HIV-related anemia is associated with increased risk of death. Prior studies suggest an inverse relationship between CD4 cell count and anemia, and a positive relationship between HIV-clinical stage and anemia. However, none have assessed the role of antiretroviral therapy (ART) treatment combinations in these relationships. Therefore, we conducted a cross-sectional study to evaluate the relationship between CD4 cell count, HIV clinical stage and anemia among 4803 Ugandan HIV-patients, and assessed the role of ART treatment combinations. We included HIV patients (> 15 years) receiving ART therapy combinations between 2010- 2015. We evaluated CD4 cell count and anemia using blood tests, and HIV-clinical staging was based upon the World Health Organization HIV-clinical staging system. Information on ART treatment combinations was obtained from patients’ medical records. Multinomial logistic regression was used to model the relationship between CD4 cell count, HIV clinical stages and anemia. We performed a sensitivity analysis to examine the role of ART treatment combinations. The odds of being severely anemic were highest among those classified in the low CD4 cell count category (<200cells/μL), and those at WHO stage IV. Odds Ratios were 3.7 (95% CI; 1.48-9.26) and 3.2 (95% CI; 1.75-5.70), respectively. Stratification by ART treatment combinations (TDF-based versus ADZ-based combination treatment) indicated an increase in the odds of being anemic with increase in HIV-clinical stage (stage II, OR: 1.99, 95% CI; 1.44-2.78; stage III, OR:3.17, 95% CI; 2.21-4.54, & stage IV, OR; 4.42, 95% CI; 2.68-7.30), for individuals receiving TDF-based treatment only. Results suggest that HIV-patients with a low CD4 cell count and, those in advanced HIV-clinical stages should consider regular hemoglobin follow-up to identify and treat anemia at its earliest stages.

Objectives To provide contemporary, national population-based estimates of complete tooth loss of older adults by English language proficiency. Methods We conducted a cross-sectional analysis of the 2017 Medical Expenditure Panel Survey among participants ≥50 years of age (n=10,452, weighted=111,895,290). Results The prevalence of complete tooth loss was higher among those with limited English proficiency (Spanish speaking: 13.7%; Other languages: 16.9%) than those proficient in English (Spanish speaking: 5.0%; Other languages: 6.0%). After adjusting for education, complete tooth loss was less common among participants for whom Spanish was their primary, with limited English proficiency relative to English only (adjusted odds ratio: 0.56; 95% confidence interval: 0.42-0.76). Among those without complete tooth loss, dental visit in the past year were less common among participants with primary languages other than English as compared to those who only speak English. Discussion Research is needed to examine the relationship of aging, oral health, and access to care.

Numerous studies have shown that consumers react imperfectly to changes in health insurance coverage. To justify consumer valuation in health insurance decision-making, I use Medical Expenditure Panel Survey (MEPS) data and conduct three studies to examine consumer’s private information in health insurance decision-making under a conceptual framework of consumer perception, which potentially is informative about Affordable Care Act (ACA) Health Insurance Marketplace consumer behavior. In the first study, I examine the joint role of individual preferences and health risk in two types of insurance decision-making: the probability of being insured and the probability of employment-based insurance if insured. Using logistic regression, I find that the healthier and wealthier consumers tend to have more positive attitudes towards health insurance and thus are more likely to be insured. The effects of health risk measures vary largely in insurance decisions conditional on different preference measures and preference levels. In the second study, I investigate insurance coverage bundle choices with multi-dimensional private information in an artificially created market setting. I adapt the approach developed by Lokshin and Ravallion (2005) and conduct logistic regression modeling to estimate the reduced forms for coverage bundle choice and consumer attitude respectively. Predicted linear indices for consumer attitude and coverage bundle choices are calculated separately, then their correlation coefficients are compared. In this study I find that consumer attitude plays a dominating role in health insurance decision-making, suggesting that risk preferences may internalize health risks and influence insurance purchasing decisions. To further explore consumer perceptions within an individual’s personal system of decision rules, in the third study, I construct coverage bundle choices in an order from the least complete to the most complete, and examine the effect of consumer perceived plan quality to coverage bundle choice decisions. I use the generalized ordered logit method and a Bayesian learning process for the analysis. I find that coverage bundle choice decisions are value-based, for which perceived plan quality plays a significant and persistent role. The study results also have important policy implications to enhancing consumer engagement and optimizing health insurance management to provide high quality care to health insurance beneficiaries.

Objective: Access to care is key to effective rectal cancer treatment. We hypothesized that ethnic/racial minorities living in high population density areas would have the greatest delays in cancer care compared to whites living in medium population density areas. Methods: Using 2004-2016 National Cancer DataBase data, we identified stage I-III patients with invasive rectal adenocarcinoma who underwent surgery. The data were analyzed by race/ethnicity (whites, blacks, or Hispanics) and population density (metropolitan or urban/rural). Multivariable ANCOVA was performed to evaluate the duration of time from diagnosis to surgery. Results: The study population consisted of 76,131 patients: 65,172 Non-Hispanic whites (NHW; 85.6%), 6,167 Non-Hispanic blacks (NHB; 8.1%), and 4,792 Hispanics (6.3%). Of these, 61,363 patients (80.6%) lived in metropolitan areas. Among direct-to-surgery patients, the greatest difference in mean time from diagnosis to surgery was 20.3 days (urban/rural NHW, 53.3 days, vs. metropolitan Hispanics, 73.6 days). Among patients receiving neoadjuvant therapy, the greatest difference in mean time from diagnosis to surgery was 18.8 days (urban/rural NHW, 136.9 days, vs. metropolitan NHB, 155.7 days). After multivariable adjustment for several socioeconomic and clinical factors, among direct-to-surgery patients, metropolitan Hispanics had a 16.5-day delay (95% CI 12.9-20.0) compared with urban/rural NHW. In patients receiving neoadjuvant therapy, metropolitan NHB had an 18.1-day delay (95% CI 16.1-20.0) compared to urban/rural NHW. Conclusion: The combination of high population density and racial/ethnic minority status was associated with delays in rectal cancer care that persisted after adjusting for other important factors. Understanding which populations are at risk and perceived obstacles to timely care will help inform interventions to minimize treatment access disparities.

Many individuals experience barriers to accessing medical care, especially in rural areas. Some barriers are attitudinal and represent perceptions of quality care. Patient satisfaction and perceived need for medical care are two such attitudinal barriers related to health care utilization, yet the relationship between these variables has not been explored. Using data from an online survey, the current study examined the association between these variables, and further, whether rurality status moderated this association. Results indicated a significant correlation between patient satisfaction and perception of need. Although the overall moderation model was significant, perception of need was not significantly associated with patient satisfaction, and rurality status did not significantly moderate the relationship. However, the covariates of sexual orientation and income did significantly predict patient satisfaction. This study highlights the complex associations of patient satisfaction, as well as the importance of social determinants of health in patients’ perceptions of quality of care.

Background: Many patients discharged from the hospital do not appropriately fill their discharge medications. At Boston Medical Center, an urban safety net facility, a bedside discharge medication delivery service was pilot tested in 2012 to ensure pediatric patients with asthma left in possession of their new medications. The service was expanded to all pediatric discharges in 2013. It is unknown whether beside delivery increases the proportion of written prescriptions captured by the hospital-owned pharmacy or if the service achieves a positive return on investment. Whether such a service improves patients’ satisfaction, medication adherence, or clinical outcomes is also unknown. Methods: Two primary methodologies were used to evaluate the impact of this novel service. The first evaluated the relative risk of filling a prescription in the hospital- owned pharmacy after the expansion of delivery eligibility criteria using two years of discharge prescription information, corresponding pharmacy fill data, and a hierarchical model with generalized estimating equations (GEE) to account for non-independent events. Initial patient-level impacts of the delivery service were evaluated through a pilot randomized controlled trial to test logistics and obtain empiric estimates of study parameters. Results: Patients were 1.44 times more likely to fill a medication at the hospital- owned pharmacy providing the delivery service after the intervention (95%CI 1.3-1.59). The increased profit generated by prescriptions captured as a result of offering the delivery service is estimated to be equivalent to 8-15% of a pharmacist full-time- equivalent (FTE), whereas only 3% of an FTE was required to provide the service, indicating a positive return on investment. Pilot study data suggest families did not differ significantly with regards to perceived satisfaction or reported outcomes whether randomized to usual care or delivery. Conclusion: A service to deliver discharge medications can yield a positive return on investment, allowing an institution to offset uncompensated care. To further study the intervention, a trial with randomization at the level of the ward or institution is needed. / 2017-10-02T00:00:00Z

No description available.

Falls are the number one mechanism of injury for The Trauma Center and Johnson City Medical Center (JCMC TC). JCMC TC is one of two level one trauma centers in the region and one of only six in the state. The main method for trauma prevention is outcome specific education and awareness. Injury prevention education is a critically needed area in the field of trauma and emergency care. Falls are the number one cause of injury in populations age >65. Socioeconomic status, age, gender, and race are all mitigating factors in the likelihood of greater length of stays, death in hospital, and death within one year of discharge for those who fall in a home setting. According to the CDC, people over the age of 75 are four to five times more likely than people under 75 to be admitted to a long-term care facility for more than a year. What is the relationship between patient characteristics and fall related outcomes in a level one trauma center? We looked at associations between patient demographics and associated outcomes for those admitted to the trauma center secondary to a ground level fall (GLF) in the home. Dataset: De-identified National Trauma Databank information was compiled by the JCMC Registrar for the past 8 years for the metrics: Injury Severity Score (ISS), length of stay, 48hr readmission, and disposition (home, nursing home, skilled nursing facility (SNF)).Demographic information, along with mechanism of fall, was collected for each patient. Patient age, gender, and date of injury was all used for statistical analysis and trend recognition. Statistical Analysis: Bivariate analyses included independent samples t-tests and Oneway ANOVA to find differences between groups. Results: T-test results show women are significantly more likely than men to be admit for a ground level fall (p<.001) and those with a higher ISS are more likely to have an extended stay in an inpatient setting (p<.001). One-Way ANOVA analysis of collected data shows an annual increase from 2006-2013 of trauma admissions for ground level falls (p<.01). Eight year analysis showed a two-fold increase in these admissions. Over 30% of patients admitted with a GLF are discharged to a SNF leading to higher societal costs due to Medicare reimbursement rates. Diagnosis related groups codes (DRG) dictate Medicare reimbursement rate of $14,091 per patient with an average facility cost of $14,196 per patient with no readmissions (Unplanned readmission within 180 days occurred at a rate of 8.3%). Conclusion: Fall education programs are necessary and needed in rural level one trauma centers to educate citizens on causes and methods of preventing falls in their homes. A decrease in these falls would lead to an increase in productive years of life and a reduction in strain on the hospital system.

Background: In late 2019, the SARS-CoV-2 virus was identified in Wuhan, China. Within a matter of weeks, the virus spread to the United States and many other countries around the world. By March 5, 2020, the first case of COVID-19 (the disease caused by the SARS-CoV-2 virus) was identified in the state of Tennessee, and the first known COVID-19 associated death in the state followed on March 20, 2020. In 2020 alone, there were 514,922 confirmed cases and 6,760 COVID-19 attributed deaths in the state of Tennessee. It is important to understand, however, that confirmed COVID-19 deaths do not accurately capture the overall impact of the COVID-19 pandemic. Many additional deaths resulted either directly from COVID-19 disease, or indirectly from the COVID-19 pandemic. This report seeks to briefly summarize the early stages of the COVID-19 pandemic and its immediate impact on the state of Tennessee and outline a novel tool for rapidly identifying excess mortality using publicly available data. Methods: Calculating excess mortality is likely to accurately capture the total deaths that occurred because of the COVID-19 pandemic, including deaths that may not have been directly attributed to COVID-19 disease. To calculate excess mortality, four years (2017-2020) of data were collected from three sources, online funeral home listings, newspaper obituaries, and the state health department. Using simple linear regression, number of deaths by month for 2017, 2018 and 2019 were used to predict expected deaths, by data source, for each month of 2020 as the baseline for comparison. The percent difference of actual deaths from the expected deaths was then calculated and compared by data source. Results: By quarter, 2020 actual funeral home listings differed from the expected by Q1:-9.29%, Q2:11.50%, Q3:7.36% and Q4:55.90%. Newspaper obituaries differed from the expected by Q1:8.05%, Q2:20.00%, Q3:9.93% and Q4:44.55%. State reported Washington County data differed from the expected by Q1:7.68%, Q2:18.85%, Q3:12.21%, Q4:48.91%. When comparing online funeral listings and newspaper obituaries to state reported data for Washington County, it is clear that either of the public data sources could have been used to identify spikes in excess mortality throughout 2020. Conclusion: These findings reveal that publicly available online funeral home death listings and local newspaper obituaries can be used as a tool to help identify spikes in excess mortality in ‘real-time’. The most notable impact being that the newspaper obituary and funeral home data was available in near real time, whereas the state reported Washington County data was not made available until October of 2021.

Introduction: Home visits have become increasingly uncommon although evidence suggests they improve healthcare quality and reduce overall expenditures. This thesis identifies the number and proportion of physician delivering home visits at patient’s end of life and describes characteristics of primary care physicians delivering end-of-life home visits and explores associations with delivery. Method: A retrospective cohort design using population-level health administrative data housed at ICES. Results: A total of 9,884 physicians were identified, of which 2,568 (25.7%) delivered at least one end-of-life home visit. Variables associated with increased odds of home visit delivery were older age, international training, capitation models of remuneration, and population size. Conclusions: This research demonstrates primary care physician’s characteristics and home visit practice patterns. This study aims to improve end-of-life primary care at a system and provider level by identifying factors associated with increased service provision. Increasing physician home services could greatly improve the dying experience of Canadians.