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Longevity in the United States ranks below most other Western nations despite spending more on healthcare per capita than any other country. Across the world, mortality has been declining, but in the USA the trend toward improvement has stalled in some middle-aged demographic groups. Cross-national studies suggest that social welfare is positively associated with longevity. The United States has less government sponsored welfare, education and healthcare than almost all other Western nations, but the level of this social welfare commitment varies across the states. In this study we examined the association of state tax burden and state government expenditures with subsequent middle-aged mortality. The primary exposure was state tax burden in 2005, defined as proportion of all state income paid to the state. We also examined the impact of state expenditures per capita in 2005 for education, healthcare, welfare, police and highways. The dependent variable was mortality during the subsequent 10 years. Death counts and population sizes by sex, age group and race strata for 2006-2015 were abstracted from CDC WONDER. Binomial logistic regression was employed based on the number of deaths and underlying population within each county-sex-age-race bin. State tax burden in 2005 varied from 5.8% to 12.2%. An increase of 1.0 percentage point in state tax burden was associated with a 5.8% (SE = 0.1%) reduction in mortality adjusted for sex, age and race, but was associated with a 1.1% (SE = 0.1%) reduction when further adjusting for state income and education levels. Controlling for sex, age and race each type of state expenditures was associated with decreases in middle aged mortality, notably K-12 education (reduction of 4.7%, SE = 0.1%, per 10% expenditure increase) except healthcare but all types were associated with mortality decreases further controlling for state income and education. The residents of states with higher state taxation and higher expenditures per capita have lower middle aged mortality rates.

We used New Hampshire Colonoscopy Registry (NHCR) data to examine the association between post-colonoscopy colorectal cancer (PCCRC) risk and an adenoma detection rate (ADR) which was calculated using exams with all indications, as compared to ADR restricted to only screening exams.INTRODUCTIONWe used New Hampshire Colonoscopy Registry (NHCR) data to examine the association between post-colonoscopy colorectal cancer (PCCRC) risk and an adenoma detection rate (ADR) which was calculated using exams with all indications, as compared to ADR restricted to only screening exams.Our cohort study included NHCR patients with an index exam and at least one follow-up event, either a colonoscopy or a CRC diagnosis. Our outcome, PCCRC was any CRC diagnosed ≥ 6 months after an index exam. The exposure variable was endoscopist-specific ADR (ADR-A), calculated for all indications, divided into quintiles. We also compared the ADR-A to a screening ADR (ADR-S). Cox regression was used to model the hazard of PCCRC on ADR, controlling for age, sex, and other covariates.METHODSOur cohort study included NHCR patients with an index exam and at least one follow-up event, either a colonoscopy or a CRC diagnosis. Our outcome, PCCRC was any CRC diagnosed ≥ 6 months after an index exam. The exposure variable was endoscopist-specific ADR (ADR-A), calculated for all indications, divided into quintiles. We also compared the ADR-A to a screening ADR (ADR-S). Cox regression was used to model the hazard of PCCRC on ADR, controlling for age, sex, and other covariates.In 32,535 patients, a lower hazard for PCCRC (n=178) was observed for ADR-A's > 23%, as compared to ADR-A's <23% (Reference) (23%-<29%: HR=0.56, 95%CI:0.36-0.87;29%-<34%: HR=0.60, 95% CI:0.38-0.94; 34%-<44%: HR=0.43,95% CI: 0.29-0.65; and ≥44%: HR=0.32, 95% CI: 0.16-0.63). The highest quartile of ADR-A (42%+)(HR=0.41 95%CI:0.23-0.75) had a similar protection from PCCRC as the highest quartile of ADR-S (35%+)(HR=0.38 95%CI:0.21-0.70). We observed 95% CIs for ADR's were 28% narrower (median=0.72;IQR:0.10) for endoscopists when using ADR-A versus ADR-S.RESULTSIn 32,535 patients, a lower hazard for PCCRC (n=178) was observed for ADR-A's > 23%, as compared to ADR-A's <23% (Reference) (23%-<29%: HR=0.56, 95%CI:0.36-0.87;29%-<34%: HR=0.60, 95% CI:0.38-0.94; 34%-<44%: HR=0.43,95% CI: 0.29-0.65; and ≥44%: HR=0.32, 95% CI: 0.16-0.63). The highest quartile of ADR-A (42%+)(HR=0.41 95%CI:0.23-0.75) had a similar protection from PCCRC as the highest quartile of ADR-S (35%+)(HR=0.38 95%CI:0.21-0.70). We observed 95% CIs for ADR's were 28% narrower (median=0.72;IQR:0.10) for endoscopists when using ADR-A versus ADR-S.Our data demonstrating lower PCCRC risk in exams performed by endoscopists with higher ADR's calculated with all exams helps to validate ADR-A as a quality measure. ADR-A may also increase precision of the calculated ADR. Endoscopists should strive for a higher ADR-A with 44% as an aspirational target.DISCUSSIONOur data demonstrating lower PCCRC risk in exams performed by endoscopists with higher ADR's calculated with all exams helps to validate ADR-A as a quality measure. ADR-A may also increase precision of the calculated ADR. Endoscopists should strive for a higher ADR-A with 44% as an aspirational target.

INTRODUCTION:We used New Hampshire Colonoscopy Registry data to examine the association between postcolonoscopy colorectal cancer (PCCRC) and sessile serrated detection rates (SSLDRs).METHODS:We included patients with either a colonoscopy or a CRC diagnosis in the NH State Cancer Registry. PCCRC was any CRC diagnosed ≥ 6 months after index examination.RESULTS:Of 26,901 patients, 162 were diagnosed with PCCRC. The hazard ratio for PCCRC was lowest for patients whose endoscopists had the highest SSLDR quintile (≥6%) (hazard ratio 0.29; 95% confidence interval 0.16-0.50).DISCUSSION:Endoscopists with higher SSLDRs had lower risks of PCCRC. These data validate SSLDR as a clinically relevant quality measure.

INTRODUCTION:We used New Hampshire Colonoscopy Registry data to examine the association between postcolonoscopy colorectal cancer (PCCRC) risk and an adenoma detection rate (ADR) which was calculated using examinations with all indications, as compared with ADR restricted to only screening examinations.METHODS:Our cohort study included New Hampshire Colonoscopy Registry patients with an index examination and at least 1 follow-up event, either a colonoscopy or a CRC diagnosis. Our outcome, PCCRC, was any CRC diagnosed ≥6 months after an index examination. The exposure variable was endoscopist-specific all-examination ADR (ADR-A), calculated for all indications, divided into quintiles. We also compared the ADR-A with a screening ADR (ADR-S). Cox regression was used to model the hazard of PCCRC on ADR, controlling for age, sex, and other covariates.RESULTS:In 32,535 patients, a lower hazard for PCCRC (n = 178) was observed for ADR-A's ≥ 23%, as compared with ADR-A's <23% (reference) (23% to <29%: hazard ratio (HR) = 0.56, 95% CI: 0.36–0.87; 29% to <34%: HR = 0.60, 95% CI: 0.38–0.94; 34% to <44%: HR = 0.43, 95% CI: 0.29–0.65; and ≥44%: HR = 0.32, 95% CI: 0.16–0.63). The highest quartile of ADR-A (42%+) (HR = 0.41, 95% CI: 0.23–0.75) had a similar protection from PCCRC as the highest quartile of ADR-S (35%+) (HR = 0.38, 95% CI: 0.21–0.70). We observed 95% CIs for ADR's were 28% narrower (median = 0.72; interquartile range (IQR): 0.10) for endoscopists when using ADR-A vs ADR-S.DISCUSSION:Our data demonstrating lower PCCRC risk in examinations performed by endoscopists with higher ADR's calculated with all examinations help to validate ADR-A as a quality measure. ADR-A may also increase precision of the calculated ADR. Endoscopists should strive for a higher ADR-A with 44% as an aspirational target.

To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC). A retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1-5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death. Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence [CIn] 8.4% [95% CI 6.5-10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% [95% CI 7.4-11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002). Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.

Background Older adults with obesity residing in rural areas have reduced access to weight management programs. We determined the feasibility, acceptability and preliminary outcomes of an integrated technology-based health promotion intervention in rural-living, older adults using remote monitoring and synchronous video-based technology. Methods A 6-month, non-randomized, non-blinded, single-arm study was conducted from October 2018 to May 2020 at a community-based aging center of adults aged ≥65 years with a body mass index (BMI) ≥30 kg/m 2 . Weekly dietitian visits focusing on behavior therapy and caloric restriction and twice-weekly physical therapist-led group strength, flexibility and balance training classes were delivered using video-conferencing to participants in their homes. Participants used a Fitbit Alta HR for remote monitoring with data feedback provided by the interventionists. An aerobic activity prescription was provided and monitored. Results Mean age was 72.9±3.9 years (82% female). Baseline anthropometric measures of weight, BMI, and waist circumference were 97.8±16.3 kg, 36.5±5.2 kg/m 2 , and 115.5±13.0 cm, respectively. A total of 142 participants were screened ( n =27 ineligible), and 53 consented. There were nine dropouts (17%). Overall satisfaction with the trial (4.7+ 0.6, scale: 1 (low) to 5 (high)) and with Fitbit (4.2+ 0.9) were high. Fitbit was worn an average of 81.7±19.3% of intervention days. In completers, mean weight loss was 4.6±3.5 kg or 4.7±3.5% ( p < 0.001). Physical function measures of 30-s sit-to-stand repetitions increased from 13.5±5.7 to 16.7±5.9 (p< 0.001), 6-min walk improved by 42.0±77.3 m ( p =0.005) but no differences were observed in gait speed or grip strength. Subjective measures of late-life function improved (3.4±4.7 points, p < 0.001). Conclusions A technology-based obesity intervention is feasible and acceptable to older adults with obesity and may lead to weight loss and improved physical function. Clinical trial registration Registered on Clinicaltrials.gov # NCT03104205 . Registered on April 7, 2017. First participant enrolled on October 1st, 2018.

Background: In adult populations, emerging evidence indicates that humans are exposed to arsenic by ingestion of contaminated foods such as rice, grains, and juice; yet little is known about arsenic exposure among children. Objectives: Our goal was to determine whether rice consumption contributes to arsenic exposure in U.S. children. Methods: We used data from the nationally representative National Health and Nutrition Examination Survey (NHANES) to examine the relationship between rice consumption (measured in 0.25 cups of cooked rice per day) over a 24-hr period and subsequent urinary arsenic concentration among the 2,323 children (6—17 years of age) who participated in NHANES from 2003 to 2008. We examined total urinary arsenic (excluding arsenobetaine and arsenocholine) and dimethylarsinic acid (DMA) concentrations overall and by age group: 6—11 years and 12—17 years. Results: The median [interquartile range (IQR)] total urinary arsenic concentration among children who reported consuming rice was 8.9 μg/L (IQR: 5.3—15.6) compared with 5.5 μg/L (IQR: 3.1—8.4) among those who did not consume rice. After adjusting for potentially confounding factors, and restricting the study to participants who did not consume seafood in the preceding 24 hr, total urinary arsenic concentration increased 14.2% (95% confidence interval: 11.3, 17.1%) with each 0.25 cup increase in cooked rice consumption. Conclusions: Our study suggests that rice consumption is a potential source of arsenic exposure in U.S. children.

Purpose To compare long-term care escalation encounters among three care patterns for new episodes of neck pain among Medicare beneficiaries. Methods We examined Medicare claims spanning a four-year period for beneficiaries with new episodes of neck pain beginning in 2019. All patients were continuously enrolled under Medicare parts A, B, and D and aged 65–99 years. We calculated the cumulative frequency and propensity- weighted rate ratios for escalated care encounters across three distinct, index-visit related neck pain treatment cohorts: 1) Spinal manipulative therapy; 2) Primary care without prescription analgesics within 7 days; 3) Primary care with prescription analgesics within 7 days. Results When compared to the primary care without analgesics cohort, the spinal manipulative therapy cohort was associated with a 64% lower rate (RR 0.36, 95% CI 0.35,0.37) for long-term care escalation encounters, while the primary care with prescription analgesics cohort was associated with an 8% higher rate (RR 1.08; 95% CI 1.05,1.10). Conclusion Initial spinal manipulative therapy was associated with a significant reduction in downstream care escalation encounters among Medicare beneficiaries with new episodes of neck pain. Our study contributes to a growing body of evidence supporting the integration of non-pharmacological care strategies for neck pain management.

Sepsis remains a leading cause of death among inpatients. Scoring systems designed to identify inpatients with sepsis currently have limited effectiveness. This single institution, retrospective, case-control study aims to improve sepsis decision support tool performance using temporal analyses of sepsis-specific and general deterioration scoring systems. Sequential Organ Failure Assessment, National Early Warning Scores (NEWS), and Modified Early Warning Scores were calculated using four years of inpatient data. Sensitivity and specificity analyses compared performance of each score, calculated as a function of both various score cut-off values and time before sepsis diagnosis using established proxies for identifying clinical suspicion for sepsis. NEWS had the best sensitivity-specificity performance (AUROC 82.7) when examining various score cutoffs and time intervals during which diagnosis criteria were met. Comparison of false positives/negatives with various score thresholds showed a low rate of false positives with a NEWS of 7. Score trends in the hours leading up to sepsis criteria being met showed a marked increase for the sepsis group while for the cases there was a decrease during a comparable period. Temporal analyses of scores for patients coded as having sepsis provides novel insights into patterns of deterioration. The methods and results provide practical details demonstrating how general deterioration algorithms can be used to alert trained responders to potential cases of sepsis to improve sepsis recognition and treatment opportunities. •Current sepsis identification scoring systems have limited effectiveness.•This study offers novel insights into sepsis diagnosis support tools via temporal pattern analysis prior to sepsis identification.•Detailed performance comparison for various scores to improve clinical score application is presented.•The methods and results presented can be used to guide improvement efforts for sepsis identification in the hospital setting.

Abstract BACKGROUND The association between long work hours and outcomes among attending surgeons remains an issue of debate. OBJECTIVE To investigate whether operating emergently the night before an elective case was associated with inferior outcomes among attending neurosurgeons. METHODS We executed a cohort study with unruptured cerebral aneurysm patients, who underwent endovascular coiling or surgical clipping from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. We investigated the association of treatment by surgeons performing emergency procedures the night before with outcomes of elective cerebral aneurysm treatment using an instrumental variable analysis. RESULTS Overall, 4700 patients underwent treatment for unruptured cerebral aneurysms. There was no difference in inpatient mortality (adjusted difference, –0.7%; 95% confidence interval [CI], –1.4% to 0.02%), discharge to a facility (adjusted difference, –0.1%; 95% CI, –1.2% to 1.2%), or length of stay (adjusted difference, –0.58; 95% CI, –1.66 to 0.50) between patients undergoing elective cerebral aneurysm treatment by surgeons who performed emergency procedures the night before, and those who did not. CONCLUSION Using a comprehensive patient cohort in New York State for elective treatment of unruptured cerebral aneurysms, we did not identify an association of treatment by surgeons performing emergency procedures the night before, with mortality, discharge to a facility, or length of stay. Our study had 80% power to detect differences in mortality (our primary outcome), as small as 4.1%. The results of the present study do not support the argument for regulation of attending work hours.