsy, respectively, while the third code was 786.50 for chest pain. The top three procedures from the MD-office setting were for immunizations (90471 and 90658) and blood counts (85025). The top three procedure codes from the outpatient hospital setting were 85025 for complete blood count, 80053 for comprehensive metabolic panel, and 80048 for basic metabolic panel. In the emergency department, the top three procedures were electrocardiogram (93010), computed tomography (70450), and chest X-ray (71020). The top five drug classes among prescription drugs billed using an NDC code were (1) anticonvulsants, (2) analgesic-opioids, (3) antidepressants, (4) penicillins, and (5) dermatologicals. The mean monthly health plan paid cost for each patient with epilepsy in 2012 was $1028 (SD. =. $3181). Of this total, $761 (SD. =. $2988; 74%) was for medical, and $267 (SD. =. $760; 26%) was for prescription pharmacy claims. Fifty-eight percent (58%) of the patients had one or more of 29 prespecified comorbidities, while 42% had none. Monthly health-care costs increased markedly as the number of comorbidities increased. This information should help guide cost estimates and resource allocation in order to optimally care for people with epilepsy. © 2014 Elsevier Inc. Source

Harris A.D.,University of Maryland Baltimore County | Pineles L.,University of Maryland Baltimore County | Belton B.,Yale New Haven Health System Center for Healthcare Solutions | Johnson J.K.,University of Maryland Baltimore County | And 27 more authors.
JAMA - Journal of the American Medical Association

IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcomewas acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. RESULTS: From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95%CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95%CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95%CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95%CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, -1.71 acquisitions per 1000 person-days, 95%CI, -6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95%CI, -4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, -2.98 acquisitions per 1000 persondays; 95%CI, -5.58 to -0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, -0.96; 95%CI, -1.71 to -0.21, P = .02), increased room-exit hand hygiene compliance (78.3%vs 62.9%, difference, 15.4%; 95%CI, 8.99%to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, -15.7; 95%CI, -40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821. Source

Manthous C.A.,Lawrence and Memorial Hospital | Sofair A.N.,Yale University
Yale Journal of Biology and Medicine

Background: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA†) has added a large number of new recipients to this program.Hypothesis: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing “sub-specialty gap” and more patients are now covered by Medi-caid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes.Methods: A brief description of previous studies demonstrating or suggesting a subspe-cialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature — most notably the Denver, Colorado health care system — to propose various solutions that may be deployed to address gaps in subspecialty coverage.Results: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data.Conclusions: There is reason to believe that a substantial proportion of U.S. citizens — those who are guaranteed a full complement of health services through Medicaid — have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions. © 2014, Yale Journal of Biology and Medicine Inc. All rights reserved. Source

Manthous C.A.,Lawrence and Memorial Hospital
Yale Journal of Biology and Medicine

Background: in 2001, graduate medical education in the united states was renovated to better complement 21st century developments in American medicine, society, and culture. As in 1910, when Abraham Flexner was charged to address a relatively non-standardized system that lacked accountability and threatened credibility of the profession, Dr. David Leach led the Accreditation Council of Graduate Medical Education (ACGME†) Outcome Project in a process that has substantially changed medical pedagogy in the united states. Methods: Brief review of the Flexner report of 1910 and 6 hours of interviews with leaders of the Outcome Project (4 hours with Dr. David Leach and 1-hour interviews with Drs. Paul Batalden and susan swing). Results: Medical educational leaders and the ACGME concluded in the late 1990s that medical education was not preparing clinicians sufficiently for lifelong learning in the 21st century. A confluence of medical, social, and historic factors required definitions and a common vocabulary for teaching and evaluating medical competency. After a deliberate consensus- driven process, the ACGME and its leaders produced a system requiring greater accountability of learners and teachers, in six explicitly defined domains of medical 'competence.' While imperfect, this construct has started to take hold, creating a common vocabulary for longitudinal learning, from undergraduate to post-graduate (residency) education and in the assessment of performance following graduate training. © 2014. Source

Wilner A.N.,Lawrence and Memorial Hospital | Sharma B.K.,Accordant Health Services | Soucy A.,Accordant Health Services | Thompson A.,Accordant Health Services | Krueger A.,Accordant Health Services
Epilepsy and Behavior

The objectives of this observational study were to determine the prevalence of the most common comorbidities in women and men with epilepsy and to demonstrate the relationship of these comorbidities to health plan paid costs. Data for 6621 members with epilepsy (52% women, 48% men) from eight commercial health plans were analyzed. The presence of comorbidities in people with epilepsy was identified by searching health insurance claims for 29 prespecified comorbidity-specific diagnosis codes. More women (50%) than men (43%) with epilepsy had one or more of the 29 comorbidities (p. <. 0.05). The top 10 comorbidities for women and their relative prevalences were psychiatric diagnosis (16%), hypertension (12%), asthma (11%), hyperlipidemia (11%), headache (7%), diabetes (6%), urinary tract infection (5%), hypothyroidism (5%), anemia (5%), and migraine (4%). For men, the top 10 comorbidities and their relative prevalences were psychiatric diagnosis (15%), hyperlipidemia (12%), hypertension (12%), asthma (8%), diabetes (5%), headache (4%), cancer (4%), coronary artery disease (3%), anemia (3%), and gastroesophageal reflux disease (3%). Seven of the top 10 comorbidities were common to both women and men. Psychiatric diagnosis was the only comorbidity among the top five comorbidities for all age groups. The presence of one comorbidity approximately tripled the health-care cost for that member compared with the cost for members who had no comorbidities. Additional comorbidities generally further increased costs. The increase in health-care cost per member per month ($) with increase in number of comorbidities was greater for men than for women (p. <. 0.05). © 2014 Elsevier Inc. Source

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