Search

Many schools around the world involuntarily began remote learning in March of 2020 as a result of the COVID-19 pandemic, which brought immediate changes and challenges to teaching and learning that are likely to influence student achievement into the foreseeable future. While large numbers of students face difficulties in learning to read under typical conditions, remote learning resulted in substantial deficits in reading outcomes. This study aimed to examine the relative impact of the pandemic on reading performance in United States (U.S.) for students with and without disabilities. and procedure: In this interpretive analysis, we compared the progress of a large sample of students (n = 219,500) by using the National Assessment of Educational Progress (NAEP) data, in two grade levels (Grades 4 and 8), with and without disabilities, at two time points (2019 and 2022). Statistically significant decreases were identified on the reading outcomes of students in U.S. Students without disabilities experienced a significant decrease in their reading outcomes pre- and post-pandemic, compared to students with disabilities (SWDs). We discuss the effects of the COVID-19 pandemic on students' reading performance and the implications for effective reading instructions in the future. • The reading performance of fourth and eighth grade students in US significantly decreased from 2019 to 2022. • The reading scores of students without disabilities (SWOD) decreased significantly, but those of students with disabilities (SWD) did not. • The difference in reading between SWD and SWOD was significant pre- and post-pandemic, with SWD underperforming SWOD. [ABSTRACT FROM AUTHOR]

Introduction: One way to foster collaboration and continuing education is medical students' participation in medical associations. However, it isn't clear if being a student member leads to continued membership. In this study, the primary goal is to determine if student membership increases membership in the South Dakota State Medical Association (SDSMA) and American Medical Association (AMA) after graduation., Methods: After validation with 10 physicians through a pilot study, the finalized survey was emailed by the South Dakota Board of Medical and Osteopathic Examiners to every South Dakota licensed physician. The survey included questions about membership in AMA, SDSMA, and other medical organizations. Descriptive data was assessed using counts and percentages. Comparisons were made based on Chi-square tests., Results: In total, 438 individuals consented and participated. Overall, 296 (67.6%) indicated membership in a medical association in medical school; 101 only AMA, 38 only SDSMA, 133 both, and 24 only other. For the 234 with a student AMA membership, 71 (30.3%) continued. Of the 171 with a student SDSMA membership, 88 (51.5%) continued. Comparing those with and without a student AMA membership, 22.6% without joined after graduation and 30.3% with continued (p = 0.07). For SDSMA memberships, 28.5% without joined after graduation, while 51.5% of those with continued. Common reasons for maintaining included professional advocacy (n = 44) and educational opportunities (n = 32), for AMA and professional advocacy (n = 58) and networking (n = 45), for SDSMA. Common reasons for non-continuation in both AMA and SDSMA, were lack of specialty representation and political disagreement., Conclusions: Those who were members of SDSMA as students were more likely to maintain their membership. This difference was less pronounced for AMA. Networking was a common reason for maintaining SDSMA. Focusing on this aspect may be beneficial for retaining members., (Copyright© South Dakota State Medical Association.)

Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

Rationale and Objectives: In February 2020, administrators for the US medical licensing examination (USMLE) announced that Step 1 reporting would change to pass/fail in hopes of reducing the overemphasis of USMLE performance on the residency selection system and improving medical student well-being. Our objective was to determine the perspectives of diagnostic radiology (DR), interventional radiology (IR), and nuclear medicine (NM) program directors (PDs) regarding pass/fail USMLE Step 1 scoring., Materials and Methods: A survey composed of thirteen questions on a three-point Likert scale, five demographic questions, and a free-text question was distributed to 179 DR, 84 IR, and 34 NM PDs from ACGME-accredited residency programs., Results: In total, 140 unique responses were obtained (response rate = 47.1%). The PD respondents had a male predominance of 79.1%, average age of 46 ± 7.2 years, and average tenure of 5.9 ± 5.2 years. A majority of PDs (69.6%) disagreed that the change is a good idea, and a minority (21.6%) believe the change will improve medical student well-being. Further, 90.7% of PDs believe a pass/fail format will make it more difficult to objectively compare applicants and most will place more emphasis on USMLE Step 2 scores and medical school reputation (89.3% and 72.7%, respectively)., Conclusion: The lasting impact of pass/fail Step 1 scoring are uncertain and many radiology PDs do not support this change. While the central motivations to reduce the overemphasis on USMLE Step 1 performance and improve medical student well-being are admirable, it remains to be seen if pass/fail scoring will accomplish these goals., (Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: Understanding postsurgical prescribing patterns and their impact on persistent opioid use is important for establishing reasonable opioid prescribing protocols. We aimed to determine national variation in postoperative opioid prescription practices following elective lumbar spine surgery and their impact on short-term refill prescriptions., Methods: The OptumLabs Data Warehouse was queried from 2016 to 2017 for adults undergoing anterior lumbar fusion, posterior lumbar fusion, circumferential lumbar fusion, and lumbar decompression/discectomy for degenerative spine disease. Discharge opioid prescription fills were obtained and converted to morphine milligram equivalents (MMEs). Age- and sex-adjusted MMEs and frequency of discharge prescriptions >200 MMEs were determined for each U.S. census division and procedure type., Results: The study included 43,572 patients with 37,894 postdischarge opioid prescription fills. There was wide variation in mean filled MMEs across all census divisions (anterior lumbar fusion: 774-1147 MMEs; posterior lumbar fusion: 717-1280 MMEs; circumferential lumbar fusion: 817-1271 MMEs; lumbar decompression/discectomy: 619-787 MMEs). A significant proportion of cases were found to have filled discharge prescriptions >200 MMEs (posterior lumbar fusion: 78.6%-95%; anterior lumbar fusion: 87.5%-95.6%; circumferential lumbar fusion: 81.4%-96.5%; lumbar decompression/discectomy: 80.5%-91%). Multivariable logistic regression showed that female sex and inpatient surgery were associated with a top-quartile discharge prescription and a short-term second opioid prescription fill, while the opposite was noted for elderly and opioid-naïve patients (all P ≤ 0.05). Prescriptions with long-acting opioids were associated with higher odds of a second opioid prescription fill (reference: nontramadol short-acting opioid)., Conclusions: In analysis of filled opioid prescriptions, we observed a significant proportion of prescriptions >200 MMEs and wide regional variation in postdischarge opioid prescribing patterns following elective lumbar spine surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Rationale: In October 2014, the antifibrotic medications pirfenidone and nintedanib became the first medications approved by the U.S. Food and Drug Administration for use in patients with idiopathic pulmonary fibrosis (IPF). Since approval, there has been no nonregistry analysis of the real-world adoption of these medications in everyday clinical practice. Objectives: To evaluate the adoption, persistence, and out-of-pocket (OOP) costs of pirfenidone and nintedanib since their approval in the United States in 2014. Methods: A retrospective cohort analysis was performed by identifying privately insured and Medicare Advantage beneficiaries with IPF. We then split the patients into three cohorts: those who were untreated and those who filled a prescription for either pirfenidone or nintedanib between October 1, 2014, and July 31, 2019. The primary outcome was adoption of the medications. Secondary outcomes included medication persistence and prescription drug costs. Results: A total of 10,996 patients with IPF were identified in the data set. A minority of patients (26.4%) with IPF identified in the cohort had started either medication since approval in 2014, with the adoption of both medications being comparable at around 13.2%. Those receiving the medications were younger (72 vs. 73.9 yr; P  < 0.0001) and healthier (3.9 vs. 4.9 comorbidities; P  < 0.0001) than those not receiving treatment. Men were significantly more likely to receive treatment than woman (30.0% vs. 21.9%; P  < 0.0001). Among treated patients, 42.8% discontinued the medications during the study period. Patients' OOP expenses per month were high for both drugs (mean, $397.51 for nintedanib; mean, $394.49 for pirfenidone). Conclusions: The adoption of both the antifibrotic medications in the United States in everyday practice has been low since approval and may be associated with the high OOP cost.

Background: Considerable uncertainty remains about the pattern of use of treatment options for Graves' disease (GD) and their comparative effectiveness and safety. Methods: Between 2005 and 2013, we identified patients with GD who received antithyroid drugs (ATDs), radioactive iodine (RAI) or surgery, and were represented in a large administrative data set in the United States (OptumLabs ® Data Warehouse). Results: We identified 4661 patients with GD: mean age 48 (SD ±14) years, white (63%), and female (80%). Patients received ATD, n  = 2817 (60%), RAI, n  = 1549 (33%), or surgery, n  = 295 (6%). Success rates were 50% for ATD, 93% for RAI, and 99% for surgery. Median time to treatment failure was 6.8 months for ATD and 3 months for RAI and surgery. When patients were required to be on ATD for at least one year before assessing failure, the failure rate decreased to 25%. Adverse effects occurred in 12% of patients receiving ATD, 6% with RAI, and 24% with surgery. Factors associated with treatment success were age >55 years (for ATD) and female sex (for RAI). About 12% of patients receiving ATD continued this treatment for >24 months as initial therapy. When patients failed ATD therapy, the most common second-line therapy was reinitiation of ATD (65%), RAI (26%), and surgery (9%). Overall, 26% of patients remain on ATD therapy (combined first or second line). Conclusions: ATD therapy was the most common GD therapy and demonstrated the lowest efficacy and infrequent significant adverse effect profile. With one fourth of patients remaining on ATD treatment (initial or second modality treatment), it becomes imperative to determine the long-term efficacy, safety, costs, and burdens of this modality of treatment.

Background: Families' experiences of assisted dying are under-investigated and families are rarely considered in clinical guidelines concerning assisted dying., Aim: To systematically review family experiences of assisted dying., Design: A systematic literature review using thematic synthesis., Data Sources: MEDLINE, Embase, CINAHL, AMED (Allied and Complementary Medicine) and PsycINFO databases (January 1992 to February 2019). Studies investigating families' experiences on the practice of legalised assisted dying were included. We excluded studies prior to legalisation within the jurisdiction, secondary data analysis and opinion papers., Results: Nineteen articles met the inclusion criteria. Publications were derived from four countries: The Netherlands, United States (Oregon, Washington and Vermont), Canada and Switzerland. Dutch studies predominately investigated family involvement in euthanasia, while Swiss and American studies only reported on assisted suicide. Eleven studies had a qualitative design, using predominately in-depth interviews; seven were retrospective surveys. Five analytical themes represented families' experiences in assisted dying: (1) context of the decision , (2) grounding the decision , (3) cognitive and emotional work , (4) experiencing the final farewell and (5) grief and bereavement . The results showed that families can be very involved in supporting patients seeking assisted dying, where open communication is maintained. Family involvement appeared to be influenced by the type of legislation in their country and the families' perception of the social acceptability of assisted dying., Conclusion: Our data confirm that families across all jurisdictions are involved in assisted suicide decision and enactment. Family needs are under-researched, and clinical guidelines should incorporate recommendations about how to consider family needs and how to provide them with evidence-based tailored interventions.

Context: Since reports on patient safety were issued by the Institute of Medicine, a number of interventions have been recommended and standards designed to improve hospital patient safety, including the Leapfrog, evidence-based safety standards. These standards are based on research conducted largely in urban hospitals, and it may not be possible to generalize them to rural hospitals., Purpose: The absence of rural-relevant patient safety standards and interventions may diminish purchaser and public perceptions of rural hospitals, further undermining the financial stability of rural hospitals. This study sought to assess the current evidence concerning rural hospital patient safety and to identify a set of rural-relevant patient safety interventions that the majority of small rural hospitals could readily implement and that rural hospitals, purchasers, consumers, and others would find relevant and useful. These interventions should help rural hospitals prioritize patient safety efforts., Methods: As background, we reviewed literature; interviewed representatives of provider, payer, consumer, and governmental groups in 8 states; and calculated patient safety indicator rates in rural hospitals using the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project National Inpatient Sample. Based on the research literature and patient safety recommendations from national organizations, we developed a list of potentially important patient safety areas for rural hospitals. The rural relevance of these safety interventions was evaluated by a national expert panel in terms of the frequency of the problem, ability to implement, and the internal and external value to rural providers, purchasers, and consumers., Findings: The limited available research suggests that patient safety events and medical errors may be less likely to occur in rural than in urban hospitals. We identified 9 areas of patient safety and 26 priority patient safety interventions relevant to rural hospitals., Conclusions: Many of the identified areas of patient safety and interventions are relevant to all types of hospitals, not just rural hospitals. However, some areas, such as transfers, are especially relevant to rural hospitals. The challenges of implementing some interventions, such as 24/7 pharmacy coverage, are significant given workforce supply and financial problems faced by many small rural hospitals. The results of this study provide an important platform for further work to test the validity and effectiveness of these interventions.

Only a few studies have assessed the economic outcomes of palliative therapy. The major areas of interest include hospice care, the process and structure of care, symptom management, and palliative chemotherapy compared to best supportive care. Compared with nonhospice care, hospice care saves at best 3% of total care costs. Advance directives done early in the disease course may save end-of-life care costs, but when done in the hospital do not save money or influence care choices. Nurse coordination of palliative care maintained clinical outcomes of dying patients and saved 40% of costs. A structured ethics review of those likely to die in the intensive care unit also appears to match the type of care to the outcome, and save costs. There are remarkably few randomized clinical trials of pain and symptom control interventions in end-of-life care, so few conclusions can be drawn about current treatments. There are no examples of chemotherapy that save money compared to best supportive care. Current data suggest that changes in palliative care cost can only come from dramatic changes in how we provide care. One model is coordinated, expert, high-volume care that can prevent end-of-life hospitalization, with early use of advance directives. Preliminary data from our program support the hypothesis that costs may be reduced by 40% to 70%.

Objective: To determine whether lamivudine or interferon-alpha (IFN-alpha) is the more successful treatment for chronic hepatitis B given a fixed drug budget., Study Design: A decision-tree model of 1 year., Patients and Methods: Average wholesale prices were used to estimate drug costs. A fixed drug budget of $558,910, sufficient to treat 100 patients with IFN-alpha, was assumed. Clinical data were taken from randomized controlled trials. The outcome measures used were hepatitis B "e" antigen (HBeAg) seroconversion rates and rates of progression to cirrhosis., Results: The analysis showed that given the fixed drug budget, 353 patients could be treated with lamivudine, resulting in an expected 62 HBeAg seroconversions, with 6 patients progressing to cirrhosis. Given the same drug budget, 100 patients could be treated with IFN-alpha, leaving 253 patients untreated. This treatment scenario would result in an expected 32 HBeAg seroconversions, with 28 patients progressing to cirrhosis. Compared with no treatment, the costs per additional HBeAg seroconversion obtained were $12,703 for lamivudine and $39,922 for IFN-alpha. In addition, each case of cirrhosis avoided through lamivudine treatment resulted in significant annual cost savings. Lamivudine therapy also provided additional clinical benefits (e.g., normalization of alanine transaminase levels, reduction in hepatitis B virus DNA levels, improvement in liver histology) to patients who do not seroconvert., Conclusion: From the perspective of a third-party payer with a fixed drug budget, lamivudine is more cost-effective therapy than IFN-alpha for the treatment of chronic hepatitis B.

The objective of this study was to describe the effect on health care utilization and costs of a program of managed care for the Medicaid disabled. The study was designed as a pre/post enrollment cohort comparison and was carried out in three Ohio counties. The subjects were disabled Medicaid-insured patients who voluntarily enrolled in a managed care program for at least 6 months between July 1, 1995 and December 31, 1997, and who had (1) at least one Medicaid claim in the 24-months pre-enrollment period and (2) overall satisfactory postenrollment encounter-level data. Ohio Medicaid provided claims and reimbursements (costs) for the pre-enrollment period and encounter-level data for the postenrollment period. Postenrollment costs were estimated by applying category-specific average pre-enrollment costs to postenrollment utilization data. We measured the following per patient-month: (1) trends in category-specific utilization and costs for up to 24 months before and after enrollment, (2) differences in overall and category-specific costs 1 year before and after enrollment, and (3) changes in the distribution of services 1 year before and after enrollment. Utilization categories included inpatient care, outpatient hospital (including emergency department) care, physician services, prescription medications, durable medical equipment and supplies, and home health care. We found that satisfactory encounter data were available in two of three counties. Of 1,179 enrollees, 592 met all inclusion criteria. Before enrollment, utilization and costs were increasing significantly in four of six categories and were unchanging in two. Postenrollment, decreasing utilization was observed for three categories, one remained unchanged, and two were increasing, but from a lower "baseline." Except for physician services and home health care, there were lower utilization and estimated costs in all categories in the year after enrollment. Estimated inpatient and total costs declined by $155/patient-month (44.9%) and $210/patient-month (37.1%), respectively. Findings were similar across sites. Inpatient care, outpatient hospital care, and prescription medications accounted for 97% of the reductions in estimated costs in the postenrollment period. Among patients voluntarily enrolled for at least 6 months, managed care for the Medicaid disabled was associated with striking decreases in health care utilization and estimated costs. The effect of managed care on these patients' satisfaction, access to specialized services, quality of care, and health outcomes are understood incompletely.

Objective: The objective of this study was to compare 2 approaches for subjecting capitation rates for disabled Medicaid-eligible patients in managed care plans to risk adjustment, the Disability Payment System (DPS) and the Ohio Prior Expenditure System (OPES)., Design: This was a retrospective cohort., Setting and Subjects: The subjects were 157,142 nonelderly disabled individuals eligible for > or =1 month during state fiscal year 1995 (SFY95) for a 3-county Ohio Medicaid managed care demonstration project., Data Source: Data were from the Ohio Medicaid eligibility and fee-for-service claims files., Analysis: As per OPES policy, individuals were classified by the duration of their eligibility in SFY93 as "old" eligibles (> or =6 months) or "new" eligibles (<6 months). Published relative payment weights for each system were adjusted and used to predict SFY95 expenditures in a budget-neutral comparison. Measures were variance in SFY95 expenditures explained by predicted payments (R2) and predictive ratios (predicted payment/actual SFY95 expenditure). Individuals with HIV/AIDS and hematological conditions, who enrolled disproportionately across the demonstration counties, were analyzed separately., Results: Of the 157,142 individuals, 56.4% were new eligibles; 40.1% of the old eligibles had no claims-documented chronic disease diagnosis in the baseline year. The overall R2 was 0.091 with OPES and 0.057 with DPS. Neither system predicted >1% of individual-level expenditures for new eligibles. OPES severely underpaid for eligibles in the top percentile of predicted expenditures; DPS had mixed results. DPS predicted SFY95 expenditures substantially better than OPES for the enrollment bias categories., Conclusions: Before Medicaid programs move to full-risk capitation for disabled populations, better risk-adjustment methods are needed, especially for eligible patients with little claims experience, high predicted expenditures, or enrollment-bias conditions.

Background: The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations., Objectives: To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status., Methods: Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described., Results: The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P<.001) and scores of screening measures for depression were significantly higher in the youngest age group (51%) compared with the oldest age groups (33% and 16%) (P<.001)., Conclusions: The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

Objective: We describe an integer programming model that, for studies requiring repeated sampling from hospitals, can aid in selecting a limited set of hospitals from which medical records are reviewed., Study Setting: The model is illustrated in the context of two studies: (1) an analysis of the relationship between variations in hospital admission rates across geographic areas and rates of inappropriate admissions; and (2) a validation of computerized algorithms that screen for complications of hospital care., Study Design: Common characteristics of the two studies: (1) hospitals are classified into categories, e.g., high, medium, and low; (2) the classification process is repeated several times, e.g., for different medical conditions; (3) medical records are selected separately for each iteration of the classification; and (4) for budgetary and logistical reasons, reviews must be concentrated in a relatively small subset of hospitals. DATA COLLECTION/EXTRACTION METHODS. In each study, hospitals are ranked based on analysis of hospital discharge abstract data., Conclusions: The model is useful for identifying a subset of hospitals at which more intensive reviews will be conducted.

Treatment cost and payment patterns and disability for work, home, and recreation activities were examined for 495 consecutive persons seen as primary care patients over one year in Northern Vermont with injuries associated with woodworking, wood related construction, and home repair activities and materials. These primary care patients were from a larger sample of 601 persons with such injuries who received either primary or tertiary care. Mean total charges were $530 and $342 respectively for work and nonwork related injuries, with highest costs for back and arm injuries, and injuries involving powered equipment and elevations. At six months post injury, patients averaged 11.6 days of disability for work, 10.3 days for home activities, and 13.1 days for recreation. Overwhelmingly, this disability was experienced by nonhospitalized patients. Median charges and disability days were far lower, reflecting the fact that the majority of injuries were minor and only 6% resulted in hospitalization. Only 29% of hospital charges for injuries at work were paid by workmen's compensation, and a third either were unpaid or were paid by the injured party. Self-employed contractors and carpenters, in particular, lacked coverage by workmen's compensation.

To examine the effect of the revision of the US national AIDS case definition in September 1987, we compared demographic and clinical information for AIDS patients diagnosed and reported to the San Francisco Department of Public Health between 1 September 1987 and 31 October 1989. Of the 3167 patients diagnosed and reported during the study period, 584 (18%) met the revised case definition only, increasing AIDS case reporting in San Francisco by 23%. One hundred and thirty-four of these 584 patients (23%) subsequently developed diagnoses meeting the old definition. After adjusting for this proportion, the revised case definition increased reporting by 17%. The mean time between initial diagnosis with a disease meeting the revised definition and subsequent development of a disease meeting the old definition was 18.5 months. Patients who met the revised case definition only were slightly older and more likely to be Black, female, and intravenous drug users (IVDUs) than those meeting the old case definition. The majority of patients who met the revised case definition only had initial diagnoses of HIV wasting syndrome (26%), HIV encephalopathy (21%), and presumptive Pneumocystis carinii pneumonia (19%). The revised AIDS case definition has significantly increased the reporting of severe morbidity associated with HIV infection, particularly among IVDUs.

Children's hospitals have been excluded from the Medicare prospective payment system (PPS) because of concerns over the applicability of the DRG case-mix system and PPS payment weights to pediatric hospitalization. Nevertheless, DRG-based payment systems are being adopted by State Medicaid agencies and private third-party payers, and the Health Care Financing Administration has been mandated to report to Congress on the feasibility of including children's hospitals in the Federal PPS. This article summarizes policy research on this issue and discusses options in the design of prospective payment systems for pediatric hospitalization.