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Health Insurance Type and Outpatient Specialist Care Among Children With Asthma
No full textImportance: Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance.
Objective: To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type.
Design, setting, and participants: In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children\u27s Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024.
Exposure: Medicaid vs private insurance.
Main outcomes and measures: The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time.
Results: Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma.
Conclusions and relevance: In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes
A rare case of aortitis presenting as chest pain: a case report and literature review
No full textIntroduction and importance: Chest pain is a frequent reason patients seek medical attention. The broad spectrum of potential etiologies makes determining the underlying cause of chest pain complex. Among cardiovascular etiologies, aortitis is a rare but life-threatening possibility that should be considered in the differential diagnosis.
Case presentation: A 53-year-old female with a history of smoking presented with progressively worsening chest and epigastric pain over several weeks. She had seen multiple physicians previously for the same symptoms with unremarkable work-ups. Physical examination was notable for severe tenderness upon palpation of her lower abdomen. The electrocardiogram and troponins were unremarkable. Computed tomography of the abdomen revealed aneurysmal dilatation of the abdominal aorta, soft tissue thickening, and surrounding inflammatory stranding, consistent with aortitis. Infectious and autoimmune work-ups were unremarkable. Intravenous steroids were initiated, and her symptoms improved significantly. Her aortitis was attributed to inflammation secondary to chronic smoking.
Clinical discussion: Aortitis is a rare condition with varied clinical presentations. Etiologies of aortitis include infection and non-infectious inflammation. Diagnosis of aortitis requires a thorough clinical assessment and prompt imaging of the aorta, with computed tomography being the preferred imaging modality.
Conclusion: Evaluation for cardiovascular chest pain must extend beyond an electrocardiogram and troponin level. Imaging should be considered in patients with atypical symptoms. Aortitis is a rare but important diagnosis requiring immediate treatment.
Keywords: aortitis; case report; chest pain; computed tomography; imaging; smoking
Barriers and facilitators to healthcare utilisation by Arab sexual minority women migrants in the USA
No full textLimited research on sexual minority women migrants demonstrate that they face elevated rates of mental health problems compared to their heterosexual and male counterparts, and less is known about their healthcare seeking behaviours. This study aimed to identify barriers and facilitators to mental and physical healthcare utilisation among first-generation (foreign-born) Arab sexual minority women migrants in the USA and to assess whether Penchansky and Thomas\u27 theory of access can be used to understand their healthcare utilisation behaviours. We conducted 20 semi-structured interviews via Zoom. Employing community-engaged research methods, four advisors, Arab sexual minority women migrants and a mental health service provider, assisted in recruitment and thematic data analysis providing a rich and nuanced understanding of study findings. Five main themes demonstrated the pivotal role of cultural humility from providers and access to medical insurance in shaping healthcare-seeking decisions. Difficulties finding therapists and navigating the referral process and wait times encouraged participants to seek care outside of the USA in their Arab countries of origin. Stigma and social support further influenced participants\u27 decisions to seek mental healthcare. The study findings inform policy and practice to foster the development of inclusive healthcare services grounded in cultural humility and to develop support groups specifically for Arab sexual minority women migrants to the USA.
Keywords: Sexual minority women; immigration; mental health
A Research Agenda to Improve Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Cardiovascular Disease. An Official American Thoracic Society Research Statement
No full textBackground: Individuals with chronic obstructive pulmonary disease (COPD) are often at risk for or have comorbid cardiovascular disease and are likely to die of cardiovascular-related causes.
Objectives: To prioritize a list of research topics related to diagnosis and management of patients with COPD and comorbid cardiovascular diseases (heart failure, atherosclerotic vascular disease and atrial fibrillation) by summarizing existing evidence and using consensus-based methods.
Methods: A literature search was performed. References were reviewed by committee co-chairs. An international, multidisciplinary committee, including a patient advocate, met virtually to review evidence and identify research topics. A modified Delphi approach was used to prioritize topics in real-time based on their potential for advancing the field.
Results: Gaps spanned the translational science spectrum from basic science to implementation: 1) disease mechanisms, 2) epidemiology, 3) subphenotyping, 4) diagnosis and management, 5) clinical trials, 6) care delivery, 7) medication access, adherence and side effects, 8) risk factor mitigation, 9) cardiac and pulmonary rehabilitation, and 10) health equity. Seventeen experts participated and quorum was achieved for all votes (\u3e80%). Of 17 topics, ≥70% agreement was achieved for 12 topics after 2 rounds of voting. Range of summative Likert score was -15 to 25. Highest priority was Conduct pragmatic clinical trials with patient-centered outcomes that collect both pulmonary and cardiac data elements. Health equity was identified as an important topic that should be embedded within all research.
Conclusions: We propose a prioritized research agenda with the purpose of stimulating high-impact research that will hopefully improve outcomes among people with COPD and cardiovascular disease.
Keywords: Chronic obstructive pulmonary disease; cardiovascular disease; research priorities
Cardiac Surgical Bleeding, Transfusion and Quality Metrics: Joint Consensus Statement by the Enhanced Recovery After Surgery Cardiac Society and Society for the Advancement of Patient Blood Management
No full textBackground: Excessive perioperative bleeding is associated with major complications in cardiac surgery, resulting in increased morbidity, mortality and cost.
Methods: An international expert panel was convened to develop consensus statements on the control of bleeding and management of transfusion, and to suggest key quality metrics for cardiac surgical bleeding. The panel reviewed relevant literature from the previous 10 years and used a modified RAND Delphi methodology to achieve consensus.
Results: Thirty consensus statements in 8 categories were developed, including prioritizing control of bleeding, pre-chest closure checklists and the need for additional quality indicators beyond re-exploration rate, such as time to re-exploration. Consensus was also reached on the need for a universal definition of excessive bleeding, the use of antifibrinolytics, optimal cessation of antithrombotic agents, and preoperative risk scoring based on patient and procedural factors to identify those at greatest risk of excessive bleeding. Furthermore, there is a need for an objective bleeding scale based on the volume and rapidity of blood loss accompanied by viscoelastic management algorithms and standardized, patient-centered blood management strategies reflecting an interdisciplinary approach to quality improvement.
Conclusions: Prioritizing the timely control and management of bleeding is essential to improving patient outcomes in cardiac surgery. To this end, a cardiac surgical bleeding quality metric that is more comprehensive than re-exploration rate alone is needed. Similarly, interdisciplinary quality initiatives that seek to implement enhanced quality indicators will likely lead to improved patient care and outcomes.
Keywords: Bleeding; Cardiac surgery; Quality metrics
Use of machine learning models to predict neurologically intact survival for advanced age adults following out-of-hospital cardiac arrest
No full textTranscatheter Versus Surgical Aortic Valve Replacement in Patients with Aortic Stenosis and Cardiogenic Shock
No full textBackground: Patients with aortic stenosis (AS) and cardiogenic shock (CS) are an extremely high-risk population with a poor prognosis in the absence of definitive therapy.
Aims: To compare the outcomes of transcatheter aortic valve replacement (TAVR) with surgical AVR (SAVR) in patients with AS-CS.
Methods: We queried the Nationwide Readmission Database (2016-2021) to identify patients hospitalized for AS-CS who underwent isolated TAVR or SAVR. In-hospital outcomes of TAVR vs SAVR were compared using multivariable regression and propensity-matching analyses. Ninety-day readmissions were compared using Cox proportional hazards regression model.
Results: Of 16,072 patients hospitalized for AS-CS, 6,381 (39.7%) underwent isolated TAVR, and 9,691 (60.3%) underwent isolated SAVR. From 2016 through 2021, the proportion of TAVR increased from 29.5% to 46.5% and the proportion of SAVR correspondingly decreased in AS-CS (ptrend\u3c0.01). After adjustment for baseline characteristics, TAVR was associated with lower odds of stroke (adjusted odds ratio [aOR] 0.59, 95% confidence interval [CI] 0.44-0.79), acute kidney injury (aOR 0.79, 95% CI 0.68-0.92), and major bleeding (aOR 0.54, 95% CI 0.40-0.72) and higher odds of vascular complications (aOR 1.55, 95% CI 1.22-1.96) compared with SAVR. In-hospital mortality, myocardial infarction, permanent pacemaker placement, and 90-day all-cause and heart failure readmissions were similar. Length of stay was shorter and total costs and nonhome discharges were lower with TAVR.
Conclusions: This nationwide observational analysis showed that TAVR is increasingly performed in patients with AS-CS and is associated with similar in-hospital mortality and 90-day readmissions, but lower in-hospital complications and resource utilization compared with SAVR.
Keywords: Aortic Stenosis; Cardiogenic Shock; In-Hospital Mortality; Outcomes; SAVR; TAVR
Confusion Assessment Method Compliance and Importance
Get PDFhttps://scholarlycommons.libraryinfo.bhs.org/nurs_presentations2024/1011/thumbnail.jp
The challenges and clinical landscape of glioblastoma immunotherapy
No full textGlioblastoma is associated with a dismal prognosis with the standard of care involving surgery, radiation therapy and temozolomide chemotherapy. This review investigates the features that make glioblastoma difficult to treat and the results of glioblastoma immunotherapy clinical trials so far. There have been over a hundred clinical trials involving immunotherapy in glioblastoma. We report the survival-related outcomes of every Phase III glioblastoma immunotherapy trial with online published results we could find at the time of writing. To date, the DCVax-L vaccine is the only immunotherapy shown to have statistically significant increased median survival compared with standard-of-care in a Phase III trial: 19.3 months versus 16.5 months. However, this trial used an external control group to compare with the intervention which limits its quality of evidence. In conclusion, glioblastoma immunotherapy requires further investigation to determine its significance in improving disease survival.
Keywords: cancer vaccines; clinical research; clinical trials; drug resistance; glioblastoma; immunotherapy
Baystate Medical Center Nursing Report - 2024
Get PDFBaystate Medical Center Nursing Report - 2024https://scholarlycommons.libraryinfo.bhs.org/bmcnursing_report/1008/thumbnail.jp