Rene Soria-Saucedo

Measuring the Social Impact of Burns on Survivors.

Many burn survivors experience social challenges throughout their recovery. Measuring the social impact of a burn injury is important to identify opportunities for interventions. The aim of this study is to develop a pool of items addressing the social impact of burn injuries in adults to create a self-reported computerized adaptive test based on item response theory. The authors conducted a comprehensive literature review to identify preexisting items in other self-reported measures and used data from focus groups to create new items. The authors classified items using a guiding conceptual framework on social participation. The authors conducted cognitive interviews with burn survivors to assess clarity and interpretation of each item. The authors evaluated an initial pool of 276 items with burn survivors and reduced this to 192 items after cognitive evaluation by experts and burn survivors. The items represent seven domains from the guiding conceptual model: work, recreation and leisure, relating to strangers, romantic, sexual, family, and informal relationships. Additional item content that crossed domains included using self-comfort and others’ comfort with clothing, telling one’s story, and sense of purpose. This study was designed to develop a large item pool based on a strong conceptual framework using grounded theory analysis with focus groups of burn survivors and their caregivers. The 192 items represent 7 domains and reflect the unique experience of burn survivors within these important areas of social participation. This work will lead to developing the Life Impact Burn Recovery Evaluation profile, a self-reported outcome measure.

Unnecessary Antibiotics for Acute Respiratory Tract Infections: Association With Care Setting and Patient Demographics

Tobacco use and lower rates of higher education, markers of poor health literacy, were associated with antibiotic overprescribing for respiratory infections, as were patient age, insurance, and provider specialty. Geographic region was significant when interaction with care setting was included.

Development of a conceptual framework to measure the social impact of burns

Measuring community reintegration following burn injury is important to assess the efficacy of therapies designed to optimize recovery. This project aims to develop and validate a conceptual framework for understanding the social impact of burn injuries in adults. The framework is critical for developing the item banks used for a computerized adaptive test. We performed a comprehensive literature review and consulted with clinical experts and burn survivors about social life areas impacted by burn injury. Focus groups with burn survivors and clinicians were conducted to inform and validate the framework. Transcripts were coded using grounded theory methodology. The World Health Organization’s International Classification of Functioning, Disability and Health, was chosen to ground the content model. The primary construct identified was social participation, which contains two concepts: societal role and personal relationships. The subdomains chosen for item development were work, recreation and leisure, relating with strangers, and romantic, sexual, family, and informal relationships. Qualitative results strongly suggest that the conceptual model fits the constructs for societal role and personal relationships with the respective subdomains. This conceptual framework has guided the implementation of a large-scale calibration study currently underway which will lead to a computerized adaptive test for monitoring the social impacts of burn injuries during recovery.

Receipt of Evidence-Based Pharmacotherapy and Psychotherapy Among Children and Adolescents With New Diagnoses of Depression.

OBJECTIVE Little is known about utilization rates of the various depression treatment options available in the private sector for children and adolescents. For privately insured youths, this study examined the utilization frequency of six treatment options for depression with varying degrees of empirical support. METHODS A nationally representative administrative claims database of privately insured individuals (Truven Analytics database, 2008-2010) was used to construct a cohort of 61,599 youths (ages six to 17 years) with depression. Multivariable logistic regression controlling for insurance type, region, and illness severity and complexity assessed, by physician specialty, the likelihood of receiving six different depression treatments (medication combined with psychotherapy, first-line medication, second-line medication, non-evidence-based medication, second-generation antipsychotics, and psychotherapy alone). RESULTS Only 58.4% of depressed youths received at least one type of depression treatment; 33.6% received psychotherapy alone, 24.8% received medication alone, and 2.7% received combination treatment. Of depressed youths receiving only medication, 24.8% received medications unsupported by empirical evidence (non-evidence-based or second-generation antipsychotics) and 50.6% received medications with equivocal support. Mental health specialists were approximately nine times (odds ratio=8.61) more likely than primary care providers to prescribe combination treatment. Other predictors of receiving combination treatment included having diagnosed major depressive disorder, being a young adolescent (ages 12-14), and residing in the Northeast. CONCLUSIONS Large proportions of depressed youths are not receiving any treatment or are receiving treatments unsupported or equivocally supported by empirical evidence. Additional research is warranted to assess factors associated with nonrecommended use of pharmacotherapies for youths with depression.

Development and validation of a complexity score to rank hospitalized patients at risk for preventable adverse drug events

Purpose. The development of risk models for 16 preventable adverse drug events (pADEs) and their aggregation into the final complexity score (C‐score) are described. Methods. Using data from 2 tertiary care facilities, logistic regression models were constructed for the first 5 hospital days that admissions were at risk for each of 16 pADEs. The best model for each pADE was validated in 100 bootstrap samples. The C‐score was then aggregated and predicted individual pADE risk as the probability to develop at least 1 pADE. Using the 100 bootstrap samples for each pADE, 100 C‐scores for validation were generated. Results. We utilized electronic health records (EHR) data from 65,518 admissions to UF Health Shands and 18,269 admissions to UF Health Jacksonville to develop risk models for 16 pADEs. Most models had very strong discriminant validity (C‐statistic > 0.8), with the highest predicted decile representing about half of manifest pADEs. Among admissions in the highest C‐score decile, about two thirds experienced at least 1 pADE (C‐statistic, 0.838; 95% confidence interval, 0.838–0.839). C‐score precision, defined as the percentage of patients consistently (i.e., at least 95 of 100 samples) ranked in the 90th percentile, was 80–84%. Conclusion. The C‐score was developed and validated for the identification of hospitalized patients at highest risk for pADEs. Aggregation of individual prediction models into a single score reduced its predictive power for most pADEs, compared with the individual risk models, but concentrated in the highest C‐score decile a patient group more than two thirds of whom experienced at least 1 pADE.

Patient cost-sharing and insurance arrangements are associated with hospital readmissions after abdominal surgery: Implications for access and quality health care

BACKGROUND Readmission rates after operative procedures are used increasingly as a measure of hospital care quality. Patient access to care may influence readmission rates. The objective of this study was to determine the relationship between patient cost-sharing, insurance arrangements, and the risk of postoperative readmissions. METHODS Using the MarketScan Research Database (n = 121,002), we examined privately insured, nonelderly patients who underwent abdominal surgery in 2010. The main outcome measures were risk-adjusted unplanned readmissions within 7 days and 30 days of discharge. Odds of readmissions were compared with multivariable logistic regression models. RESULTS In adjusted models,

Factors That Predict the Use of Psychotropics Among Children and Adolescents With PTSD: Evidence From Private Insurance Claims

1,284 increase in patient out-of-pocket payments during index admission (a difference of one standard deviation) was associated with 19% decrease in the odds of 7-day readmission (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.78-0.85) and 17% decrease in the odds of 30-day readmission (OR 0.83, 95% CI 0.81-0.86). Patients in the noncapitated point-of-service plans (OR 1.19, 95% CI 1.07-1.33), preferred provider organization plans (OR 1.11, 95% CI 1.03-1.19), and high-deductible plans (OR 1.12, 95% CI 1.00-1.26) were more likely to be readmitted within 30 days compared with patients in the capitated health maintenance organization and point-of-service plans. CONCLUSION Among privately insured, nonelderly patients, increased patient cost-sharing was associated with lower odds of 7-day and 30-day readmission after abdominal surgery. Insurance arrangements also were significantly associated with postoperative readmissions. Patient cost sharing and insurance arrangements need consideration in the provision of equitable access for quality care.

The prevalence and correlates of severe depression in a cohort of Mexican teachers

OBJECTIVE This study aimed to determine which characteristics of youths with posttraumatic stress disorder (PTSD) were associated with receiving prescriptions for antidepressants, antipsychotics, or benzodiazepines. METHODS A 2011-2012 retrospective cohort of children and adolescents with a new episode of PTSD was extracted from medical and pharmacy claims from a nationally representative sample of privately insured persons. Multivariate logistic regression assessed attributes (demographic characteristics, mental and general medical comorbidities, insurance arrangements, specialty type, and geographic location) associated with utilization of antidepressants, antipsychotics, and benzodiazepines. RESULTS Among 7,726 youths with a new episode of PTSD in 2012, just less than 60% received psychotherapy alone, about 6% received pharmacotherapy, and about 35% received neither psychotherapy nor pharmacotherapy. Among utilizers of medications, 71.3% used antidepressants and 21.6% used antipsychotics. Youths prescribed medication tended to be older and have more general medical and mental comorbidities. Provider specialty, capitated insurance arrangements, and more comorbidities predicted being prescribed antidepressants. History of hospitalization, noncapitated insurance arrangements, nonuse of psychotherapy, and more comorbidities predicted being prescribed antipsychotics. Antidepressants and antipsychotics were more likely to be used in the South. CONCLUSIONS Only three-fifths of youths with PTSD received first-line treatment (psychotherapy). More than one in 20 received pharmacotherapy, which appeared to be associated with the most severe and complex presentations. More than one-third of youths with PTSD received neither therapy nor medication, signaling compromised quality of care. Future research should confirm the factors associated with pharmacotherapy prescription and explore ways to increase the use of psychotherapy in primary care.

Drug Interactions With Non–Vitamin K Oral Anticoagulants

BACKGROUND Depression is among the 10 major causes of disability in Mexico. Yet, local contextual factors associated to the disorder remain poorly understood. We measured the impact of several factors on severe depression such as demographics, pharmacotherapy, multimorbidity, and unhealthy behaviors in Mexican teachers. METHODS A total of 43,845 Mexican female teachers from 12 Mexican states answered the Patient Health Questionnaire (PHQ9). Data were part the Mexican Teachers Cohort prospective study, the largest ongoing cohort study in Latin America. Unadjusted and adjusted estimates assessed the impact of several contextual factors between severe versus mild-no depression cases. RESULTS In total 7026 teachers (16%) had a PHQ9 score compatible with severe depression. From them, only 17% received psychotropics, compared to 60% for those with a formal diagnosis. Less than 5% of teachers with PHQ9 scores compatible with severe depression had a formal diagnosis. Adjusted analysis reported higher odds of pharmacotherapy, having ≥ 3 comorbidities, higher levels of couple, family and work stress, fewer hours of vigorous physical activity, higher alcohol consumption, and smoking as risk factors for severe depression. Also, rural residents of northern and center states appeared more severely depressed compared to their urban counterparts. On average, the PHQ9 scores differed by ~ 10 points between severe and mild-no depressed teachers. LIMITATIONS A cross-sectional design. Also, the study focused on female teachers between ages 25 and 74 years old, reducing the generalizability of the estimates. CONCLUSION Under-diagnosis of clinical depression in Mexican teachers is concerning. Unhealthy behavior is associated with severe depression. The information collected in this study represents an opportunity to build prevention mechanisms of depression in high-risk subgroups of female educators and warrants improving access to mental care in Mexico.

Associations Between Medication Class and Subsequent Augmentation of Depression Treatment in Privately Insured US Adults

RBC transfusions were seen among all sexes, race/ethnicities, patient risk severities, payer types, and admission types (Table). No statistically significant reductions in RBC transfusions were seen in children (aged <18 years) or private investor–owned hospitals. Significant interactions were observed for time and all covariates (P for interaction < .05). A significantly greater decrease in RBC transfusions was seen for elective admissions (aRR, 0.74 [95% CI, 0.67-0.80]) compared with nonelective admissions (aRR, 0.86 [95% CI, 0.810.91]; P for interaction < .001).