Explore the vast range of titles available.

Major life changes may play a causative role in health through lifestyle factors, such as alcohol. The objective was to examine the impact of stressful life events on heavy alcohol consumption among French adults. Trajectories of excessive alcohol consumption in 20,625 employees of the French national gas and electricity company for up to 5 years before and 5 years after an event, with annual measurements from 1992. We used repeated measures analysis of time series data indexed to events, employing generalized estimating equations. For women, excessive alcohol use increased before important purchase (p = 0.021), children leaving home (p<0.001), and death of loved ones (p = 0.03), and decreased before widowhood (p = 0.015); in the year straddling the event, increased consumption was observed for important purchase (p = 0.018) and retirement (p = 0.002); at the time of the event, consumption decreased for marriage (p = 0.002), divorce, widowhood, and death of loved one (all p<0.001), and increased for retirement (p = 0.035). For men, heavy alcohol consumption increased in the years up to and surrounding the death of loved ones, retirement, and important purchase (all p<0.001), and decreased after (all p<0.001, except death of loved one: p = 0.006); at the time of the event, consumption decreased for all events except for children leaving home and retirement, where we observed an increase (all p<0.001). For women and men, heavy alcohol consumption decreased prior to marriage and divorce and increased after (all p<0.001, except for women and marriage: p = 0.01). Stressful life events promote healthy and unhealthy alcohol consumption. Certain events impact alcohol intake temporarily while others have longer-term implications. Research should disentangle women's and men's distinct perceptions of events over time.

Generalized additive models for location, scale, and shape (GAMLSS) are a class of semi-parametric models with potential applicability to health care cost data. We compared the bias, accuracy, and coverage of GAMLSS estimators with two distributions [gamma and generalized inverse gaussian (GIG)] using a log link to the generalized linear model (GLM) with log link and gamma family and the log-transformed OLS. The evaluation using simulated gamma data showed that the GAMLSS and GLM gamma model had similar bias, accuracy, and coverage and outperformed the GAMLSS GIG. When applied to simulated GIG data, the GLM gamma was similar or improved in bias, accuracy, and coverage compared to the GAMLSS GIG and gamma; furthermore, the GAMLSS estimators produced wildly inaccurate or overly-precise results in certain circumstances. Applying all models to empirical data on health care costs after a fall-related injury, all estimators produced similar coefficient estimates, but GAMLSS estimators produced spuriously smaller standard errors. Although no single alternative was best for all simulations, the GLM gamma was the most consistent, so we recommend against using GAMLSS estimators using GIG or gamma to test for differences in mean health care costs. Since GAMLSS offers many other flexible distributions, future work should evaluate whether GAMLSS is useful when predicting health care costs.

Background Major life changes may play a causative role in health through lifestyle factors, such as alcohol. The objective was to examine the impact of stressful life events on heavy alcohol consumption among French adults. Methods Trajectories of excessive alcohol consumption in 20,625 employees of the French national gas and electricity company for up to 5 years before and 5 years after an event, with annual measurements from 1992. We used repeated measures analysis of time series data indexed to events, employing generalized estimating equations. Results For women, excessive alcohol use increased before important purchase (p = 0.021), children leaving home (p<0.001), and death of loved ones (p = 0.03), and decreased before widowhood (p = 0.015); in the year straddling the event, increased consumption was observed for important purchase (p = 0.018) and retirement (p = 0.002); at the time of the event, consumption decreased for marriage (p = 0.002), divorce, widowhood, and death of loved one (all p<0.001), and increased for retirement (p = 0.035). For men, heavy alcohol consumption increased in the years up to and surrounding the death of loved ones, retirement, and important purchase (all p<0.001), and decreased after (all p<0.001, except death of loved one: p = 0.006); at the time of the event, consumption decreased for all events except for children leaving home and retirement, where we observed an increase (all p<0.001). For women and men, heavy alcohol consumption decreased prior to marriage and divorce and increased after (all p<0.001, except for women and marriage: p = 0.01). Conclusion Stressful life events promote healthy and unhealthy alcohol consumption. Certain events impact alcohol intake temporarily while others have longer-term implications. Research should disentangle women's and men's distinct perceptions of events over time.

Falls in the older adult population are a substantial burden on the public's health and the nation's health care expenditures. Much is known about the epidemiology of falls and strategies to prevent falls, but comparatively little is known about fall-related injuries—particularly the cost implications of such injuries. The recent emphasis on comparative- and cost-effectiveness research as a strategy to improve the quality of health services is a step toward evidence-based public health and health care policy. Sound research and methodological techniques are needed in order to help researchers and policymakers develop effective fall prevention guidelines. This dissertation focuses on the cost implications of fall-related injuries in 3 distinct aims. Chapter 2 (Manuscript 1) presents a descriptive study of the components of health care costs associated with increased costs after a medical fall for fallers admitted to hospital for initial injury compared to those who were not admitted. The results suggest that inpatient and long-term care drive the increase in costs for admitted fallers, while outpatient and \"other\" (e.g., skilled nursing and home health) drive cost increases for nonadmitted fallers. Chapter 3 (Manuscript 2) describes a cost-benefit analysis comparing Tai Chi to multifactorial interventions to prevent medical falls. The key finding of this study is that Tai Chi has a more favorable net present value, number of medical falls prevented, and incremental cost-effectiveness ratio compared to all other alternatives, but multifactorial rehabilitation has the largest impact on its targeted medical fall rate. The study presented in Chapter 4 (Manuscript 3) seeks to improve the science of economic evaluation by comparing existing statistical models used to analyze cost data to a newly developed approach: Generalized Additive Models for Location, Scale, and Shape (GAMLSS). The analysis suggests that Generalized Linear Models (GLMs) with log link and Gamma family perform better than GAMLSS when analyzing health care cost data. Overall, these 3 papers address different aspects of the economic evaluation of fall-related injuries and have the following main findings: (1) the components driving costs after a medical fall differ by injury severity and over time; (2) public health interventions might produce the highest value opportunity for medical fall prevention, but targeted clinical interventions might have the highest comparative effectiveness; (3) cost distributions resembling those of our medical fallers' dataset are a challenge for statistical models, and GAMLSS—a new approach with potential to overcome these challenges—is not necessarily an improvement over traditional GLMs.

This article examines the cost components that drive increased total costs after a medical fall over time, by severity of injury. The study found that large cost increases after a fall that resulted in hospitalization are mainly associated with inpatient and postacute care, while cost spikes after a fall that did not result in hospitalization are due to outpatient, ambulatory surgery, and community health services. However, the components driving cost increases varied throughout the year after the medical fall.

Background Risk-adjustment (RA) models are used to account for severity of illness in comparing patient outcomes across hospitals. Researchers specify covariates as main effects, but they often ignore interactions or use stratification to account for effect modification, despite limitations due to rare events and sparse data. Three Agency for Healthcare Research and Quality (AHRQ) hospital-level Quality Indicators currently use stratified models, but their variable performance and limited interpretability motivated the design of better models. Methods We analysed patient discharge de-identified data from 14 State Inpatient Databases, AHRQ Healthcare Cost and Utilization Project, California Department of Health Care Access and Information, and New York State Department of Health. We used hierarchical group lasso regularisation (HGLR) to identify first-order interactions in several AHRQ inpatient quality indicators (IQI) - IQI 09 (Pancreatic Resection Mortality Rate), IQI 11 (Abdominal Aortic Aneurysm Repair Mortality Rate), and Patient Safety Indicator 14 (Postoperative Wound Dehiscence Rate). These models were compared with stratum-specific and composite main effects models with covariates selected by least absolute shrinkage and selection operator (LASSO). Results HGLR identified clinically meaningful interactions for all models. Synergistic IQI 11 interactions, such as between hypertension and respiratory failure, suggest patients who merit special attention in perioperative care. Antagonistic IQI 11 interactions, such as between shock and chronic comorbidities, illustrate that naïve main effects models overestimate risk in key subpopulations. Interactions for PSI 14 suggest key subpopulations for whom the risk of wound dehiscence is similar between open and laparoscopic approaches, whereas laparoscopic approach is safer for other groups. Model performance was similar or superior for composite models with HGLR-selected features, compared to those with LASSO-selected features. Conclusions In this application to high-profile, high-stakes risk-adjustment models, HGLR selected interactions that maintained or improved model performance in populations with heterogeneous risk, while identifying clinically important interactions. The HGLR package is scalable to handle a large number of covariates and their interactions and is customisable to use multiple CPU cores to reduce analysis time. The HGLR method will allow scholars to avoid creating stratified models on sparse data, improve model calibration, and reduce bias. Future work involves testing using other combinations of risk factors, such as vital signs and laboratory values. Our study focuses on a real-world problem of considerable importance to hospitals and policy-makers who must use RA models for statutorily mandated public reporting and payment programmes.

Arthrodesis of an osteoarthritic second metatarsophalangeal (MTP) joint is suboptimal because of altered gait mechanics; hence, joint-preserving procedures are of value. Autograft interpositional arthroplasty is one available option with excellent results, but there are potential concerns regarding donor site morbidity and insufficiency of the autograft material. We present here an alternative technique, an interpositional arthroplasty using allograft. Our technique includes a dorsal incision and joint exposure, removal of cartilage from the metatarsal head, and interposition of human decellularized dermal allograft sutured to the metatarsal head. Allograft interpositional arthroplasty is a feasible technique and can be further investigated as an alternative procedure for patients with second MTP osteoarthritis. Level of Evidence: Level V, expert opinion.

Category: Lesser Toes Introduction/Purpose: Success has been reported in treating first metatarsophalangeal joint osteoarthritis with allograft interpositional arthroplasty, but little has been published regarding the use of similar techniques for the second metatarsophalangeal joint. We hypothesized that second metatarsophalangeal joint allograft interpositional arthroplasty would result in improvement in patient-reported outcomes, a low rate of postoperative complications, and a low rate of reoperation at minimum follow-up of one year. Methods: A retrospective review of medical records was conducted for patients having undergone allograft interpositional arthroplasty of the second metatarsophalangeal joint with at least one year of postoperative follow-up. Our technique included a dorsal incision and joint exposure, removal of the cartilage from the metatarsal head using a conical reamer, suture of a human decellularized dermal allograft to the metatarsal head though drill holes, and capsular repair (Figure 1). Preoperative and postoperative findings were compared, including Foot Function Index (FFI) and radiographic joint space measured on the AP view. Postoperative range of motion and satisfaction with the procedure were quantified. Results: In total, 5 patients met inclusion criteria. Mean follow-up was 3.2+/-2.1 years. Three of 5 patients (60.0%) reported that they would have the procedure again, and mean satisfaction with the procedure was 6.0+/-5.1 out of 10. One patient had conversion to fusion at 2 postoperative years. Among the 4 unfused patients, Foot Function Index decreased from 75.7+/-29.8 preoperatively to 52.0+/-46.5 at final follow-up (p=0.526). Mean final arc of motion was 35.0+/-7.1 degrees. Radiographic joint space was 0.4+/-0.3 mm preoperatively, increased to 2.2+/-0.5 mm immediately postoperatively, and decreased to 1.5+/-0.8 mm at final follow-up. The final follow-up joint space trended towards a larger number among the patients who stated they would have the procedure again compared to the patients who stated they would not (2.6+/-1.0 mm versus 0.4+/-0.4 mm, p=0.178). Conclusion: Second metatarsophalangeal joint allograft interpositional arthroplasty is a reasonable alternative to arthrodesis for management of isolated late-stage second metatarsophalangeal joint osteoarthritis. Arthrodesis of the second metatarsophalangeal joint is suboptimal due to altered gait mechanics; hence, novel joint preserving procedures are of value. Despite the modest results of interpositional arthroplasty in this limited series, the procedure can result in pain relief while allowing for motion in a subset of patients. The major determinant of success among our cohort was the maintenance of radiographic joint space at final follow-up.

Category: Other Introduction/Purpose: Scribes are utilized as a means to reduce administrative burden on surgeons and enhance the physician- patient interaction. Virtual scribe services (VSS) are a contemporary take on the scribe that use a HIPAA-compliant smart device to record patient encounters for transmission, remote transcription, and insertion into the electronic medical record. The purpose of this study was to determine if the use of a VSS could decrease the total time an orthopaedic surgeon spends on documentation without diminishing the patient experience when compared to traditional post-encounter dictation (TD). Methods: Patients presenting for a first-time visit with an orthopaedic foot and ankle surgeon were consented and randomized to VSS or TD prior to the physician-patient encounter. Time spent with the patient in the exam room and time used to document away from the patient were recorded. A validated post-encounter survey assessed patient satisfaction, perception of physician empathy, understanding of the plan, and perception of the amount of time spent with the physician on scales of 0 to 10. An a priori sample size calculation with an alpha level set at 0.05 and power of 80% estimated that 50 patients were necessitated to demonstrate a 2-minute difference in time spent documenting away from the patient. Comparisons were made using a two-sample Student’s t-test. Results: Of the 50 patients enrolled, 25 were randomized to VSS. No differences in demographic characteristics were identified between cohorts (p>0.05 for each). Time spent documenting away from the patient differed between VSS and TD (1.19±0.65 minutes for VSS versus 5.80±1.70 minutes for TD, p<0.001) as did time elapsed between the end of the visit and the start of dictation (0±0 for VSS versus 123±70 minutes for TD, p<0.001). There was a trend towards more time spent with the patient in the VSS group than in the TD group (14.25±5.86 minutes versus 11.37±5.07 minutes, p=0.069). There were no differences between groups in survey responses regarding satisfaction, empathy, understanding, or perception of sufficient time spent with the physician (p>0.05 for each; Table 1). Conclusion: VSS in an orthopaedic foot and ankle practice decreases documentation time by approximately 4 minutes per new patient compared to TD, resulting in 2 hours of reclaimed physician time for every 30 new patients. With VSS, documentation is completed during the visit versus TD which is dictated on average 2 hours later. A validated survey identified no differences in patient satisfaction, perception of physician empathy and sufficient time spent with the physician, or understanding of the plan with VSS versus TD. Orthopaedic surgeons should consider VSS a HIPAA-compliant documentation option with time savings and no measurable difference in patient satisfaction.