1,721,008 research outputs found
Clinical use of photobiomodulation for the prevention and treatment of oral mucositis: the real-life experience of MASCC/ISOO members
Get PDFAimTo assess clinical use and patient outcome of photobiomodulation (PBM) for oral mucositis (OM) prevention and treatment among specialized practitioners.MethodsA poll was emailed to the members of the Mucositis Study Group of MASCC/ISOO. The PBM parameters used by the respondents were analyzed using exploratory statistical methods to identify combinations of PBM parameters (patterns) that characterize the variance in the protocols (principal component analysis).ResultsResponses were received from 101 MSG members, with 78 providing analyzable data. Most of the responders were dental practitioners or oral medicine specialists. PBM was used by 59% of the responders for OM or targeted therapy stomatitis. Technical parameters varied widely. Most responders used wavelengths & SIM;650 nm intra-orally. The spot-size and distance from the tissue were the main factors driving the variation. All PBM users noted that PBM relieved pain, either immediately or a delayed effect. High likelihood of pain relief (measured as responder's report of pain relief in 67-100% of patients) was reported by 22% and 19% of PBM users for immediate pain relief and delayed pain relief, respectively. The most common reported barriers to using PBM were financial considerations, time constraints, lack of training or experience and concern about the potential for malignant transformation or increased risk of cancer recurrence.ConclusionsThe use of PBM for OM prevention or treatment is in early phases of adoption in practices, facing some obstacles to implement it. A wide variation in technical parameters was found. Nonetheless, responses indicate that PBM provided pain relief
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Get PDF“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Rural-Urban Disparities in Risk-adjusted Rates of Emergency Department Visits of Nursing Homes: Roles of Facility Characteristics, Market Factors, and State Policies
No full textThesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Health Services Research and Policy, 2019.Rural-urban disparity has been a longstanding issue in the United States. Nursing home (NH) residents are at high risk of having emergency department (ED) visits, but evidence on rural-urban disparity in ED visits is very limited. Medicaid reimbursement rates and bed-hold policies have been shown to affect hospitalizations of urban NH residents, but their effects on ED visits and rural NHs remain unknown. This study analyzed 2011–2013 national Medicare claims, NH Minimum Data Set 3.0 assessment data, the Certification And Survey Provider Enhanced Reporting data, Area Health Resources File, Rural-Urban Commuting Areas Codes, and state Medicaid policies. We constructed and validated three NH-level risk-adjusted rates of long-stay residents: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED). We then examined rural-urban differences in ED rates, and conducted Blinder-Oaxaca decompositions to understand the mechanism driving the differences. We also evaluated the different effects of Medicaid reimbursement rates and bed-hold policies on three risk-adjusted rates of ED visits for rural vs urban NHs. The risk-adjusted rates averaged 9.7%, 3.4%, and 3.2% for any ED visit, outpatient ED, and PAED, respectively. Compared to urban NHs, rural NHs were associated with much lower rates of any ED, outpatient ED, and PAED. Observable differences in market factors and NH characteristics significantly explained rural-urban differences in rates of various ED visits. More generous Medicaid rates were associated with lower rates of all types of ED visits, and Medicaid bed-hold policies were associated with higher rates of ED visits in urban NHs. However, effects of Medicaid NH policies on ED utilization were weaker in rural NHs than urban NHs. To the best of our knowledge, this is the first study to systematically examine rural-urban differences in rates of various ED visits, and also the first to examine the effects of Medicaid policies on ED visits for rural and urban NHs. Our study emphasizes the importance of addressing special challenges faced by rural NHs such as limited access to hospital services and shortage of qualified staffing, which might be more critical than Medicaid reimbursement rates in improving NH quality as evident by ED use
Trends in Opioid Administration and Fall-Related Injuries among Veterans with Dementia Residing in Department of Veterans Affairs’ Community Living Centers
No full textThesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Health Services Research and Policy, 2022.ntroduction : Residents living in the Department of Veterans Affairs (VA) Community Living Centers (CLCs are VA nursing homes) with Alzheimer’s disease and Related Dementias (ADRD) have been reported to have significantly lower odds of reporting pain and receiving any pain treatment and therefore require safe and effective administration of opioid. Objective : This thesis examined changes in opioid administration and fall-related injuries (FRI) among CLC residents with ADRD across three regulatory periods: 1) Pre-Opioid Safety Initiative (October 2012 – June 2013), 2) Pre-CDC guidelines (January 2014 – November 2015) and 3) Post-VA guidelines (March 2017 – September 2018). Aim 1 examined changes in opioid administration patterns (any opioid administration, concurrent administration with benzodiazepine, long-term or high-dose opioid administration); Aim 2 examined changes in CLC-level incident and continued opioid administration patterns; and Aim 3 examined whether FRI were reduced with better opioid administration among Veterans in periods 2 and 3 compared to period 1. Methods : I used VA and Medicare data to define comorbidities, and Minimum Data Set (MDS) nursing home resident assessments to extract patient level characteristics. CLC medication administration were captured from the VA Corporate Data Warehouse bar-code medication administration. In Aim 1, I used negative binomial regression models testing time trends. In Aim 2, I first calculated average risk-adjusted opioid administrations per CLC per regulatory time period, and then used this as the outcome in a linear regression model testing time trends. In Aim 3, I used inverse probability weighted Generalized Linear Models of FRI, with weights established from projecting period 1 propensities of opioid administration to periods 2 and 3, and tested time trends. Results : Opioid safety initiatives were associated with decreasing opioid administration and risk-adjusted incident or continued opioid administration duration and dosage, and with reduced fall-related injuries in periods 2 and 3 compared to period 1 among CLC residents with ADRD. Conclusion : Opioid safety initiatives were related to decreasing opioid administration and fall-related injuries. Future studies should focus on whether decreasing opioid administration resulted in uncontrolled pain or other pain-related adverse outcomes, or whether better pain treatments were utilized to replace or complement opioid administration
Appropriate Similarity Measures for Author Cocitation Analysis
Get PDFWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Continuity of Care and Health Care Utilization and Cost among Communitydwelling Older Veterans with Dementia
No full textThesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Health Services Research and Policy, 2020.With the aging population, the number of older Americans with dementia is expected to grow rapidly. Patients with dementia are reported to have higher health care utilization and cost compared to those without dementia, or patients with heart disease and cancer. Although dementia is a complex neuropsychiatric illness often accompanied by other medical comorbidities, most care for patients with dementia is provided within primary care. Continuity of care (COC) has been regarded a core attribute of primary care. Recent healthcare reforms promote COC through the Patient Protection and Affordable Care Act’s Patient-Centered Medical Home, accountable care organization, and Veterans Health Administration (VHA) Patient-Aligned Care Team (PACT). This dissertation aims to examine the causal impact of continuity of care on health care utilization and cost among community-dwelling older veterans living with dementia. This study uses VHA (enrollment, inpatient and outpatient records, purchased care claims) and Medicare (enrollment and all claims) data linked at the veteran level in fiscal year (FY) 2014-2015 to comprehensively measure COC, health care utilization and cost for veterans. The study cohort is community-dwelling veterans with dementia aged 66 and older and enrolled in Traditional Medicare. This study has three specific aims: (1) to determine the impact of COC on health care cost; (2) to determine the impact of COC on hospitalization; and (3) to determine the impact of COC on successful discharge to community after index hospitalization among community-dwelling older veterans with dementia. COC is measured by the Bice-Boxerman Continuity of Care (BBC) index on a 0-1 scale which measures the dispersion of the veteran’s outpatient visits across all primary care providers and dementia-related specialists. This study uses a linear model of health care cost and a probit model of hospitalization and successful community discharge after hospitalization in FY 2015 explained by COC and other covariates (socio-demographics, socio-economic status, risk factors and market characteristics) in FY 2014. An instrumental variable approach is applied to address the endogeneity of COC and health care utilization and cost. The instrument is whether veteran changes residence by more than 10 miles in FY 2014. Results show that better COC results in lower total VHA and Medicare cost; and the mechanism can be explained by higher non-institutional medical and social long-term care cost (e.g. home-based primary care and adult day health care) and lower institutional cost (i.e. acute inpatient, emergency department, and nursing home). Better COC results in less acute hospitalizations, and this effect primarily comes from the reduction in hospitalization for neuro-psychiatric diseases/disorders but not other hospitalization reasons or potentially preventable hospitalization. Better COC results in higher probability of successful community discharge following hospitalization. In conclusion, this dissertation finds that better COC results in lower total health care cost, less hospitalization and greater probability of successful community discharge after hospitalization among community-dwelling older veterans living with dementia. These findings support the important role of COC in health care systems and thus supporting efforts to improve COC as a means to reducing health care cost, curbing hospitalization and increasing successful community discharge after hospitalization among older adults with dementia
Nursing Home Primary Care and Resident Outcomes: An Application of Social Network Analysis
No full textThesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Health Services Research and Policy, 2020.Over 3.5 million people reside in a nursing home (NH) every year. Hospitalizations of NH residents are frequent and costly, many of which are potentially avoidable. NH medical staff, including the medical director, attending physicians, and nurse practitioners/physician assistants (NPPAs), play a key role in provision of primary care and the decisions to hospitalize or send residents to the Emergency Department (ED). The organization of nursing homes’ medical staff (NH Medical Staff Organization, NHMSO), such as number/type of medical staff, medical staff practice model and employment arrangements, have been found to be associated with care processes and resident outcomes in a few studies. However, these studies have largely relied on surveys of NH leadership which barely provided granular information regarding medical staff interaction and coordination in care processes. In hospital and outpatient settings, studies have used claims data to map patient sharing topologies among healthcare providers, most of which have been conceptualized to reflect aspects of care coordination or collaboration, and were found to be associated with patient outcomes, health utilization and costs. Similarly, NH medical staff may or may not coordinate care via resident-sharing arrangements of cross-coverage for emergency and out-of-hour services, group practice where a panel of residents are seen by alternating among providers in a group, and physicians delegating tasks to other physicians or NPPAs. But the associations between resident-sharing topologies among NH medical staff and resident outcomes had hereto not been explored. Over 3.5 million people reside in a nursing home (NH) every year. Hospitalizations of NH residents are frequent and costly, many of which are potentially avoidable. NH medical staff, including the medical director, attending physicians, and nurse practitioners/physician assistants (NPPAs), play a key role in provision of primary care and the decisions to hospitalize or send residents to the Emergency Department (ED). The organization of nursing homes’ medical staff (NH Medical Staff Organization, NHMSO), such as number/type of medical staff, medical staff practice model and employment arrangements, have been found to be associated with care processes and resident outcomes in a few studies. However, these studies have largely relied on surveys of NH leadership which barely provided granular information regarding medical staff interaction and coordination in care processes. In hospital and outpatient settings, studies have used claims data to map patient sharing topologies among healthcare providers, most of which have been conceptualized to reflect aspects of care coordination or collaboration, and were found to be associated with patient outcomes, health utilization and costs. Similarly, NH medical staff may or may not coordinate care via resident-sharing arrangements of cross-coverage for emergency and out-of-hour services, group practice where a panel of residents are seen by alternating among providers in a group, and physicians delegating tasks to other physicians or NPPAs. But the associations between resident-sharing topologies among NH medical staff and resident outcomes had hereto not been explored. of physicians sharing residents with NPPAs). Claims-based resident outcomes during 180 days’ follow-up, included number of hospitalizations, potentially avoidable hospitalizations, and emergency department (ED) visits without hospitalization. In the analyses of resident outcomes, two-level negative binomial Generalized Estimating Equation (GEE) models were employed with survey and claims-based network measures of NHMSO, respectively, as the main independent variables, controlling for individual residents’ risk factors and care preference, and NH characteristics. Analyses were stratified by NH bed size and rural/urban location which may determine NHs’ economy of scale and human resources, and thus moderate the relationships between measures of NHMSO and resident outcomes. Beta regression models were employed to test the relationships between each of the survey measures of NHMSO and its hypothesized corresponding claims-based network measure, which served as the dependent variable in the model. Other NH characteristics were controlled for in the models. Analyses were stratified by NH bed size and rural/urban location to test whether the relationships between survey and claims based network measures of NHMOS differed in large versus small NHs and in rural versus urban NHs. Findings Open versus closed medical staff practice model was associated with fewer hospitalizations (Incidence Rate Ratio (IRR) =0.89) and fewer potentially avoidable hospitalizations (IRR=0.89) across all NHs, fewer hospitalizations (IRR=0.86) and fewer ED visits (IRR=0.86) in small NHs but more ED visits (IRR=1.19) in large NHs. Medical director attending a high versus none proportion of residents was associated with fewer hospitalizations (IRR=0.79) overall, fewer hospitalizations (IRR=0.66) and fewer potentially avoidable hospitalizations (IRR=0.66) in large NHs, fewer hospitalizations (IRR=0.84) but more ED visits (IRR=1.36) in urban NHs. Any NH-employed NPPAs was associated with fewer hospitalization (IRR=0.91) and fewer potentially avoidable hospitalizations (IRR=0.86) overall, fewer hospitalizations (IRR=0.87), fewer potentially avoidable hospitalizations (IRR=0.80) and fewer ED visits (IRR=0.87) in large NHs, and fewer hospitalizations (IRR=0.88), fewer potentially avoidable hospitalizations (IRR=0.83) and fewer ED visits (IRR=0.88) in urban NHs. Closed versus open medical staff practice model was associated with denser network (marginal effects (ME) =0.03) overall, denser network (ME=0.04) in small NHs and denser network (ME=0.04) in urban NHs. Medical director attending a high versus moderate proportion of residents was associated with greater centralization overall (ME=0.11), in small NHs (ME=0.10), large NHs (me=0.12) and urban NHs (ME=0.12). Any NH-employed NPPAs was associated with greater likelihood of MD-NPPA comanagement overall (ME=0.04), in large NHs (ME=0.06) and urban NHs (ME=0.05). Higher density by one standard deviation was associated with fewer potentially avoidable hospitalizations (IRR=0.95) and fewer ED visits (IRR=0.95) overall, fewer hospitalizations (IRR=0.91), fewer potentially avoidable hospitalizations (IRR=0.86) and fewer ED visits (IRR=0.79) in large NHs, and fewer hospitalizations (IRR=0.92), fewer potentially avoidable hospitalizations (IRR=0.88) and fewer ED visits (IRR=0.93) in rural NHs. Greater centralization by one standard deviation was associated with fewer potentially avoidable hospitalizations (IRR=0.94) and fewer ED visits (IRR=0.95) in small NHs but more hospitalizations (IRR=1.10) and more potentially avoidable hospitalizations (IRR=1.11) in large NHs. Greater MD-NPPA co-management by one standard deviation was associated with fewer hospitalizations (IRR=0.95; 0.93; 0.93) and fewer potentially avoidable hospitalizations (IRR=0.95; 0.94; 0.92) across all NHs, in small NHs and in rural NHs. Greater MD-NPPA co-management was associated with fewer ED visits (IRR=0.94) in rural NHs but more ED visits (IRR=1.05) in urban NHs. Conclusion This study identified several NH management practices that may help reduce hospital transfers among long-stay residents. Small NHs may benefit from open medical staff practice where residents are seen by community physicians. A higher involvement of medical director in resident care may help reduce hospitalizations but not ED visits in urban NHs. Large NHs or urban NHs may benefit from employing their own NPPAs. Although the findings are potentially informative, more studies are needed to investigate the causal effects of NH management practices on resident outcomes possibly via a longitudinal study design. Claim-based measures of resident-sharing networks among NH medical staff were found to reflect aspects of NH medical staff organization that, while correlating with survey measures, provided important additional insights. Claims data are easily accessible in computerized systems for all NHs nationwide and resident-sharing networks among NH medical staff can be derived periodically. The NH industry may consider using resident-sharing networks as a tool to monitor NHMSO over time. Effective management of resident-sharing relationships among NH medical staff appears to have the potential to reduce hospital transfers among long-stay residents. Large NHs and rural NHs may consider building a denser network via formal arrangements of resident-sharing among medical staff. Small NHs may benefit from a centralized network by assigning one medical practitioner to co-manage care by sharing residents with all other medical staff, while large NHs may benefit from a decentralized network where medical staff are equally accountable for care co-management. Small NHs and rural NHs may consider adopting a collaborative care model between physicians and NPPAs. Again, NHs need to take these suggestions with caution as this study did not indicate the causality of the association, i.e. that the resident sharing network measures caused the studied outcomes. Future studies can employ mixed methods to understand the underlying mechanisms of resident-sharing networks, such as the formation of resident sharing among medical staff and their causal impact on resident outcomes
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