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Purpose: The purpose of this paper is to identify workforce skills that protect an occupation from elimination due to automation technology. Design/methodology/approach: The authors apply a Gaussian process (GP) classifier, based on the level of non-automatable work activities in an occupation, to USA and Colombian occupational datasets. Findings: The authors find that communication, interpersonal relationship management and decision-making skills are most important in occupations that are resistant to automation. Research limitations/implications: The results are based on work activities data from the Occupational Information Network (O*NET) database developed for the USA labor market. This dataset does not capture significant differences in work activities, where they exist, for the same occupation between the two countries. The findings are also limited to Colombia. Readers should be careful to extrapolate the findings outside of this geography. Originality/value: The authors discover that automation is likely to be a global phenomenon that can only be slightly mitigated by cultural and political factors.

This essay presents results of an exploratory project from 2000-2002 on folk medicine amongLatinx healers in Los Angeles, initiated because little research had been conducted on botánicas anywhere in the United States. The findings reveal that most of the healers are steeped in more than one religious and healing tradition, and that many of these specialists are not, as sometimes assumed, poorly educated, unsophisticated, or adversaries of biomedical care. In addition, clientele are not exclusively Latinx, immigrants, or impoverished, and they seek help for physical, emotional, interpersonal, legal, and other problems including alcoholism, the last of which practitioners attend to with plant and ritual therapies as well as by recommending treatment centers. Data from this study can help inform educational and medical programs regarding faith-based and herbal therapies by vernacular practitioners in Los Angeles. [ABSTRACT FROM AUTHOR]

Objectives: As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence.Methods: Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence.Results: Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%).Conclusion: One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence. [ABSTRACT FROM AUTHOR]

Background: Proxy respondents are frequently used in health surveys, and the proxy is most often the spouse. Longstanding concerns linger, however, about the validity of using spousal proxies, especially for older adults. The purpose of this pilot study was to evaluate the concordance between self-reports and spousal proxy reports to a standard health survey in a small convenience sample of older married couples.Methods: We used the Seniors Together in Aging Research (STAR) volunteer registry at the University of Iowa to identify and consent a cross-sectional, convenience sample of 28 married husband and wife couples. Private, personal interviews with each member of the married couple using a detailed health survey based on the 2012 Health and Retirement Study (HRS) instrument were conducted using computer assisted personal interviewing software. Within couples, each wife completed the health survey first for herself and then for her husband, and each husband completed the health survey first for himself and then for his wife. The health survey topics included health ratings, health conditions, mobility, instrumental activities of daily living (IADLs), health services use, and preventative services. Percent of agreement and prevalence and bias adjusted kappa statistics (PABAKs) were used to evaluate concordance.Results: PABAK coefficients indicated moderate to excellent concordance (PABAKs >0.60) for most of the IADL, health condition, hospitalization, surgery, preventative service, and mobility questions, but only slight to fair concordance (PABAKs = -0.21 to 0.60) for health ratings, and physician and dental visits.Conclusions: These results do not allay longstanding concerns about the validity of routinely using spousal proxies in health surveys to obtain health ratings or the number of physician and dental visits among older adults. Further research is needed in a nationally representative sample of older couples in which each wife completes the health survey first for herself and then for her husband, each husband completes the health survey first for himself and then for his wife, and both spouses' Medicare claims are linked to their health survey responses to determine not just the concordance between spousal reports, but the concordance of those survey responses to the medical record. [ABSTRACT FROM AUTHOR]

Background: Undiagnosed, or diagnosed and untreated osteoporosis (OP) increases the likelihood that falls result in hip fractures, decreased quality of life (QOL), and significant medical expenditures among older adults. We tested whether a tailored dual energy x-ray absorptiometry (DXA) test result letter and an accompanying educational bone-health brochure affected patient satisfaction, QOL, or OP knowledge.Methods: The Patient Activation after DXA Result Notification (PAADRN) study was a double-blinded, pragmatic, randomized trial which enrolled patients from 2012 to 2014. We randomized 7,749 patients presenting for DXA at three health care institutions in the United States who were ≥ 50 years old and able to understand English. Intervention patients received a tailored letter four weeks after DXA containing their results, 10-year fracture risk, and a bone-health educational brochure. Control patients received the results of their DXA per the usual practices of their providers and institutions. Satisfaction with bone health care, QOL, and OP knowledge were assessed at baseline and 12- and 52-weeks after DXA. Intention-to-treat analyses used multiple imputation for missing data and random effects regression models to adjust for clustering within providers and covariates.Results: At 12-weeks 6,728 (86.8 %) and at 52-weeks 6,103 participants (78.8 %) completed their follow-up interviews. The intervention group was more satisfied with their bone health care compared to the usual care group at both their 12- and 52-week follow-ups (standardized effect size = 0.28 at 12-weeks and 0.17 at 52-weeks, p < 0.001). There were no differences between the intervention and usual care groups in QOL or OP knowledge at either time point.Conclusions: A tailored DXA result letter and bone-health educational brochure sent to patients improved patient satisfaction with bone-related health care.Trial Registration: Clinical Trials.gov Identifier: NCT01507662 First received: December 8, 2011. [ABSTRACT FROM AUTHOR]

Objectives: To compare concordance of survey reports of health service use versus claims data between self respondents and spousal and nonspousal relative proxies.Data Sources: 1995-2010 data from the Survey on Assets and Health Dynamics among the Oldest Old and 1993-2010 Medicare claims for 3,229 individuals (13,488 person-years).Study Design: Regression models with individual fixed effects were estimated for discordance of any hospitalizations and outpatient surgery and for the numbers of under- and over-reported physician visits.Principal Findings: Spousal proxies were similar to self respondents on discordance. Nonspousal proxies, particularly daughters/daughters-in-law and sons/sons-in-law, had less discordance, mainly due to reduced under-reporting.Conclusions: Survey reports of health services use from nonspousal relatives are more consistent with Medicare claims than spousal proxies and self respondents. [ABSTRACT FROM AUTHOR]

This essay examines last meal requests by those facing execution. After surveying food and beverage selections, I explore how culinary choices are marked by ethnicity, region, class, and gender, as well as inflected by memories, the longing for certain sensory experiences, and the intent to make a moral, political, or philosophical statement. I also consider which last suppers and comments have inspired movies, TV shows, musical compositions, and advertising; why the public desires information about the food requested by those facing death; how the condemned's meals have become politicized, feeding arguments by both those for and those against the death penalty; what the origin of the last meal ritual is; and why the custom is perpetuated. Possessing varied meanings for different participants in the drama of execution, the ceremonial last meal is one of the most powerful symbolic elements within a larger phenomenon laden with rituals and symbols. [ABSTRACT FROM AUTHOR]

To assess the extent to which chronic condition (CC) status and severity affected how soon children had a dental visit after enrolling in Medicaid. Enrollment and claims data (2003-2008) for newly Medicaid-enrolled children ages 3-14 in Iowa. 3M Clinical Risk Grouping methods were used to identify CC status (no/yes) and CC severity (less severe/more severe). Survival analysis was used to identify the factors associated with earlier first dental visits after initially enrolling in Medicaid. Children with a CC were 17 percent more likely to have earlier first dental visits after enrolling in Medicaid ( p<.0001). There was no significant difference by CC severity. Children who lived in a dental health professional shortage area and those who did not utilize primary medical care had significantly later first Medicaid dental visits, whereas these factors failed to reach statistical significance for children with a CC. While newly Medicaid-enrolled children with a CC were significantly more likely to have earlier first dental visits, we failed to detect a relationship between CC severity and the time to first Medicaid dental visit. The determinants of first Medicaid dental visits were heterogeneous across subgroups of newly Medicaid-enrolled children. Future studies should identify the sociobehavioral factors associated with CCs that are potential barriers to earlier first Medicaid dental visits for newly Medicaid-enrolled children. [ABSTRACT FROM AUTHOR]

Background: Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use. Methods: We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use. Results: There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6%. Average annual prevalence between 1993 and 2007 was 4.8% with a range from 4.1% to 5.4%. Approximately 42% of the users consumed chiropractic services only in a single calendar year while 38% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16% had at least one year in which they exceeded Medicare's "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined. Conclusion: There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance". [ABSTRACT FROM AUTHOR]

Background: 5.8 M living Americans have experienced a stroke at some time in their lives, 780K had either their first or a recurrent stroke this year, and 150K died from strokes this year. Stroke costs about $66B annually in the US, and also results in serious, long-term disability. Therefore, it is prudent to identify all possible risk factors and their effects so that appropriate intervention points may be targeted. Methods: Baseline (1993-1994) interview data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to 1993-2005 Medicare claims. Participants were 5,511 self-respondents ≥ 70 years old. Two ICD9-CM case-identification approaches were used. Two approaches to stroke case-identification based on ICD9-CM codes were used, one emphasized sensitivity and the other emphasized specificity. Participants were censored at death or enrollment into managed Medicare. Baseline risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting post-baseline nonstroke hospitalizations was included to reflect health shocks, and sensitivity analyses were conducted to identify its peak effect. Competing risk, proportional hazards regression was used. Results: Post-baseline strokes occurred for 545 (9.9%; high sensitivity approach) and 374 (6.8%; high specificity approach) participants. The greatest static risks involved increased age, being widowed or never married, living in multi-story buildings, reporting a baseline history of diabetes, hypertension, or stroke, and reporting difficulty picking up a dime, refusing to answer the delayed word recall test, or having poor cognition. Risks were similar for both case-identification approaches and for recurrent and first-ever vs. only first-ever strokes. The time-dependent health shock (recent hospitalization) marker did not alter the static model effect estimates, but increased stroke risk by 200% or more. Conclusion: The effect of our health shock marker (a time-dependent recent hospitalization indicator) was large and did not mediate the effects of the traditional risk factors. This suggests an especially vulnerable post-hospital transition period from adverse effects associated with both their underlying health shock (the reasons for the recent hospital admission) and the consequences of their treatments. [ABSTRACT FROM AUTHOR]

Research on food abounds, from the history of differing types of fare to the relationship between provisioning and culture, gender roles, and eating disorders. In disciplines concerned with health and nutrition, few studies focus on the metaphorical aspects of alimentation; while many ethnographic works do deal with the symbolic nature of gastronomy, they tend to emphasize eating as commensality and food as an expression of identity in ethnic, regional, and religious groups. Symbolic discourse involving cuisine is pervasive and complex, however, manifesting itself in a wide variety of contexts and exhibiting multiple meanings that may be ambiguous, conflicting, or pernicious. Understanding how messages are conveyed through culinary behavior requires an examination not only of victuals but also of the preparation, service, and consumption o f food--for all are grist for the mill of symbolization. Here, I bring together a number of ideas about the iconic nature of cooking and eating: what is fodder for symbol creation, how and why meanings are generated, and what some of the effects of food-related representations are. I also problematize identity as it relates to food. My goal is to suggest directions for future research on foodways as well as applications in fields concerned with nutrition education, counseling, and dietary change. [ABSTRACT FROM AUTHOR]

Presents a study to examine the costs and effectiveness of several different options for automated external defibrillator deployment in the United States commercial air transportation system. Context; Objective; Design, setting, and subjects; Main outcome measures; Results; Conclusion.

The article discusses the best practices study on issues concerning trails with rails, conducted by the Institute of Transportation Engineers (ITE) Transportation Planning Council in the U.S. The common grounds on locating trails along active railroads include frequent use of railroad tracks by everyone and importance of right of way for future expansions and maintenance. The article also presents a summary of conflicting opinions, as well as preliminary recommendations on trails with rails.

The central United States is plagued by frequent catastrophic flooding, such as the flood events of 1993, 2008, 2011, 2013, 2014 and 2016. The goal of this study is to examine whether it is possible to describe the occurrence of flood and heavy precipitation events at the sub-seasonal scale in terms of variations in the climate system. Daily streamflow and precipitation time series over the central United States (defined here to include North Dakota, South Dakota, Nebraska, Kansas, Missouri, Iowa, Minnesota, Wisconsin, Illinois, West Virginia, Kentucky, Ohio, Indiana, and Michigan) are used in this study. We model the occurrence/non-occurrence of a flood and heavy precipitation event over time using regression models based on Cox processes, which can be viewed as a generalization of Poisson processes. Rather than assuming that an event (i.e., flooding or precipitation) occurs independently of the occurrence of the previous one (as in Poisson processes), Cox processes allow us to account for the potential presence of temporal clustering, which manifests itself in an alternation of quiet and active periods. Here we model the occurrence/non-occurrence of flood and heavy precipitation events using two climate indices as time-varying covariates: the Arctic Oscillation (AO) and the Pacific-North American pattern (PNA). We find that AO and/or PNA are important predictors in explaining the temporal clustering in flood occurrences in over 78% of the stream gages we considered. Similar results are obtained when working with heavy precipitation events. Analyses of the sensitivity of the results to different thresholds used to identify events lead to the same conclusions. The findings of this work highlight that variations in the climate system play a critical role in explaining the occurrence of flood and heavy precipitation events at the sub-seasonal scale over the central United States. [ABSTRACT FROM AUTHOR]

Focuses on the Omnibus Trade and Competitiveness Act and its provisions. Use of the International System of Units or the metric system by 1996; Impact on math and science teaching; Effects on language arts and social studies; Development of relationship skills and applications skills in students for an operational understanding of the metric system; Model for teaching.

Purpose To assess the efficacy and safety of a sustained-release intracanalicular dexamethasone insert for the treatment of postoperative ocular inflammation and pain in patients having cataract surgery. Setting Twenty-one United States sites. Design Prospective multicenter randomized parallel-arm double-masked vehicle-controlled phase 3 study. Methods Patients with planned clear corneal cataract surgery were randomized (1:1) to receive dexamethasone insert or placebo, and the treatment was placed in the canaliculus of the eye immediately after surgery (Day 1). The primary efficacy endpoints were complete absence of anterior chamber cells at Day 14 and complete absence of pain at Day 8. Results The study comprised 438 adult patients (216 in the treatment arm and 222 in the placebo arm). At Day 14, significantly more patients had an absence of anterior chamber cells in the dexamethasone insert arm compared with placebo (52.3% versus 31.1%; P <.0001). At Day 8, significantly more patients had an absence of ocular pain in the dexamethasone insert arm compared with placebo (79.6% versus 61.3%; P <.0001). The dexamethasone insert arm showed no increase compared with placebo in incidence of all adverse events or ocular adverse events. Twice as many placebo patients required rescue therapy, compared with treated patients at Day 14. Conclusions Both primary endpoints were successfully met. In addition, patients receiving the dexamethasone insert experienced a decrease in inflammation after surgery as early as Day 4 through Day 45, and a decrease in pain as early as one day after surgery (Day 2) through Day 45. The dexamethasone insert was well-tolerated, and the adverse events profile was similar to placebo. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to examine the effect of adult dental benefit cuts on child dental use in Washington state Medicaid and determine if cuts affect child demographic subgroups differentially., Research Design: The study used an interrupted time-series methodology to measure differences in child dental use after adult dental benefit elimination and reinstatement. Monthly data came from Washington state Medicaid enrollee and dental claim files from January 2008 to December 2015., Subjects: Medicaid-enrolled children with at least one Medicaid-enrolled adult in the same household were the intervention group, and Medicaid-enrolled children without a Medicaid-enrolled adult in the same household were the control group., Measures: The outcome was the monthly proportion of Medicaid-enrolled children with a dental examination per 10,000 Medicaid-enrolled children., Results: After adult dental benefits elimination, dental examinations among children with Medicaid-enrolled adults in the same household gradually decreased, corresponding to 65 fewer dental examinations per 10,000 children per year (5.4 fewer dental examinations per 10,000 children per month; 95% confidence interval: -7.7, -3.1; P =0.006). Adult dental benefits had no effect on dental examination for children without a Medicaid-enrolled adult in the same household. Dental examinations for children with a Medicaid-enrolled adult in the same household continued to gradually decrease after adult benefits reinstatement. Children younger than age 6 were the most adversely impacted by changes to adult Medicaid dental benefits., Conclusion: Policymakers should consider the spillover effects and ethical considerations of eliminating adult Medicaid dental benefits on children's access to dental care., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Veteran suicides have increased despite mental health investments by the Veterans Health Administration (VHA)., Objective: To examine relationships between suicide and acute inpatient psychiatric bed occupancy and other community, hospital and patient factors., Methods: Retrospective cohort study using administrative and publicly available data for contextual community factors. The study sample included all veterans enrolled in VHA primary care in 2011-2016 associated with 111 VHA hospitals with acute inpatient psychiatric units. Acute psychiatric bed occupancy, as a measure of access to care, was the main exposure of interest and was categorised by quarter as per cent occupied using thresholds of ≤85%, 85.1%-90%, 90.1%-95% and >95%. Hospital-level analyses were conducted using generalised linear mixed models with random intercepts for hospital, modelling number of suicides by quarter with a negative binomial distribution., Results: From 2011 to 2016, the national incidence of suicide among enrolled veterans increased from 39.7 to 41.6 per 100 000 person-years. VHA psychiatric bed occupancy decreased from a mean of 68.2% (IQR 56.5%-82.2%) to 65.4% (IQR 53.9%-79.9%). VHA hospitals with the highest occupancy (>95%) in a quarter compared with ≤85% had an adjusted incident rate ratio (IRR) for suicide of 1.10 (95% CI 1.01 to 1.19); no increased risk was observed for 85.1%-90% (IRR 0.96; 95% CI 0.89 to 1.03) or 90.1%-95% (IRR 0.96; 95% CI 0.89 to 1.04) compared with ≤85% occupancy. Of hospital and community variables, suicide risk was not associated with number of VHA or non-VHA psychiatric beds or amount spent on community mental health. Suicide risk increased by age categories, seasons, geographic regions and over time., Conclusions: High VHA hospital occupancy (>95%) was associated with a 10% increased suicide risk for veterans whereas absolute number of beds was not, suggesting occupancy is an important access measure. Future work should clarify optimal bed occupancy to meet acute psychiatric needs and ensure adequate bed distribution., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor., Objective: To examine whether the frequency of changing reminder signs affects HH adherence among health care workers., Design, Setting, and Participants: This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018., Interventions: Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly., Main Outcomes and Measures: Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group., Results: Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups., Conclusions and Relevance: The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change., Trial Registration: ClinicalTrials.gov Identifier: NCT02223455.

In patients with hypogammaglobulinemia secondary to chronic lymphocytic leukemia (CLL) or multiple myeloma (MM), intravenous immune globulin (IVIg) may be administered to reduce the risk of infection. Since 2013, IVIg products have carried a boxed safety warning about the risk of thromboembolic events (TEEs), with TEEs reported in 0.5% to 15% of patients treated with IVIg. In this retrospective cohort study of older patients with CLL or MM identified from the Surveillance, Epidemiology, and End Results-Medicare Linked Database, we assessed rates of clinically serious TEEs in 2724 new users of IVIg and a propensity-matched comparison group of 8035 nonusers. For the primary end point, arterial TEE, we observed a transient increased risk of TEE during the day of an IVIg infusion and the day afterward (hazard ration = 3.40; 95% confidence interval [CI]: 1.25, 9.25); this risk declined over the remainder of the 30-day treatment cycle. When considered in terms of absolute risk averaged over a 1-year treatment period, the increase in risk attributable to IVIg was estimated to be 0.7% (95% CI: -0.2%, 2.0%) compared with a baseline risk of 1.8% for the arterial TEE end point. A statistically nonsignificant risk increase of 0.3% (95% CI: -0.4%, 1.5%) compared with a baseline risk of 1.1% was observed for the venous TEE end point. Further research is needed to establish the generalizability of these results to patients receiving higher doses of IVIg for other indications.

Background: While age-related cognitive decline may affect all stages in the response process--comprehension, retrieval, judgment, response selection, and response reporting--the associations between objective cognitive tests and the agreement between self-reports and Medicare claims has not been assessed. We evaluate those associations using the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD)., Methods: Eight waves of reinterviews (1995-2010) were linked to Medicare claims for 3661 self-respondents yielding 12,313 person-period observations. Cognitive function was measured by 2 episodic memory tests (immediate and delayed recall of 10 words) and 1 mental status test (backward counting, dates, and names). Survey reports on 12 diseases and 4 health services were mapped to Medicare claims to derive counts of concordant reports, underreports, and overreports, as were the numbers of hospital episodes and physician visits. GEE negative binomial and logistic regression models were used., Results: Better mental status was associated with more concordant reporting and less underreporting on disease history and the number of hospital episodes. Better mental status and delayed word recall were associated with more concordant reporting and less underreporting on health services use. Better delayed recall was significantly associated with less underreporting on the number of physician visits. These associations were not appreciably altered by adjustment for demographic characteristics, socioeconomic status, self-rated health, or secular trends., Conclusion: We recommend that future surveys of older adults include an objective measure of mental status (rather than memory), especially when those survey reports cannot be verified by access to Medicare claims or chart review.

Objectives: We examined the relationship between preventive well baby visits (WBVs) and the timing of first dental examinations for young Medicaid-enrolled children., Methods: The study focused on children born in 2000 and enrolled continuously in the Iowa Medicaid Program from birth to age 41 months (n = 6322). The main predictor variables were number and timing of WBVs. The outcome variable was timing of first dental examination. We used survival analysis to evaluate these relationships., Results: Children with more WBVs between ages 1 and 2 years and ages 2 and 3 years were 2.96 and 1.25 times as likely, respectively, to have earlier first dental examinations as children with fewer WBVs. The number of WBVs before age 1 year and the timing of the WBVs were not significantly related to the outcome., Conclusions: The number of WBVs from ages 1 to 3 years was significantly related to earlier first dental examinations, whereas the number of WBVs before age 1 year and the timing of WBVs were not. Future interventions and policies should actively promote first dental examinations by age 12 months at WBVs that take place during the first year of life.

Background: Reducing length of stay (LOS) has been a priority for hospitals and health care systems. However, there is concern that this reduction may result in increased hospital readmissions., Objective: To determine trends in hospital LOS and 30-day readmission rates for all medical diagnoses combined and 5 specific common diagnoses in the Veterans Health Administration., Design: Observational study from 1997 to 2010., Setting: All 129 acute care Veterans Affairs hospitals in the United States., Patients: 4,124,907 medical admissions with subsamples of 2 chronic diagnoses (heart failure and chronic obstructive pulmonary disease) and 3 acute diagnoses (acute myocardial infarction, community-acquired pneumonia, and gastrointestinal hemorrhage)., Measurements: Unadjusted LOS and 30-day readmission rates with multivariable regression analyses to adjust for patient demographic characteristics, comorbid conditions, and admitting hospitals., Results: For all medical diagnoses combined, risk-adjusted mean hospital LOS decreased by 1.46 days from 5.44 to 3.98 days, or 2% annually (P < 0.001). Reductions in LOS were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (2.85 days) and community-acquired pneumonia (2.22 days). Over the 14 years, risk-adjusted 30-day readmission rates for all medical diagnoses combined decreased from 16.5% to 13.8% (P < 0.001). Reductions in readmissions were also observed for the 5 specific common diagnoses, with greatest reductions for acute myocardial infarction (22.6% to 19.8%) and chronic obstructive pulmonary disease (17.9% to 14.6%). All-cause mortality 90 days after admission was reduced by 3% annually. Of note, hospitals with mean risk-adjusted LOS that was lower than expected had a higher readmission rate, suggesting a modest tradeoff between hospital LOS and readmission (6% increase for each day lower than expected)., Limitations: This study is limited to the Veterans Health Administration system; non-Veterans Affairs admissions were not available. No measure of readmission preventability was used., Conclusion: Veterans Affairs hospitals demonstrated simultaneous improvements in hospital LOS and readmissions over 14 years, suggesting that as LOS improved, hospital readmission did not increase. This is important because hospital readmission is being used as a quality indicator and may result in payment incentives. Future work should explore these relationships to see whether a tipping point exists for LOS reduction and hospital readmission., Primary Funding Source: Office of Rural Health and the Health Services Research & Development Service, Veterans Health Administration, U.S. Department of Veterans Affairs.

We compared the extent to which having an intellectual or developmental disability was associated with rates at which Iowa Medicaid-enrolled children ages 3 to 8 had first dental checkups after an initial dental examination. We hypothesized that these children would have later first dental checkups than would children without an intellectual or developmental disability. Findings suggest no significant difference in the time to first dental checkup for children by intellectual or developmental disability status. Those who took over 12 months to see a dentist for their initial dental examination were 1.68 times as likely to have an earlier first dental checkup as children whose initial dental examination occurred within 4 months of being enrolled. Results suggest that having an intellectual or developmental disability is not associated with later first dental checkups for this population.

Background: Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function., Methods: We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests., Results: Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status., Conclusions: In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

Background: Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines., Methods: The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop., Results: The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline., Conclusions: Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

Objective: To assess the impact of chronic condition (CC) status and CC severity, respectively, on the odds of receiving dental treatment under general anesthesia (GA) for Medicaid-enrolled children by age group., Methods: This was a retrospective analysis of Iowa Medicaid-enrolled children <15 years (n = 62 721) from 2005 to 2008. 3M Clinical Risk Grouping Software identified each child's CC status (yes/no) and assigned children with a CC into a hierarchal CC severity group (episodic/life-long/complex). Multiple variable logistic regression models were used to identify the determinants of dental treatment under GA., Results: Less than 1% of children received dental treatment under GA. While there was no significant difference in dental treatment under GA by CC status for children <6, those with a life-long CC were twice as likely to receive dental treatment under GA as demographically similar children with an episodic CC (P < 0.05). Children ages 6-14 with a CC were three times as likely as those without a CC to receive treatment under GA (P = 0.001). There was also a direct relationship between CC severity and dental treatment under GA use for older children. Those living in nonmetropolitan areas were more likely to receive treatment under GA as were children who previously received dental treatment under GA., Conclusions: Chronic condition status and severity were more important determinants of dental treatment under GA for Medicaid-enrolled children ages 6-14 than for those <6. Understanding these relationships is a critical step in developing clinical strategies and interventions aimed at preventing dental disease for Medicaid-enrolled children whose reasons for needing dental treatment under GA are modifiable.

Background: We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old., Methods: Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect., Results: The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

Objectives: To develop and validate the constipation treatment satisfaction questionnaire (CTSAT-Q) for use in patients with chronic constipation and irritable bowel syndrome with constipation (IBS-c)., Methods: Questionnaire development included item representation from the reviewed literature, focus groups, and pretesting. Dimensions related to treatment satisfaction were identified with exploratory factor analysis, verified with confirmatory factor analysis (CFA), and tested with structural equation modeling., Results: A total of 31,988 email invitations were disseminated to obtain 311 qualified respondents with diagnoses for chronic constipation and IBS-c using ROME II criteria, which required that two of the following symptoms: fewer than 3 bowel movements per week, hard or lumpy stools, straining with defecation, and a sensation of incomplete evacuation, a sensation of anorectal obstruction, and the use of manual maneuvers to assist defecation be present 25% of the time during the last year. Approximately 84% of the sample was female. Item-to-total correlations were 0.66 for activities, ranged from 0.60 to 0.67 for expectations, from 0.59 to 0.69 for value, from 0.56 to 0.60 for effectiveness, and 0.68 to 0.79 for treatment satisfaction. All standardized parameter estimates from CFA were significant (P < 0.01). The chi-square was 46.98, df = 41, P = 0.241, comparative fit index = 0.996, Tucker-Lewis Index = 0.994, root mean square error of approximation = 0.022, indicating an excellent fit between the sample data and proposed model. Treatment satisfaction was a strong and significant predictor of effectiveness, activities, and value (P < 0.001)., Conclusions: The CTSAT-Q was demonstrated to be reliable and valid, and appears to assess treatment satisfaction for patients with chronic constipation and patients with IBS-c.

Background: We identified hip fracture risks in a prospective national study., Methods: Baseline (1993-1994) interview data were linked to Medicare claims for 1993-2005. Participants were 5,511 self-respondents aged 70 years and older and not in managed Medicare. ICD9-CM 820.xx (International Classification of Diseases, 9th Edition, Clinical Modification) codes identified hip fracture. Participants were censored at death or enrollment into managed Medicare. Static risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting postbaseline hospitalizations was included., Results: A total of 495 (8.9%) participants suffered a postbaseline hip fracture. In the static proportional hazards model, the greatest risks involved age (adjusted hazard ratios [AHRs] of 2.01, 2.82, and 4.91 for 75-79, 80-84, and > or =85 year age groups vs those aged 70-74 years; p values <.001), sex (AHR = 0.45 for men vs women; p < .001), race (AHRs of 0.37 and 0.46 for African Americans and Hispanics vs whites; p values <.001 and <.01), body mass (AHRs of 0.40, 0.77, and 1.73 for obese, overweight, and underweight vs normal weight; p values <.001, <.05, and <.01), smoking status (AHRs = 1.49 and 1.52 for current and former smokers vs nonsmokers; p values <.05 and <.001), and diabetes (AHR = 1.99; p < .001). The time-dependent recent hospitalization marker did not alter the static model effect estimates, but it did substantially increase the risk of hip fracture (AHR = 2.51; p < .001)., Conclusions: Enhanced discharge planning and home care for non-hip fracture hospitalizations could reduce subsequent hip fracture rates.

Background: Accessing dental care is a significant problem for children in Medicaid and S-SCHIP (Separate State Children's Health Insurance Program). Previous studies have indicated that the design of the Medicaid or S-SCHIP dental program can have an impact on the ability to use services., Objective: To evaluate the factors related to how quickly children had any dental visit and had a preventive dental visit after first enrolling in the Iowa Medicaid and S-SCHIP programs. The primary question was whether the structure of the dental plan was related to improved access to care., Methods: Iowa Medicaid and S-SCHIP dental claims and enrollment files for FY 2001 through 2003 were used to identify children who were newly enrolled in the programs and their use of dental services. Factors related to the time to a child's first dental visit were analyzed using survival analytic techniques., Results: After 6 months in the program, between 21% and 36% of children had received their first dental visit, depending on their dental plan. This increased from 39% to 56% after 1 year. Based on the survival analysis, earlier dental utilization was related to the type of plan in which the child was enrolled as well as the child's age, race, and urban/rural location., Conclusions: Children in the S-SCHIP 2 dental plan, which had an open provider network and paid dentists' full charges, were most likely to have had a dental visit sooner after enrollment. States looking for options to improve access to dental care in their Medicaid and S-SCHIP programs should consider contracting with dental plans with these features.

In this paper we consider rank-based tests for paired survival data, in which pair members are subject to the same right censoring time. Linear signed-rank tests have already been developed for the two-treatment problem in which pair members receive the opposite treatments. Assuming a bivariate accelerated failure time model, we extend this class of linear signed-rank tests to the case of multiple covariates, making this methodology applicable to more complicated experimental designs. These tests can be reformulated as weighted sums of contigency table measures, giving an alternative method of computation and intuitive view of how these tests work. A simulation study of their small-sample performance relative to other tests demonstrates that the linear signed-rank tests have greater power in cases of moderately to highly correlated data.