Charles E. McConnel

The demand for prehospital emergency services in an aging society

This research examines the implications of an aging society on the demand for prehospital emergency medical services (EMS). Using a large comprehensive set of population-based EMS utilization data (N = 73874) and population data from the 1990 Census for the City of Dallas, Texas, rates of utilization for eight age groups were computed for total EMS incidents, incidents requiring transport services, and a sub-category of transport services for individuals requiring services for life-threatening conditions. The pattern of utilization associated with age was found to be tri-modal with rates rising geometrically with age for individuals aged 65 and over. Compared to the age group 45 to 64 years of age, rates of utilization for those aged 85 years and older were 3.4 times higher (P < 0.001) for total EMS incidents, 4.5 times higher (P < 0.001) for emergency transports and 5.2 times higher (P < 0.001) for incidents of a life-threatening nature. A broad categorization of all EMS incidents by reason for requiring services indicates that the observed age-associated increase in utilization is due primarily to medical conditions rather than incidents arising from trauma. Finally, gender and racial/ethnic differences in utilization are briefly considered.

Modestly Increased Use of Colonoscopy When Copayments Are Waived

BACKGROUND & AIMS Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use. METHODS We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50-64 years at any point in FYs 2002-2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver. RESULTS The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14-1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12-1.26). CONCLUSIONS Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening.

Distributional change in physician manpower, United States, 1963-80

Using data from the American Medical Associations Physician Masterfiles (1963-80) and the GINI index of resource concentration as a global measure of changes in the pattern of locational choice, the expectation of a more uniform distribution of physicians is shown to have been met for all major categories of physicians except General Practitioners. Increases in the supply of Surgical Specialists, Medical Specialists, and Other Specialists were accompanied by increases in the index of dispersion across counties of 23.1 per cent, 17.9 per cent and 21 per cent, respectively. By 1980, Surgical Specialists were the most uniformly distributed of all physician groups. The distributional implications of location theory for physicians are addressed and evidence relevant to evaluating this economic theory of locational choice is presented.

Charges associated with pediatric head injuries: A five-year retrospective review of 41 pediatric hospitals in the US

Abstract: Background: Brain injuries are a significant public health problem, particularly among the pediatric population. Brain injuries account for a significant portion of pediatric injury deaths, and are the highest contributor to morbidity and mortality in the pediatric and young adult populations. Several studies focus on particular mechanisms of brain injury and the cost of treating brain injuries, but few studies exist in the literature examining the highest contributing mechanisms to pediatric brain injury and the billed charges associated with them. Methods: Data were extracted from the Pediatric Health Information System (PHIS) from member hospitals on all patients admitted with diagnosed head injuries and comparisons were made between ICU and non-ICU admissions. Collected data included demographic information, injury information, total billed charges, and patient outcome. Results: Motor vehicle collisions, falls, and assaults/abuse are the three highest contributors to brain injury in terms of total numbers and total billed charges. These three mechanisms of injury account for almost

Racial and Ethnic Patterns in the Utilization of Prehospital Emergency Transport Services in the United States

1 billion in total charges across the five-year period, and account for almost half of the total charges in this dataset over that time period. Conclusions: Research focusing on brain injury should be tailored to the areas of the most pressing need and the highest contributing factors. While this study is focused on a select number of pediatric hospitals located throughout the country, it identifies significant contributors to head injuries, and the costs associated with treating them.

Maternal depressive symptoms predict adolescent healthcare utilization and charges in youth with type 1 diabetes (T1D)

INTRODUCTION This descriptive research used a large, urban population-based data set for prehospital, emergency medical transports to examine racial/ethnic patterns of access and utilization for several broad categories of emergency medical transport services. METHODS Fire department files of approximately 39,000 reports on service provision were used to establish rates of transport utilization per 1,000 population in 1990, the most recent year for which reliable city-level census data were available. Data were categorized by three age groups (< 25 years, 25-64 years, > or = 65 years), three racial/ethnic groups (non-Hispanic whites, African-Americans, Hispanics), and gender. Transport rates were computed for total utilization, trauma incidents, and incidents due to medical conditions. Racial/ethnic rates were analyzed for each age and gender group and age- and gender-standardized rates were analyzed and presented in a graphical comparison. Statistical analyses of racial/ethnic differences were conducted using Tukey-type tests of multiple comparisons of proportions, with significant differences evaluated at the p = 0.001 level of significance. RESULTS Significant differences between racial/ethnic groups in the utilization of emergency transport services existed for all pair-wise comparisons including comparisons by each of the three age groups and gender. For total utilization, unadjusted rates are highest for African-Americans (65.9/1,000) and lowest for Hispanics (25.8/1.000). Likewise, African-American rates were substantially higher for both gender groups and across all age groups. Categorized by gender and age group under age > or = 65 years, non-Hispanic whites are observed to have the lowest rates for both males and females under the age 65 years, while Hispanics have the lowest rates in the group 65 years old However, when rates are age- and gender-standardized, compared to African-Americans and Hispanics, rates for non-Hispanic whites are significantly lower for total transports and for trauma and medically related transports (p = 0.001). CONCLUSION Age- and gender-standardized rates for emergency medical transport were found to be lowest for non-Hispanic, whites, moderately higher for Hispanics, and substantially higher for African-Americans, who experienced transport rates nearly three times higher than were the rates for non-Hispanic whites. Further research is required to establish the extent to which racial/ethnic differences observed in this geographically restricted study reflect variations between racial/ethnic groups in the underlying need for services.

Association of Non-High-Density Lipoprotein Cholesterol with Psychosocial Dysfunction in Children and Adolescents with Obesity.

OBJECTIVE To examine whether maternal depressive symptoms predict diabetes-related health care utilization and charges in adolescents with Type 1 diabetes. METHOD Mothers of adolescents ages 11-18 with Type 1 diabetes completed the Center for Epidemiological Studies Depression Scale at enrollment and at 12-month follow-up. Demographic and disease-related variables, including HbA1c, were also assessed. Health care utilization data and charges for diabetes-related care (i.e., endocrine clinic visits, emergency room visits, and hospitalizations) for the period of 12 and 24 months following enrollment were assessed. RESULTS Maternal depressive symptoms at enrollment predicted higher utilization/charges at 12- and 24-month follow-up, after controlling for demographic and disease-related variables and adolescent depressive symptoms. High maternal depressive symptoms at baseline were associated with

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients

8,405 additional charges over the next 2 years. Adolescents of mothers with high depressive symptoms were twice as likely to have an emergency room visit and three times as likely to have a hospitalization. CONCLUSION Maternal depressive symptoms are an independent predictor of health care utilization and charges in adolescents with Type 1 diabetes. Interventions aimed at identifying and treating depressive symptoms in mothers could not only enhance caregiver quality of life but could also be economically advantageous for payers and providers.

Disability and the Future of Work: A Speculative Essay

BACKGROUND Children with obesity have worse psychosocial functioning compared to their non-overweight peers. Adult studies suggest that several metabolic factors may participate in the etiology of depression in obesity. METHODS We evaluated the association of several metabolic parameters with psychosocial dysfunction in children with obesity, through a retrospective review of electronic medical records in patients ages 6-17. All parents were asked to complete the Pediatric Symptom Checklist (PSC) questionnaire, a validated measurement of psychosocial dysfunction in children. RESULTS PSC scores were available in 618 patients. Overall, 11.2% of patients had a PSC score ≥28, suggestive of psychosocial dysfunction. Non-high-density lipoprotein (HDL) cholesterol was associated with a higher PSC score (p = 0.02), after adjusting for age, sex, race, socioeconomic status, and BMI z-score. CONCLUSIONS Consistent with adult studies, in children and adolescents with obesity, non-HDL cholesterol may play a role in the etiology of psychosocial dysfunction. Further studies are warranted.

Tunnelled central venous catheter-related bloodstream infection in Canadian blood stem cell transplant recipients: Associated costs

Abstract In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time. Summit Participants Deb Adler1, Christopher Alban, MD, MBA2, Mark Bondi, PhD3, Michelle Braun, PhD4, Xavier Cagigas, PhD5, Morgan Daven6, Robert L. Denney, PsyD7,8, Lisa Drozdick, PhD9, Norman L. Foster, MD10,11, Ula Hwang, MD12–15, Laurie Ivey, PsyD16, Grant Iverson, PhD7,17, Joel Kramer, PsyD18, Laura Lacritz, PhD7,19, Melinda Lantz, MD20, Lisa Latts, MD, MSPH, MBA21, Shari M. Ling, MD22, Ana Maria Lopez, MD23–26, Michael Malone, MD27,28, Lori Martin-Plank, PhD, MSN, MSPH, RN29, Katie Maslow, MSW30, Don Melady, MSc(Ed), MD31–33, Melissa Messer34, John Meyers, PsyD7, Charles E. McConnel, PhD19, Randi Most, PhD36, Margaret P. Norris, PhD37, William Perry, PhD7,85,39, Neil Pliskin, PhD40, David Shafer, MBA41, Nina Silverberg, PhD42, Tresa Roebuck-Spencer, PhD43,44, Colin M. Thomas, MD, MPH45, Laura Thornhill, JD46, Jean Tsai, MD, PhD10,47, Nirav Vakharia, MD48, Martin Waters, MSW49 Organizations Represented Alzheimer’s Association, Chicago, IL AMA/CPT Health Care Professionals Advisory Committee, Chicago, IL American Academy of Clinical Neuropsychology (AACN), Ann Arbor, MI American Academy of Neurology (AAN), Minneapolis, MN American Association of Geriatric Psychiatry (AAGP), McLean, VA American Association of Nurse Practitioners (AANP), Austin, TX American Board of Professional Neuropsychology (ABN), Sarasota, FL American College of Emergency Physicians (ACEP), Philadelphia, PA American College of Physicians (ACP), Philadelphia, PA American Geriatrics Society (AGS), New York, NY American Psychological Association (APA), Washington, DC Beacon Health Options, Boston, MA Canadian Association of Emergency Physicians, Ottawa, ON, Canada Collaborative Family Healthcare Association (CFHA), Rochester, New York Gerontological Society of America, Washington, DC Hispanic Neuropsychological Society (HNS), Los Angeles, CA IBM Watson Health, Denver, CO International Federation of Emergency Medicine, West Melbourne, Australia International Neuropsychological Society (INS), Salt Lake City, UT National Academy of Neuropsychology (NAN), Denver, CO Optum of UnitedHealth Group, Minneapolis, MN Pearson, New York City, New York Psychological Assessment Resources, Inc, Lutz, FL Society for Clinical Neuropsychology, Washington, DC U.S. Department of Veterans Affairs, Washington, DC *Please note that participation in the Summit does not constitute organizational endorsement of this report