OBJECTIVES:Edentulism and diabetes mellitus (DM) are frequently seen among older adults. However, the joint effect of edentulism and DM on mortality was understudied. We aim to examine the joint effect of edentulism and DM on all-cause mortality and to what extent the joint effect varies by race/ethnicity. METHODS:Analysis of US Health and Retirement Study (HRS) data (2006-2018) included 11,813 non-Hispanic Whites, 2216 non-Hispanic Blacks, and 1337 Hispanics aged ≥ 50 years old. Mortality data came from the National Death Index or HRS surveys. Edentulism was self-reported and DM was determined by self-reported diagnosis, medication use, or glycosylated hemoglobin. Cox proportional-hazard models with inverse probability treatment weighting were applied. RESULTS:During mean follow-up of 9.6 years, 2874 Whites, 703 Blacks, and 441 Hispanics died. DM was associated with higher mortality across all groups (Whites: HR = 1.43, 95% CI = 1.25-1.64; Blacks: HR = 1.62, 95% CI = 1.28-2.04; Hispanics: HR = 1.46, 95% CI = 1.07-1.99). However, edentulism predicted higher mortality only in Whites (HR = 1.65, 95% CI = 1.51-1.80). Having both conditions showed highest mortality risk in all groups (Whites: HR = 2.31, 95% CI = 1.56-3.42; Blacks: HR = 1.94, 95% CI = 1.45-2.59; Hispanics: HR = 1.77, 95% CI = 1.16-2.70), with a significant additive interaction observed only in Whites (relative excess risk due to interaction = 0.22, p < 0.05). CONCLUSIONS:DM and edentulism pose an additive risk for mortality in Whites, and there are racial/ethnic differences in edentulism-related mortality.

This article reviews economic studies based on data from high income countries published from 2007 to early 2024 to address three questions: (1) How accurate are subjective beliefs, mainly measured by subjective probabilities, compared to their objective counterparts? Objective evidence comes from another source (e.g., life table, empirical study, expert opinion), or subsequent realizations of beliefs elicited at baseline. (2) How are subjective beliefs determined? (3) Do subjective beliefs affect health behaviors? Several domains are included: survival, and health behaviors—smoking, alcohol consumption and impaired driving, preventive care, diet, and COVID-19 precautions. Results on a single domain, (e.g., survival), do not generalize to, e.g., COVID-19 results. Subjective probabilities embody private information (e.g., self-assessed health, parent longevity). However, individuals seem insufficiently informed about population-level probabilities. There is no systematic overestimation or underestimation of objective probabilities. Several determinants of beliefs are identified (demographic characteristics, education, cognition, current self-assessed health, health histories), but evidence on underlying mechanisms is lacking, how determinants, (e.g., education), affect beliefs. Subjective beliefs, even with substantial noise, often affect health behaviors. Given prior evidence that beliefs are influenced by health shocks, this article reviews research on effects of health shocks on health behaviors. A major health shock to an individual—a new diagnosis (e.g., diabetes) or a serious adverse health event (e.g., heart attack), by changing subjective probabilities leads to some healthier behaviors, however, sometimes only temporarily. Behaviors may also be influenced by utility loss following a health shock, e.g., learning about pecuniary and non-pecuniary costs of hospitalization.

PURPOSE:To quantify patient reported treatment burden while receiving intravesical therapy for bladder cancer and to survey patient perspectives on in-home intravesical therapy. MATERIALS AND METHODS:We conducted a cross-sectional survey of the Bladder Cancer Advocacy Network Patient Survey Network. Survey questions were developed by investigators, then iteratively revised by clinician and patient advocates. Eligible participants had to have received at least 1 dose of intravesical therapy delivered in an ambulatory setting. RESULTS:Two hundred thirty-three patients responded to the survey with median age of 70 years (range 33-88 years). Two-thirds of respondents (66%, 151/232) had received greater than 12 bladder instillations. A travel time of >30 minutes to an intravesical treatment facility was reported by 55% (126/231) of respondents. Fifty-six percent (128/232) brought caregivers to their appointments, and 36% (82/230) missed work to receive treatment. Sixty-one respondents (26%) felt the process of receiving bladder instillations adversely affected their ability to perform regular daily activities. Among those surveyed, 72% (168/232) reported openness to receiving in-home intravesical instillations and 54% (122/228) answered that in-home instillations would make the treatment process less disruptive to their lives. CONCLUSIONS:Bladder cancer patients reported considerable travel distances, time requirements, and need for caregiver support when receiving intravesical therapy. Nearly three-quarters of survey respondents reported openness to receiving intravesical instillations in their home, with many identifying potential benefits for home over clinic-based therapy.

You have accessJournal of UrologyCME1 Apr 2023MP48-06 PATIENT-REPORTED TREATMENT BURDEN OF INTRAVESICAL THERAPY FOR BLADDER CANCER Amanda Myers, Benjamin Ristau, Matthew Mossanen, Deborah Kaye, Mark Tyson, Stephanie Chisolm, Frank Sloan, Colleen Ball, Angela Smith, and Timothy Lyon Amanda MyersAmanda Myers More articles by this author , Benjamin RistauBenjamin Ristau More articles by this author , Matthew MossanenMatthew Mossanen More articles by this author , Deborah KayeDeborah Kaye More articles by this author , Mark TysonMark Tyson More articles by this author , Stephanie ChisolmStephanie Chisolm More articles by this author , Frank SloanFrank Sloan More articles by this author , Colleen BallColleen Ball More articles by this author , Angela SmithAngela Smith More articles by this author , and Timothy LyonTimothy Lyon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intravesical therapy is the mainstay of treatment for non-muscle invasive bladder cancer (NMIBC). However, patients with NMIBC can face time, travel, and financial barriers to access intravesical therapy which may impact patient adherence to treatment. Therefore, we sought to quantify patient-reported treatment burden while receiving intravesical therapy for bladder cancer. METHODS: We conducted a cross-sectional survey of bladder cancer patients in the Bladder Cancer Advocacy Network (BCAN) Patient Survey Network to investigate patient-reported burden of intravesical therapy. Multiple choice survey questions were developed by investigators, then iteratively revised and improved by review from clinician and patient advocate stakeholders during the 2021 BCAN annual meeting. Eligible participants received at least one dose of intravesical therapy, including BCG and/or chemotherapy, delivered in an ambulatory setting. Survey was administered in November 2021 and was available for 1 month to respondents. RESULTS: A total of 233 patients responded to the survey (18% response rate), with a median age of 70 years (range 33-88). Respondents were 36% female and 97% white. A travel time >30 minutes to an intravesical treatment facility was reported by 55% (126/231) of patients, and 33% (77/231) reported personal out-of-pocket costs greater than $25 associated with each trip. Fifty-six percent (129/232) brought caregivers to their appointments. More than half of patients (56%, 129/232) reported spending more than 2 hours on each intravesical instillation, with 18% (42/232) spending more than 4 hours. Missing work for intravesical installations was reported by 36% (82/230) of patients, and of those who did, the majority (70%, 57/81) missed at least half a day of work (4 or more hours). Sixty-one respondents (26%) felt the process of receiving bladder instillations adversely affected their ability to perform regular daily activities. BCG shortages increased travel or wait time for intravesical therapy for 9% (20/229) of respondents. CONCLUSIONS: Bladder cancer patients reported considerable travel distances, time requirements, out-of-pocket costs, and need for caregiver support in the process of receiving intravesical therapy. Innovative intravesical care delivery processes are needed to reduce the burden of care for our bladder cancer patients. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e657 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Myers More articles by this author Benjamin Ristau More articles by this author Matthew Mossanen More articles by this author Deborah Kaye More articles by this author Mark Tyson More articles by this author Stephanie Chisolm More articles by this author Frank Sloan More articles by this author Colleen Ball More articles by this author Angela Smith More articles by this author Timothy Lyon More articles by this author Expand All Advertisement PDF downloadLoading ...

Diabetes mellitus (DM) is a recognized risk factor for dementia, and increasing evidence shows that tooth loss is associated with cognitive impairment and dementia. However, the effect of the co-occurrence of DM and edentulism on cognitive decline is understudied. This 12-y cohort study aimed to assess the effect of the co-occurrence of DM and edentulism on cognitive decline and examine whether the effect differs by age group. Data were drawn from the 2006 to 2018 Health and Retirement Study. The study sample included 5,440 older adults aged 65 to 74 y, 3,300 aged 75 to 84 y, and 1,208 aged 85 y or older. Linear mixed-effect regression was employed to model the rates of cognitive decline stratified by age cohorts. Compared with their counterparts with neither DM nor edentulism at baseline, older adults aged 65 to 74 y (β = −1.12; 95% confidence interval [CI], −1.56 to −0.65; P < 0.001) and those aged 75 to 84 y with both conditions (β = −1.35; 95% CI, −2.09 to −0.61; P < 0.001) had a worse cognitive function. For the rate of cognitive decline, compared to those with neither condition from the same age cohort, older adults aged 65 to 74 y with both conditions declined at a higher rate (β = −0.15; 95% CI, −0.20 to −0.10; P < 0.001). Having DM alone led to an accelerated cognitive decline in older adults aged 65 to 74 y (β = −0.09; 95% CI, −0.13 to −0.05; P < 0.001); having edentulism alone led to an accelerated decline in older adults aged 65 to 74 y (β = −0.13; 95% CI, −0.17 to −0.08; P < 0.001) and older adults aged 75 to 84 (β = −0.10; 95% CI, −0.17 to −0.03; P < 0.01). Our study finds the co-occurrence of DM and edentulism led to a worse cognitive function and a faster cognitive decline in older adults aged 65 to 74 y.

from 96.4% to 99.7%, and proportion of POP-p performed OP increased from 76.5% to 82.8%. 99.9% of OAB-p were performed OP. Charges for SUI-p performed IP were $16,705 higher than those performed OP (p [ 0.007) and charges for POP-p performed IP were $21,864 higher than those performed OP (p < 0.0001). Predictors of SUI-p and POP-p being performed OP included private insurance, fewer co-morbidities, and receiving care at a rural facility or at a center in the Midwest or South. Additionally, SUI-p were more likely to be performed OP for patients < 52 years of age. POP-p were more likely to be performed IP than SUI-p (OR 20.8; 95% CI 20.2 - 21.5), while OAB-p were less likely to be performed IP than SUI-p (OR 0.01; 95% CI 0.01 e 0.02). CONCLUSIONS: An increasing majority of SUI and OAB pro- cedures performed nationwide are performed in OP settings. These procedures performed OP carry less charge than those performed IP and are more likely for younger, healthier patients with private insurance.

This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP) hospitals or non-federal public (PUB) hospitals? Alternative theories of NFP behavior are described. Our review of individual empirical hospital studies of quality, service mix, community benefit, and cost/efficiency in the United States published since 2000 indicates that no systematic difference exists in cost/efficiency, provision of uncompensated care, and quality of care. But FPs are more likely to provide profitable services, higher service intensity, have lower shares of uninsured and Medicaid patients, and are more responsive to external financial incentives. That FP hospitals are not more efficient runs counter to property rights theory, but their relative responsiveness to financial incentives supports it. There is little evidence that FP market presence changes NFP behaviors. Observed differences between FP and NFP hospitals are mostly a "little deal."

Abstract This study examined the relationships between the concomitance of diabetes mellitus (DM) and edentulism and mortality among Black, Hispanic, and White older adults in the US. We used data from the 2006-2016 Health and Retirement Study with 2,108 Black, 1,331 Hispanic, and 11,544 White respondents aged 50+. Results of weighted Cox proportional hazards models showed that the concomitance of DM and edentulism was associated with a higher mortality risk for Blacks (Hazard Ratio [HR] = 1.58, p < 0.01), Hispanics (HR = 2.16, p < 0.001) and Whites (HR = 1.61, p < 0.001). Findings also indicated that DM was a risk factor for mortality across all racial/ethnic groups, but edentulism was a risk factor only for Whites (HR = 1.30, p < 0.001). This study revealed that the risk of DM and edentulism on mortality varied among racial/ethnic groups. Our study gives alternative explanations for the observed findings.

China has made profound progress in advancing universal health coverage (UHC) over the past two decades. New Cooperative Medical Scheme (NCMS) was initiated in 2003 to provide health insurance coverage to rural population. Its benefit packages and cost-sharing mechanism have changed significantly over time. This study aims to assess the impact of changing NCMS policies on NCMS enrollees' service utilisation, medical financial burden and equity between 2003 and 2013. Data are from China National Health Services Survey (NHSS) which is conducted every 5 years. We used the subsample of NHSS that were enrolled in NCMS in 2003, 2008 and 2013. From 2003 to 2013, we found increased service utilisation and an elimination of inequity in service utilisation with respect to income. Contradicting prior findings of increasing financial burden after the NCMS implementation, we identified significant protective effect of NCMS against financial risks, and a reduction in percentage of households with high medical expenditure in the middle-income and high-income quintiles. The rural residents from the low-income groups have high financial risk, therefore, should be the priority target for future reforms. In pursuit of UHC globally, many countries struggle to provide good coverage to the disadvantaged rural population and balance between the competing priorities of various UHC dimensions. Our trend analysis revealed China's two-stage approach with NCMS reform that first focused on expanding population coverage, then on service coverage and financial risk protection. This path could potentially be replicated in other middle-income and low-income countries to pave the way for UHC.

Book Review Health AffairsVol. 40, No. 8: Prescription Drugs, Global Health & More Complexities Of US Health CareFrank A. Sloan AffiliationsFrank A. Sloan ([email protected]) is the J. Alexander McMahon Distinguished Professor Emeritus of Health Policy and Management and a professor emeritus of economics at Duke University, in Durham, North Carolina.PUBLISHED:August 2021Free Accesshttps://doi.org/10.1377/hlthaff.2021.01086AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth care providersTechnologyResearchersPharmaceuticalsGovernment programs and policiesMedical devicesIn 550 pages Rob Burns provides a comprehensive descriptive account of US health care as it exists today. The U.S. Healthcare Ecosystem consists of five sections containing twenty-six chapters on a wide range of topics. Section I is an introduction to US health care. Section II centers on specific providers of health care, including both traditional providers and newer forms of health services delivery. Section III covers private and public payers and how they oversee the care they cover. Section IV describes health-sector technology, and Section V provides a further description of the public sector as it pertains to health care, including the roles of federal, state, and local governments.As the eleven initial pages of brief comments on The U.S. Healthcare Ecosystem emphasize, this book not only is a uniquely comprehensive, up-to-date description of US health care but also reflects Burns’s considerable experience as a researcher, teacher, and mentor, most recently and for years in the health care program at the University of Pennsylvania’s Wharton School. All of the book’s chapters provide useful information. To me, the sections on providers and technology sectors are particularly outstanding. Much of the material in the introduction to the US health care system and the discussion of the public sector is largely available from other sources. However, if an instructor is limited to one book, it is good to have all of the relevant material in one place.I have worked for decades on the supply-side issues described in the section on providers. Nevertheless, during my reading of this section, I again realized how much I have to learn. In particular, Burns brings readers up to date on the latest issues (as of the past two or three years), displaying in-depth knowledge of institutional details. Some of my fellow economists seem to think that “institutional” is outmoded. I disagree. This book contains immense detail on health care institutions that is new information even for experts.I did find that the rationale for public-sector involvement in health care takes a back seat in this book. To illustrate, the words “federal bureaucracy” appear in the title of the chapter on Medicare and Medicaid, which is situated near the end of the book. This seems reminiscent of Ronald Reagan’s remark that “Government is the problem.” I could not find a discussion of “externalities,” or the costs or benefits that affect people other than the patient who received the personal health care services, in the text, either.The book is very strong on descriptive detail. There are many figures—too many for the author to adequately describe in the text. I did not find any discussion of such concepts as moral hazard or adverse selection, and little on risk selection by payers and the complexities of risk adjustment. Economies of scale are mentioned, but readers are told little about what the empirical evidence shows or how they have been measured. The author often summarizes findings from a body of literature in a sentence or two. As an empirical researcher, I wonder how the author arrived at his conclusions. Is “no effect” a reflection of conflicting findings or consistent insignificant parameter estimates? Has greater weight been given to the more methodologically sound studies? Are conclusions based on meta-analysis? In addition, often a term is used before it is explained, such as “drug formularies.” I would prefer explaining the meaning of the term (even in a box) the first time it is introduced rather than later in the chapter.My criticisms are not fatal flaws. Many nonstudent readers will be familiar with the above concepts. Students may have to rely on other texts for fuller explanations of some key concepts. Sometimes we professors go too deeply into methodological detail, but my preference is to have more theory and more information on empirical methods than the book provides. There is a risk that some readers will infer that conclusions are just opinions with which they can disagree. The book has “questions to ponder” at the end of each chapter. Some of the questions are hard to answer using just the material in the book—in these cases, professors will need to provide additional background information.In sum, this book is well worth reading if you are a graduate student in health care management or health economics or a researcher interested in health care. Public policy makers and graduate students in public policy can learn a lot, provided they overcome the book’s comparatively greater emphasis on business. Undergraduates will want to know what is on the test and will need some direction from their professors. The book’s role is not to eliminate professors but, rather, to provide complementary material for their use. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 August 2021 Information© 2021 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

424 Background: FDA guidelines for NMIBC clinical trial design have stimulated a marked increase in NMIBC trial conduct. However, NMIBC patient (PT) input to define acceptable treatment toxicity thresholds and clinical measures most meaningful to NMIBC PTS has been lacking. We conducted a survey to investigate treatment side effect tolerance levels, respondent-ranked clinical relevance of various trial efficacy measures, and differences in responses between PTS, caregivers (CG), and healthcare providers. Methods: In 8/2018, an NMIBC Patient-Driven Endpoints working group was formed at the Bladder Cancer Advocacy Network (BCAN) Think Tank meeting. Through iterative focus groups, a 21-question survey composed of 4 domains (demographics, treatment history, acceptable toxicity thresholds, and clinical benefit metrics) was designed. The BCAN Patient Survey Network and other social media platforms were utilized to distribute and publicize the survey. A unique IP address was required to eliminate duplicate respondents. Categorical and ordinal variables were reported as frequencies with 95% confidence intervals. Continuous variables were reported as medians with ranges. Frequency differences in specific variables of interest according to respondent roles were assessed by Chi-square testing with significance set at p < .05. Results: From 7/18-8/30/20, 845 survey responses were recorded. Key demographics included: 647 (76.7%) PTS, 77 CG (9.1%), 67 urologists (UROL) (7.9%), 35 medical oncologists (ONC) (4.1%), 59.8% male, 85.0% Caucasian non-Hispanic, median age 64.0 years, and 62.7% with NMIBC at diagnosis. Any reversible toxicity was deemed acceptable in 68.8% of PT, 61.0% of CG, 62.7% of UROL, and 54.3% of ONC respondents p = 0.09. Any permanent toxicity was deemed acceptable by 15.6% of PT, 11.7% of CG, 16.4% of UROL, and 20.0% of ONC respondents p = 0.54. Differences in acceptance of individual treatment related toxicities according to roles were observed p < .05 and will be presented. Mean rank order of potential clinical trial endpoints with a rank of 1 for most clinically meaningful benefit to 5 for least meaningful were 1.96 for avoidance of cystectomy, 2.13 for prevention of muscle invasion, 2.87 for 24-month recurrence free survival (RFS), 3.55 for 12-month RFS, and 3.97 for complete response rate with little variation according to respondent roles. Conclusions: Threshold levels for global reversible and permanent treatment toxicity rates were similar across respondent roles. Complete response was consistently ranked lowest in clinical relevance among all respondent roles. These survey results provide important patient and provider benchmarks for acceptable toxicity thresholds within future NMIBC trial designs and suggest an increased emphasis on bladder preservation and durability of response in evaluating the merits of new NMIBC therapies.

OBJECTIVEBoth diabetes mellitus (DM) and poor oral health are common chronic conditions and risk factors of Alzheimer's disease and related dementia among older adults. This study assessed the effects of DM and complete tooth loss (TL) on cognitive function, accounting for their interactions.METHODSLongitudinal data were obtained from the 2006, 2012, and 2018 waves of the Health and Retirement Study. This cohort study included 7,805 respondents aged 65 years or older with 18,331 person-year observations. DM and complete TL were self-reported. Cognitive function was measured by the Telephone Interview for Cognitive Status. Random-effect regressions were used to test the associations, overall and stratified by sex.RESULTSCompared with older adults without neither DM nor complete TL, those with both conditions (b = -1.35, 95% confidence interval [CI]: -1.68, -1.02), with complete TL alone (b = -0.67, 95% CI: -0.88, -0.45), or with DM alone (b = -0.40, 95% CI: -0.59, -0.22), had lower cognitive scores. The impact of having both conditions was significantly greater than that of having DM alone (p < .001) or complete TL alone (p = 0.001). Sex-stratified analyses showed the effects were similar in males and females, except having DM alone was not significant in males.CONCLUSIONThe co-occurrence of DM and complete TL poses an additive risk for cognition. Healthcare and family-care providers should pay attention to the cognitive health of patients with both DM and complete TL. Continued efforts are needed to improve older adults' access to dental care, especially for individuals with DM.

Abstract Using data from the 2006, 2012, and 2018 waves of the Health and Retirement Study, we estimated effects of co-occurrence of diabetes mellitus (DM) and complete tooth loss (CTL), both self-reported, on cognitive function among 10,816 adults age 50+. Cognitive function was measured using a shortened version of the Telephone Interview for Cognitive Status. Results from the fixed effects linear regression model show that in comparison to those with neither condition, adults having both DM and CTL had the worst cognitive function (b = 1.49, p < 0.001), followed by having CTL alone (b = 0.78, p < 0.001), and having DM alone (b = 0.42, p < 0.001). Our study suggests that CTL is a stronger risk factor for lower cognitive function than DM, and the co-occurrence of DM and CTL poses additive risk. Further research is needed to investigate the pathway from DM and CTL to poor cognition.

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.CONTEXT:The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.METHODS:Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.FINDINGS:Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.CONCLUSIONS:Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

INTRODUCTION:The aim of this research was to assess the association between inflammation and oral health and diabetes, as well as the mediating role of oral hygiene practice in this association. METHODS:Data were from the 2009-2010 National Health and Nutrition Examination Survey. The analytical sample consisted of 2,191 respondents aged 50 and older. Poor oral health was clinically defined by significant tooth loss (STL) and periodontal disease (PD). Diabetes mellitus (DM) was determined by glycemic levels. The outcome variable was serum C-reactive protein (CRP) level, dichotomised as ≥1 mg/dL (elevated CRP) vs <1 mg/dL (not elevated CRP). Two path models, one using STL and DM as the independent variable, the other using PD and DM as the independent variable, were estimated to assess the direct effects of having poor oral health and DM on elevated CRP and the mediating effects of dental flossing. RESULTS:In path model 1, individuals having both STL and DM (adjusted odds ratio [AOR], 1.92; 95% confidence interval [CI], 1.30-2.82) or having STL alone (AOR, 2.30; 95% CI, 1.68-3.15) were more likely to have elevated CRP than those with neither STL nor DM; dental flossing (AOR, 0.92, 95% CI, 0.88-0.96) was associated with lower risk of elevated CRP. In path model 2, no significant association was found between having both PD and DM and elevated CRP; dental flossing (AOR, 0.91; 95% CI:, 0.86-0.94) was associated with lower risk of elevated CRP. CONCLUSIONS:Findings from this study highlight the importance of improving oral health and oral hygiene practice to mitigate inflammation. Further research is needed to assess the longer-term effects of reducing inflammation.

Abstract We examined the impact of diabetes mellitus (DM) and edentulism on the trajectory of cognitive decline, using the Health and Retirement Study. We analyzed self-reported DM and edentulism collected in 2006 and cognition data from 2006 and its follow up waves through 2018. Among 15,709 eligible participants age 50+ in 2006, 65.96% had neither DM nor edentulism (Group 1), 15.12% had DM alone (Group 2), 13.79% had edentulism alone (Group 3), and 5.12% had both conditions (Group 4). Results from linear mixed-effects models show that in comparison to Group 1, individuals in Group 4 had the lowest level of cognitive function, followed by those in Group 3 and Group 2. Group 4 had a modestly faster rate of cognitive decline (p=0.052). This study illustrates that co-occurrence of DM and edentulism has a higher risk of more rapid cognitive decline with advancing age than the presence of each condition alone.

Although the Affordable Care Act's Medicaid expansion reduced uninsurance, less is known about its impact on mortality, especially in the context of the opioid epidemic. We conducted a difference-in-differences study comparing trends in mortality between expansion and nonexpansion states from 2011 to 2016 using the Centers for Disease Control and Prevention mortality data. We analyzed all-cause deaths, health care amenable deaths, drug overdose deaths, and deaths from causes other than drug overdose among adults aged 20 to 64 years. Medicaid expansion was associated with a 2.7% reduction (p = .020) in health care amenable mortality, and a 1.9% reduction (p = .042) in mortality not due to drug overdose. However, the expansion was not associated with any change in all-cause mortality (0.2% reduction, p = .84). In addition, drug overdose deaths rose more sharply in expansion versus nonexpansion states. The absence of all-cause mortality reduction until drug overdose deaths were excluded indicate that the opioid epidemic had a mitigating impact on any potential lives saved by Medicaid expansion.

Driving while intoxicated causes many traffic accidents and deaths. Two decisions are closely related, whether to engage in heavy drinking, and to drive, conditional on heavy drinking. This paper reviews the extensive literature on heavy drinking, addiction, and driving after heavy drinking. Relevant public policies involve a combination of deterrence, incapacitation, and treatment. While there is empirical support for the rational addiction model applied to heavy drinking, some attributes of drinker-drivers differ from others (e.g., impulsivity in domains other than alcohol consumption, hyperbolic discounting). Policies most effective in reducing drinking and driving are alcohol excise taxes, minimum drinking age and zero tolerance laws for underage persons, dram shop and social host liability, and criminal sanctions overall. Empirical studies have not determined which specific criminal sanctions are most effective. A major impediment to criminal sanctions as a deterrent is that the probability of being stopped/arrested when driving while intoxicated is extremely low,

Background: Parental criminal justice system (CJS) involvement is a marker for child protective services (CPS) involvement. Objective: To document how parental criminal case processing affects children's CPS involvement. Participants and setting: Participants included mothers and fathers with a serious criminal charge (mothers = 78,882; fathers = 165,070) and without any criminal charge (mothers = 962,963; fathers = 743,604) between 2008-2012. Statewide North Carolina records on court proceedings, births, CPS assessments/investigations, and foster care placements were used. Methods: The observational unit was an individual's first charge date of a year. Outcomes were CPS assessment/investigation and foster care entry within six months and alternatively three years following the charge. Key explanatory variables were whether the charges resulted in prosecution, conviction following prosecution, and an active sentence conditional on conviction. An instrumental variables approach was used. Results: Parents charged with a criminal offense had higher rates of having a CPS assessment/ investigation during the three years preceding the charge than parents who were not charged. Among mothers who were convicted, CPS assessment/investigation increased 8.1 percent (95 % CI: 2.2, 13.9) and 9.5 percent (95 % CI: 1.3, 17.6) 6 months and 3 years following the charge. An active sentence increased CPS assessment/investigations by 21.6 percent (95 % CI: 6.4, 36.7) within 6 months. For fathers, active sentence increased foster care placement by 1.6 percent (95 % CI: 0.24, 2.9) within 6 months of the criminal charge. Conclusions: Changing parental incarceration rates would change CPS caseloads substantially. The criminal justice and CPS systems work with overlapping populations, data and services sharing should be considered a high priority.