Background: In spite of temporal advancements in medicine, hypertension (HTN) remains a leading cardiovascular risk factor with suboptimal rates of control. The burden imposed by this cardiovascular risk factor on the nation’s emergency system is not well-understood. We sought to characterize emergency department (ED) visits among adults ≥18 years that included a diagnosis of hypertension in the 2006-2010 Nationwide Emergency Department Sample. Methods: We defined hypertension using ICD-9 diagnosis codes based on the Agency for Healthcare Research and Quality indicators for potentially preventable conditions. Appropriate sampling weights were applied to obtain national estimates and 95% confidence intervals. Results: Over the 5-year period, the estimated total annual rate of ED visits among US adults was 98.3 million - 19.9% (n=19,534,992) of these visits included HTN as diagnosis. Rates of ED visits with HTN tended to increase over time [ 2006: 18.1 (17.6 - 18.6), 2007: 19.0 (18.5 - 19.5); 2008: 20.0 (19.4 - 20.5); 2009: 20.7 (20.1 - 21.3); 2010: 21.5 (20.9 - 22.1)]. Annual weighted rates of HTN varied across age groups, payer status, and neighborhood income ( Table ). In the multivariable logistic regression model, that accounted for clustering and sampling weights, the odds of ED visits with HTN was significantly lower among younger patients and those who were uninsured/self-pay, higher among Medicare recipients, and lower among patients from neighborhoods with higher median income or urban locations. Conclusion: Between 2006 and 2010, an estimated 1,953 per 10,000 visits to the ED each year included a diagnosis of hypertension among adult patients. National estimates of ED visits with HTN differ across patient and hospital characteristics, and likely represent an opportunity to monitor and address the burden of this potentially preventable condition.

BACKGROUND:Health care costs associated with use of complementary and alternative medicine (CAM) by patients with spine problems have not been studied in a national sample. OBJECTIVES:To estimate the total and spine-specific medical expenditures among CAM and non-CAM users with spine problems. RESEARCH DESIGN:Analysis of the 2002-2008 Medical Expenditure Panel Survey. SUBJECTS:Adults (above 17 y) with self-reported neck and back problems who did or did not use CAM services. MEASURES:Survey-weighted generalized linear regression and propensity matching to examine expenditure differences between CAM users and non-CAM users while controlling for patient, socioeconomic, and health characteristics. RESULTS:A total of 12,036 respondents with spine problems were included, including 4306 (35.8%) CAM users (40.8% in weighted sample). CAM users had significantly better self-reported health, education, and comorbidity compared with non-CAM users. Adjusted annual medical costs among CAM users was $424 lower (95% confidence interval: $240, $609; P<0.001) for spine-related costs, and $796 lower (95% confidence interval: $121, $1470; P = 0.021) for total health care cost than among non-CAM users. Average expenditure for CAM users, based on propensity matching, was $526 lower for spine-specific costs (P<0.001) and $298 lower for total health costs (P = 0.403). Expenditure differences were primarily due to lower inpatient expenditures among CAM users. CONCLUSIONS:CAM users did not add to the overall medical spending in a nationally representative sample with neck and back problems. As the causal associations remain unclear in these cross-sectional data, future research exploring these cost differences might benefit from research designs that minimize confounding.

Most healthcare quality improvement and cost reduction efforts currently focus on care processes, or transitions-for example, the hospital discharge process. While identification and adoption of best practices to address these aspects of healthcare are essential, more is needed for systems that serve vulnerable populations: to account for social factors that often inhibit patients' ability to take full advantage of available healthcare. Our urban safety net healthcare system developed and implemented an innovative quality improvement approach. The programs, Guided Chronic Care (TM), and Passport to Wellness, use Assertive Care and provide social support for patients between medical encounters, enabling patients to make better use of the healthcare system and empowering them to better manage their conditions. Results: The majority of patients reported problems with mobility and nearly half reported anxiety or depression. Early indications show improved quality of care and significant reduction in costs. Challenges encountered and lessons learned in implementing the programs are described, to assist others developing similar interventions.

OBJECTIVES Complementary and alternative medicine (CAM) providers are becoming more integrated into the United States health care system. Because patients self-select CAM use, risk adjustment is needed to make the groups more comparable when analyzing utilization. This study examined how the choice of risk adjustment method affects assessment of CAM use on overall health care utilization. DESIGN AND SUBJECTS Insurance claims data for 2000-2003 from Washington State, which mandates coverage of CAM providers, were analyzed. Three (3) risk adjustment methods were compared in patients with musculoskeletal conditions: Adjusted Clinical Groups (ACG), Diagnostic Cost Groups (DCG), and the Charlson Index. Relative Value Units (RVUs) were used as a proxy for expenditures. Two (2) sets of median regression models were created: prospective, which used risk adjustments from the previous year to predict RVU in the subsequent year, and concurrent, which used risk adjustment measures to predict RVU in the same year. RESULTS The sample included 92,474 claimants. Prospective models showed little difference in the effect of CAM use on RVU among the three risk adjustment methods, and all models had low predictive power (R(2) ≤0.05). In the concurrent models, coefficients were similar in direction and magnitude for all risk adjustment methods, but in some models the predicted effect of CAM use on RVU differed by as much as double between methods. Results of DCG and ACG models were similar and were stronger than Charlson models. CONCLUSIONS Choice of risk adjustment method may have a modest effect on the outcome of interest.

Copyright information: Taken from of life at the end of lifehttp://www.hqlo.com/content/5/1/51Health and Quality of Life Outcomes 2007;5():51-51.Published online 3 Aug 2007PMCID:PMC2077331. Smith.

OBJECTIVES:The purpose of this analysis was to compare health care expenditures between insured patients with back pain, fibromyalgia syndrome, or menopause symptoms who used complementary and alternative medical (CAM) providers for some of their care to a matched group of patients who did not use any CAM care. Insurance coverage was equivalent for both conventional and CAM providers.DESIGN:Insurance claims data for 2000-2003 from Washington State, which mandates coverage of CAM providers, were analyzed. CAM-using patients were matched to CAM-nonusing patients based on age group, gender, index medical condition, overall disease burden, and prior-year expenditures.RESULTS:Both unadjusted tests and linear regression models indicated that CAM users had lower average expenditures than nonusers. (Unadjusted: $3,797 versus $4,153, p = 0.0001; beta from linear regression -$367 for CAM users.) CAM users had higher outpatient expenditures that which were offset by lower inpatient and imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than nonusers, p < 0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens.CONCLUSIONS:This analysis indicates that among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM.

We used exploratory factor analysis within the confirmatory analysis framework, and data provided by family members and friends of 205 decedents in Missoula, Montana, to construct a model of latent-variable domains underlying the Quality of Dying and Death questionnaire (QODD). We then used data from 182 surrogate respondents, who were survivors of Seattle decedents, to verify the latent-variable structure. Results from the two samples suggested that survivors' retrospective ratings of 13 specific aspects of decedents' end-of-life experience served as indicators of four correlated, but distinct, latent-variable domains: Symptom Control, Preparation, Connectedness, and Transcendence. A model testing a unidimensional domain structure exhibited unsatisfactory fit to the data, implying that a single global quality measure of dying and death may provide insufficient evidence for guiding clinical practice, evaluating interventions to improve quality of care or assessing the status or trajectory of individual patients. In anticipation of possible future research tying the quality of dying and death to theoretical constructs, we linked the inferred domains to concepts from identity theory and existential psychology. We conclude that research based on the current version of the QODD might benefit from the use of composite measures representing the four identified domains, but that future expansion and modification of the questionnaire are in order.

This study investigated provider-based complementary/alternative medicine use and its association with receipt of recommended vaccinations by children aged 1-2 years and with acquisition of vaccine-preventable disease by children aged 1-17 years. Results were based on logistic regression analysis of insurance claims for pediatric enrollees covered by two insurance companies in Washington State during 2000-2003. Primary exposures were use of chiropractic, naturopathy, acupuncture, or massage practitioner services by pediatric enrollees or members of their immediate families. Outcomes included receipt by children aged 1-2 years of four vaccine combinations (or their component vaccines) covering seven diseases, and acquisition of vaccine-preventable diseases by enrollees aged 1-17 years. Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations. Children aged 1-17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. Use of provider-based complementary/alternative medicine by other family members was not independently associated with early childhood vaccination status or disease acquisition. Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. Interventions enlisting the participation of complementary/alternative medicine providers in immunization awareness and promotional activities could improve adherence rates and assist in efforts to improve public health.

BACKGROUND Women with ovarian cancer have reported abdominal/pelvic pain, bloating, difficulty eating or feeling full quickly, and urinary frequency/urgency prior to diagnosis. We explored these findings in a general population using a dataset of insured women aged 40-64 and investigated the potential effectiveness of a routine review of claims data as a prescreen to identify women at high risk for ovarian cancer. METHODS Data from a large Washington State health insurer were merged with the Seattle-Puget Sound Surveillance, Epidemiology and End Results (SEER) cancer registry for 2000-2004. We estimated the prevalence of symptoms in the 36 months prior to diagnosis for early and late-stage ovarian cancer cases and for two comparison groups. The potential performance of a passive screener that would flag women with two or more visits for any of the symptoms in the previous 2-month period was examined. RESULTS Of the 223,903 insured women, 161 had incident cases of ovarian cancer. Both early and late-stage patients had a higher prevalence of abdominal/pelvic pain and bloating than the comparison groups, primarily in the 3 months before diagnosis. The passive screener had a sensitivity of 0.31 and specificity of 0.83 and usually identified women right before diagnosis. Assuming an average cost of $500 per false positive, the screener would be considered cost-effective if the true positives had an average increase of 8.5 years of life expectancy. CONCLUSIONS These results support previous findings that ovarian cancer symptoms were reported in health insurance claims and were more prevalent before diagnosis, but the symptoms may occur too close to the diagnosis date to provide useful diagnostic information. The passive screening approach should be reevaluated in the future using electronic medical records; if found to be effective, the method may be potentially useful for other incident diseases.

This study investigated end-of-life priorities of terminally ill patients and their intimate associates. A primary goal was to reduce the number of items in an existing instrument measuring survivors' evaluations of the quality of dying and death. Three Seattle-area patient samples (chronic obstructive pulmonary disease patients, hospice patients, and participants in an efficacy trial of complementary comfort care) and their significant others provided priority rankings of 26 experiences at end of life. Two items represented top priorities for all subgroups: time with family/friends and pain control. Clustered multivariate probit regression models suggested only a few significant differences between participant groups in priority rankings: higher education increased the priority placed on having available means to hasten death, cancer patients and persons in the hospice sample (likely those experiencing disproportionate pain) assigned pain control higher priority than other groups, persons in the clinical trial (which included massage as an intervention) assigned higher priority to human touch, and racial/ethnic minorities emphasized the importance of having funeral arrangements made. In the clinical trial sample (the most recently interviewed), the importance attributed to taking care of health care costs increased over time. If researchers were to use a reduced set of the 17 items mentioned among the top five priorities by at least 10% of the sample, none of the items that varied significantly between subgroups or over time would be eliminated. This change would reduce respondent burden in future investigations, simplify analyses aimed at identifying domains underlying the dying-and-death experience, and exclude the top-priority item of fewer than 4% of respondents.

Improving end-of-life care is a priority in the United States, but assigning priorities for standard care services requires evaluations using appropriate study design and appropriate outcome indicators. A recent randomized controlled trial with terminally ill patients produced no evidence of benefit from massage or guided meditation, when evaluated with measures of global quality of life or pain distress over the course of patient participation. However, reanalysis using a more targeted outcome, surrogates’ assessment of patients’ benefit from the study intervention, suggested significant gains from massage—the treatment patients gave their highest preassignment preference ratings. The authors conclude that adding a menu of complementary therapies as part of standard end-of-life care may yield significant benefit, that patient preference is an important predictor of outcome, and that modifications in trial design may be appropriate for end-of-life studies.

Purpose: To describe the use of chiropractic care by urban and rural residents in Washington state with musculoskeletal diagnoses, all of whom have insurance coverage for this care. The analyses investigate whether restricting the analyses to insured individuals attenuates previously reported differences in the prevalence of chiropractic use between urban and rural residents as well as whether differences in provider availability or patient cost-sharing explain the difference in utilization. Methods: Claims data from 237,500 claimants in 2 large insurance companies in Washington state for calendar year 2002 were analyzed, using adjusted clinical group risk adjustment for differences in disease burden and rural urban commuting area codes for rurality definition. Findings: The proportion of claimants using chiropractors was higher in rural than urban residents (44% vs 32%, P < .001). Lack of conventional providers in rural areas did not completely explain this difference, nor did differences in patient cost-sharing or demographics. Among those who used chiropractors, those in urban areas had more chiropractic visits than users of chiropractic in rural areas. Conclusions: Among insured adults, use of chiropractic care was higher in rural than in urban areas. Reasons suggested for this difference in previous reports were not borne out in this data set.

This article reports findings from a randomized controlled trial of massage and guided meditation with patients at the end of life. Using data from 167 randomized patients, the authors considered patient outcomes through 10 weeks post-enrollment, as well as next-of-kin ratings of the quality of the final week of life for 106 patients who died during study participation. Multiple regression models demonstrated no significant treatment effects of either massage or guided meditation, delivered up to twice a week, when compared with outcomes of an active control group that received visits from hospice-trained volunteers on a schedule similar to that of the active treatment arms. The authors discuss the implications of their findings for integration of these complementary and alternative medicine therapies into standard hospice care.

We have optimized a simple and rapid preparation procedure for mushroom DNA extraction from colonies on media or from fruiting bodies for PCR amplification. The protocol combines microwaving twice for 1 min, cooling for 10 min, and centrifuging for 5 min. By using this procedure, more than 100 samples of mushroom DNA can be prepared within 1 h. The DNA obtained can be used for (1) identifying mushroom species by PCR and subsequent sequencing, (2) amplifying low copy number genes (at least 2,000 bp), and (3) screening genetic transformants. This technique will contribute to the mycology of mushroom species.

OBJECTIVE To assess the use of complementary and alternative medicine (CAM) providers and the associated expenditures by specific treatment phases among patients with cancer. STUDY DESIGN Cross-sectional analysis of medical services utilization and expenditures during the 3 therapeutic phases of initial, continuing, and end-of-life life treatment. METHODS Analysis of an insurance claims database that had been matched to the Washington State Surveillance, Epidemiology, and End Results cancer registry. RESULTS Of 2900 registry-matched patients, 63.2% were female, the median age was 54 years, and 92.7% were of white race/ethnicity. Breast cancer was the most frequent diagnosis (52.7%), followed by prostate cancer (24.7%), lung cancer (10.1%), colon cancer (7.0%), and hematologic malignancies (5.6%). Patients using CAM providers represented 26.5%. The proportion of patients using CAM was similar during each treatment phase. All patients used some conventional care. Age, female sex, breast cancer diagnosis, and white race/ethnicity were significant predictors of CAM use. Diagnosis of a musculoskeletal problem occurred at some time during the study for 72.1% of patients. CAM provider visits represented 7.2% of total outpatient medical visits, and 85.1% of CAM visits resulted in a musculoskeletal diagnosis. Expenditures for CAM providers were 0.3%, 1.0%, and 0.1% of all expenditures during the initial, continuing, and end-of-life phases, respectively. CONCLUSIONS For patients with cancer, musculoskeletal issues were the most commonly listed diagnosis made by a CAM provider. Although expenditures associated with CAM are a small proportion of the total, additional studies are necessary to determine the importance that patients place on access to these services.

Purpose: The role that sex education plays in the initiation of sexual activity and risk of teen pregnancy and sexually transmitted disease (STD) is controversial in the United States. Despite several systematic reviews, few epidemiologic evaluations of the effectiveness of these programs on a population level have been conducted.Methods: Among never-married heterosexual adolescents, aged 15-19, years, who participated in Cycle 6 (2002) of the National Survey of Family Growth and reported on formal sex education received before their first sexual intercourse (n = 1719), we compared the sexual health risks of adolescents who received abstinence-only and comprehensive sex education to those of adolescents who received no formal sex education. Weighted multivariate logistic regression generated population-based estimates.Results: Adolescents who received comprehensive sex education wen, significantly less likely to report teen pregnancy (ORadj = .4, 95% CI = .22-69, p = .001) than those who received no formal sex education, whereas there was no significant effect of abstinence-only education (ORadj = .7, 95% CI = .38-1.45, p = .38). Abstinence-only education did not reduce the likelihood of engaging in vaginal intercourse (ORadj = .8, 95% CI = .51-1.31, p = .40), but comprehensive sex education was marginally associated with a lower likelihood of reporting having engaged in vaginal intercourse (ORadj = -7, 95% CI = .49-1.02, p = .06). Neither abstinence-only nor comprehensive sex education significantly reduced the likelihood of reported STD diagnoses (ORadj = 1.7, 95% CI = .57-34.76, p = .36 and ORadj = 1.8, 95% CI = .67-5.00, p = .24 respectively).Conclusions: Teaching about contraception was not associated with increased risk of adolescent sexual activity or STD. Adolescents who received comprehensive sex education had a lower risk of pregnancy than adolescents who received abstinence-only or no sex education. 0 2008 Society for Adolescent Medicine. All rights reserved.