Cumulative Utilization Research Articles

Prescription of hormone replacement therapy among cervical cancer patients with treatment-induced premature menopause

ObjectiveTo examine the utilization of hormone replacement therapy (HRT) among newly diagnosed cervical cancer patients who experienced premature menopause due to primary treatment.MethodsThe MarketScan Databases were used to identify newly...

Running Every Time, Planking Sometimes: Youth Adherence to a Neuromuscular Training Program

ABSTRACT Introduction/Purpose Neuromuscular training warm-up programs are effective in reducing sport and recreation injuries when adherence is adequate. To understand how to improve adherence, it is important to analyze different measures of adherence, such as the utilization of different exercises and components. Methods The intervention arm of a randomized controlled trial in junior high school hysical education (PE) was included in this study. After one school was excluded because of inadequate adherence data, five schools (32 classes) were analyzed. For 12 wk, the schools implemented the Implementing a School Prevention Program to Reduce Injuries Through Neuromuscular Training (iSPRINT) program comprising 15 exercises in four components (aerobic, agility, strength, balance). Utilization fidelity, cumulative utilization (program/component/exercise), and utilization frequency (program/component) were calculated. Results An iSPRINT session was conducted (i.e., ≥1 exercise out of 15 was performed) during 858 out of 1572 (54.6%) PE classes. Utilization fidelity was 13 (Q1, Q3: 7, 14) out of 15 exercises. Between the five schools, utilization fidelity ranged from 5 to 14 exercises. The most frequently utilized exercise was the forward run (96% of all iSPRINT sessions), and the least frequently utilized exercise was forward running with intermittent stops (36%). Utilization frequency of different exercises in individual schools varied from 9% to 100%. On average, the program was conducted twice a week. Out of all the iSPRINT sessions, 98% included aerobic, 89% included agility, 90% included strength, and 78% included balance exercises. Conclusions On average, the schools adhered well to the program, and all components were implemented to some extent. This indicates that there are no program components or exercises that are systematically underperformed. With adherence varying between the schools, it is important to take into account that the implementation context may differ across school environments and barriers to maximizing adherence require consideration.

Estimation of the maximum utilization area including home range and peripheral sites.

There is increasing evidence that occasional utilization area (peripheral sites), in addition to typical utilization area (home range), is important for wildlife conservation and management. Here we estimated the maximum utilization area (MUA), including both typical and occasional utilization areas, based on asymptotic curves of utilization area plotted against sample size. In previous studies, these curves have conventionally been plots of cumulative utilization area versus sample size, but this cumulative method is sensitive to stochastic effects. We propose a new method based on simulation studies where outcomes of replicated simulations are averaged to reduce stochastic effects. In this averaged method, possible combinations of sample size with the same number of location data replicated from a dataset were averaged and applied to the curves of utilization area. The cumulative method resulted in a large variation of MUA estimates, depending on the start date as well as total sample size of the dataset. In the averaged method, MUA estimates were robust against changes in the start date and total sample size. The large variation of MUA estimates arose because location data on any day including the start date are affected by unpredictable effects associated with animal activity and environmental conditions. In the averaged method, replicates of sample size resulted in a reduction of temporal stochasticity, suggesting that the method stably provides reliable estimates for MUA.

Effects of long-term phosphorus application on crop yield, phosphorus absorption, and soil phosphorus accumulation in maize-wheat rotation system.

In this study, we examined the effects of four phosphorus treatments on crop yields, and analyzed crop phosphorus uptake and phosphorus utilization efficiency, as well as changes in soil phosphorus deficit in maize-wheat rotation system, based on a 7-year field experiment in Baoding City, Hebei Province. The results showed that long-term phosphorus application significantly increased the yield and phosphorus uptake of maize and wheat. The yield and phosphorus uptake of maize and wheat showed a parabolic trend that first increased and then decreased with the increases of phosphorus application. The utilization efficiency of phosphorus fertilizer in the corn season was higher than that in the wheat season under various phosphorus application treatments. The cumulative utilization efficiency of phosphorus fertilizer in the wheat season showed a downward trend. The decline rate showed that optimized phosphorus application > 70% optimized phosphorus application >130% optimized phosphorus application. The cumulative utilization efficiency of phosphorus fertili-zer in the corn season showed an upward trend. For the rising rate, the optimized phosphorus application > 70% optimized phosphorus application > 130% optimized phosphorus application. Both the apparent phosphorus surplus and the accumulated phosphorus surplus of the soil without phosphorus application were under phosphorus deficiency. Under the treatment of phosphorus application, soil phosphorus showed a status of phosphorus surplus. The higher the phosphorus application rate, the longer the accumulation period, the higher the soil phosphorus surplus. Under the straw returning condition, phosphorus application rate for wheat of 105-150 kg·hm-2 and the phosphorus application rate for maize of 63-90 kg·hm-2 in Hebei fluvo-aquic soil could ensure the high crop yield, keep the phosphorus utilization efficiency at a high level, and reduce soil phosphorus accumulation and environmental risks.

Hospitalization Patterns and Medicare Spending for Non-Malignant Morbidity Among Older Survivors of Non-Hodgkin Lymphoma (NHL)

Introduction: Growth in the number of older cancer survivors in the face of projected healthcare workforce shortages is challenging the US health-care system in delivering appropriate care. A risk-stratified approach based on burden of morbidity and healthcare expertise is urgently needed to provide efficient and cost-effective care. We examined the cumulative, non-malignant, condition-specific hospitalization rates and associated spending in older NHL survivors compared to non-cancer controls, using a population-based approach, to develop evidence for risk-stratified care. Methods: Using SEER-Medicare data, we identified 14,533 patients diagnosed with NHL at age >65y (2008-2015). An age, race, sex, and follow-up time comparable non-cancer cohort (n=14,533) was also identified. Hospitalizations for 10 health conditions were used to examine cumulative utilization burden of non-malignant morbidity by time from diagnosis to 5y or date of bone marrow transplant (whichever came first), censoring at 6 mo prior to death or end-of-study (12/31/2016). We estimated the average number of hospitalizations per 100 individuals, up to 1y and 5y, accounting for the competing risk of leaving the cohort (BMT or 6 months prior to death). We calculated incident rate ratios [IRR] per person-time comparing NHL patients to controls controlling for pre-cancer comorbidity, Dual Medicaid-Medicare coverage, race/ethnicity, and pre-NHL hospitalization. We calculated Medicare spending per hospitalization and per person-year (adjusted to 2016 pricing), defining high hospitalization or high spending using the 90th percentile cutpoint for predicted hospitalization or spending. Results: Hospitalization: In Fig 1, we summarize the average number of condition-specific hospitalizations/100 individuals by 1y and by 5y. Adjusting for demographics and pre-existing comorbidity, NHL patients were significantly more likely to be hospitalized when compared with controls (IRR1y=3.08, IRR5y=1.54, all p<0.001). Compared with controls, NHL patients were at higher risk for hospitalizations related to cardiovascular disease (IRR1y=3.08, IRR5y=1.54, all p<0.001), age-related conditions (IRR1y=7.14, IRR5y=2.53, all p<0.001), gastrointestinal (GI) disease (IRR1y=5.84, IRR5y=2.30, all p<0.001), and pulmonary conditions (IRR1y=3.06, IRR5y=1.36, p<0.001). Factors associated with high hospitalization rates included a diagnosis of diffuse large B cell lymphoma (RR=6.36, p<0.001) and ≥2 pre-existing comorbidities (RR=10.1, p<0.001), non-white race/ethnicity (Black: RR=1.74, p<0.001; Hispanic (RR=1.97, p<0.001), residence in low-education area (RR=1.49, p<0.001) or low-income area (RR=37, p<0.001), or rural residence (RR=1.38, p<0.001). The high-hospitalization subgroup (n=1,435) had 3.24 times the hospitalization rate when compared with the lowest-hospitalization subgroup (p<0.001). Spending: Average hospitalization spending per person-year was higher in the NHL cohort (Y1: $8,178 vs. $1,621; 5y: $3,805 vs. $1,543) when compared with non-cancer controls (Fig 2). The average spending per hospitalization over 5y was also higher for the NHL cohort ($16,950 vs. $13,474, Fig 3). Pulmonary conditions were associated with the largest per hospitalization spending differential between NHL and controls ($18k vs. $9k). Other per hospitalization spending disparities between NHL patients and controls included GI disease ($17.8k vs. $10.2k) and age-related conditions ($12.6k vs. $7.9k). The NHL high-spending group was similar to the high-hospitalization group (71% overlap). The highest spending group had 2.5 times the spending compared with the lowest spending (10th percentile) group (p<0.001). Conclusions: Medicare beneficiaries diagnosed with NHL experience significantly greater rates of non-malignant hospitalizations and spending compared to their non-cancer counterparts. These hospitalizations are related to cardiovascular disease, gastrointestinal disease, pulmonary complications and aging-related conditions. Non-white DLBCL patients from lower SES with ≥2 comorbidities and living in rural areas were at greatest risk of high hospitalization and spending, providing evidence for a targeted risk-stratified care. Disclosures Mehta: Seattle Genetics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Roche-Genentech: Research Funding; Merck: Research Funding; TG Therapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Affimed: Research Funding; Takeda: Research Funding; Incyte: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Innate Pharmaceuticals: Research Funding; fortyseven Inc/Gilead: Research Funding; Juno Parmaceuticals/BMS: Research Funding; Gelgene/BMS: Research Funding; Oncotartis: Research Funding; Kite/Gilead: Research Funding.

How much, how often, how well? Adherence to a neuromuscular training warm-up injury prevention program in youth basketball

ABSTRACT Adherence is a key implementation outcome that determines the effectiveness of an intervention. This study, an observational design involving coaches and players from 33 high school basketball teams, evaluated the dimensions of adherence to a basketball-specific neuromuscular training (NMT) warm-up program in youth basketball. Coach adherence (daily report of team adherence) was collected prospectively. Adherence measures: cumulative utilization (proportion of total sessions possible), utilization fidelity (average # of exercises completed per NMT session), utilization frequency (average # of NMT sessions completed per week) were calculated and further evaluated for optimal adherence (≥80%, ≥10.4 exercises/session and ≥2 sessions/week, respectively) per coach. Additionally, exercise fidelity (proportion of players performing individual exercises correctly) was assessed. Coach (n = 31; 27–59 years) median cumulative utilization was 80%, utilization fidelity was 12 (of a possible 13 exercises per session) and utilization frequency was 2.3 sessions per week. Optimal adherence ranged from 52% to 71% across measures of adherence. Player exercise fidelity was 48%. Time constraint (47%) was the most frequently reported adherence barrier. While coach adherence to the NMT warm-up program was reasonably high across measures of adherence, a considerable proportion of coaches did not attain optimal adherence levels and player exercise fidelity was low.

P0788HEALTHCARE RESOURCE UTILIZATION AND COSTS IN A DAPA-CKD-LIKE POPULATION USING A CONTEMPORARY US HEALTHCARE COHORT

Abstract Background and Aims Recent studies have shown an association between Sodium Glucose Co-Transporter 2 inhibitor (SGLT-2i) class of drugs and lower healthcare costs compared with other glucose lowering therapy, in type 2 diabetes (T2D) patients mainly as a result of reduced rates of cardiovascular and other T2D-associated outcomes. The DAPA-CKD Trial (A study to evaluate the effect of dapagliflozin on renal outcomes and CV mortality in patients with CKD) is the first SGLT-2i renal outcomes trial to test the efficacy and safety of an SGLT-2i, dapagliflozin, in patients with CKD with and without T2D. The objective of this study is to assess the healthcare resource utilization and cost in a “DAPA-CKD-like population” (eGFR 25-75ml/min/1.73m2 and UACR 200-5000mg/g) using a contemporary US healthcare system. Method Data from the Henry Ford Health System (HFHS) were used to identify persons with CKD stages 2 through 4 between 2006 and 2016 (based on eGFR labs) and patients were followed through 2018. Persons with no confirmatory eGFR > 90 days from index date, death within 30 days, history of renal transplant, and evidence of renal replacement therapy, or progression to CKD stage 5 during the baseline period (6 months pre or post index date) were excluded. Inpatient admissions, inpatient days, emergency department encounters, and ambulatory care encounters with primary care, specialty care and overall were assessed. Cumulative utilization was evaluated for all patients and evaluation based on the follow-up time. Patients were censored on date of death, last contact with the Health System or at December 31st, 2018. The utilization rates are the total observed utilization divided by follow-up time and reported as an annual rate. Billing records for all care with HFHS were used to estimate costs. Results 6,557 patients (mean age 62.9 years, 46.2% male) met the eligibility criteria and are included in the study cohort. The population was stratified by UACR (0-<30, 30–199, 200–5,000mg/g). The DAPA-CKD-like population (200-5000mg/g) was associated with significantly higher annualized per-patient healthcare costs, $39,222/yr (UACR 200-5000mg/g) vs. $19,547/yr (UACR <30mg/g). This increased healthcare utilization was predominantly driven by increased acute care, including hospital admissions, inpatient days and emergency department visits. Persons in the highest UACR category were almost three times more likely to have a hospital admission compared to the lowest UACR (rates 0.55/year vs. 0.20/year, respectively; see Figure below). Persons in the lowest UACR category had more primary care visits per year compared with those with highest UACR (5.81 vs 5.21). In contrast, the highest number of outpatient specialist visits per year was reported for the DAPA-CKD-like population (7.55 vs. 6.74). Conclusion This analysis of a contemporary US healthcare system demonstrated that there exists a high disease burden in the DAPA-CKD-like population as seen by the substantial increase in healthcare resource utilization and costs compared to other cohorts of patients with a lower UACR. These results highlight the need for innovative therapies to improve patient outcomes in this population.

Distribution of breeding humpback whale habitats and overlap with cumulative anthropogenic impacts in the Eastern Tropical Atlantic

AbstractAimSpecies distribution modelling is a useful tool for determining important habitats. By accounting for specific animal behaviour in the model, it is possible to identify finer‐scale patterns of habitat use. Together with spatially explicit data on anthropogenic activities, models can be used to assess human impacts and inform conservation management. This study used observations of breeding behaviour to identify fine‐scale breeding habitats of humpback whales (Megaptera novaeangliae), as well as potential overlap of these habitats with cumulative anthropogenic impacts.LocationEastern Tropical Atlantic, West Africa.MethodsMaxent was used to model humpback distribution using pertinent environmental predictors and an integrated dataset of humpback whale occurrences filtered for breeding‐specific behaviours. In conjunction with multiple anthropogenic activities, a subsequent cumulative utilization and impact analysis assessed the degree of overlap between predicted breeding habitat and potential anthropogenic impacts.ResultsGreatest habitat suitability occurred in warm coastal waters of Gabon, and other highly suitable areas occurred off Equatorial Guinea (Bioko Island), Cameroon and Angola. Sea surface temperature and height contributed most to the model. Highest overlap between humpback whales and potential impacts from anthropogenic activities occurred off Gabon, Equatorial Guinea (Bioko Island), Cameroon and Angola. Impacts associated with oil and gas development (where oil and gas platforms serve as an indicator for industry activity) appeared to contribute most to potential cumulative impact.Main ConclusionsDepth and sea surface temperature of predicted breeding habitats were consistent with previous studies. However, lesser known characteristics such as sea surface height and wind speed, resulting in potentially more sheltered areas for breeding whales, may also be important in delineating finer‐scale habitat suitability. Identified areas of high potential cumulative impact occurred within exclusive economic zones of multiple countries and likely represent the minimum level of impact to humpback whales in the region, highlighting the need for additional research and effective management throughout the area.

Exploring the potential of a risk stratification tool to move forward in integrated, person-centered primary care

Introduction: Despite growing numbers of patients facing chronic multimorbidity with complex care needs, current integrated primary care approaches for chronic disease are still highly standardized and single disease-focused. To facilitate a more person-centered approach, a risk stratification tool distinguishing patient subgroups with homogeneous care needs could be valuable. The aim of the present study was to explore the degree to which routinely registered patient characteristics can be used to stratify chronically ill into care utilization subgroups. Methods: We conducted a two-year retrospective cohort study using routinely-registered chronically ill patient characteristics from Electronic Health Records EHRs total population of 481,842 patients, 129 Dutch general practices. Care utilization was used as a proxy for care needs and operationalized as the number of duration-weighted consultations per patient. Cumulative care utilization was divided into three equal parts i.e. care utilization subgroups. Chi-square, ANOVA and post-hoc tests p Results: A division of the cohort 66 practices, n= 85,457 into three subgroups with equal care utilization i.e. each consuming one-third of cumulative weighted consultations showed a ‘low-utilization’ subgroup covering almost two-third of patients 63.8%, while the ‘medium-utilization’ and ‘high-utilization’ subgroups represented significantly smaller proportions of the cohort 24.5% and 11.7%, respectively. Compared to the low and middle group, this last subgroup contains relatively older patients, more females, lower socio-economic status and higher multimorbidity and combinations of physical and mental chronic conditions. Discussions: The significant differences in patient characteristics between the three care utilization subgroups are in line with findings from previous studies. Enriched with other relevant patient characteristics such as personal income and family size, the care utilization subgroups could stimulate to consider person-centred rather than disease-specific characteristics in aligning care to the needs of chronically ill. An individual consultation could for instance be built around the patient, having multiple conditions, instead of offering a fragmented consultation for every condition. Conclusions: The present study shows that care utilization subgroups, distinct in patient characteristics, can be developed from patient characteristics routinely registered in EHRs. Lessons learned: It was demonstrated that even a simple stratification of chronically ill based on care utilization shows great variety of patient characteristics between the subgroups. These insights are promising for the development of a risk stratification tool to support person-centered, integrated primary care. Limitations: This study lacks the inclusion of social patient characteristics not routinely registered in EHRs and data on care utilization outside primary care. Besides, care utilization was used as a proxy of care needs. Suggestions for future research: A more sophisticated analysis, like Latent Class Analysis, could be employed to examine latent classes of care needs amongst chronically ill. Moreover, a predictive analysis technique, such as machine learning, is needed to create insight into the use of patient characteristics in allocating chronically ill to a matching care needs subgroup.

A 15N tracing technique-based analysis of the fate of fertilizer N: a 4-year case study in eastern China

ABSTRACTThe fate of fertilizer N applied with different irrigation amounts in tobacco fields was quantitatively studied by applying 15N double-labelled NH4NO3 in lysimeters. The 15N (fertilizer N originating from the fertilizer applied in 2011) in tobacco plants, 15N in soils and 15N loss were observed continuously from 2011 to 2014. The results showed that 21.6% of 15N was utilized by tobacco plants, 72.1% remained in the 0–60 cm soil layer and 6.3% was lost from the soil–plant system after the first season’s harvest (2011) of flue-cured tobacco. During the four seasons from 2011 to 2014, cumulative utilization of 15N by tobacco plants was 34.3%, while 54.2% remained in the 0–60 cm soil layer, and 11.5% was lost via mechanisms such as leaching and volatilization. The fate of 15N in terms of accumulation in plants and soils or losses from the soil–plant system from 2012 to 2014 was greatly affected by the fertilizer and irrigation management strategies in 2011. The results of this investigation suggest that the major amount of fertilizer N applied during the first season remains available in the soil for utilization by tobacco plants after 4 years.

Levelized Electricity Cost of Five Solar Photovoltaic Plants of Different Capacities

This paper deals with the calculation of Levelized Electricity Cost (LEC) of five Solar Photovoltaic power (SPV) plants of different capacities 1MW, 5MW, 10MW, 25MW and 130MW. The calculation has been performed from the power generated data of the year 2014. The effect of different parameters like interest rate, inflation rate, deprecation time (plant life) and cumulative utilization factor (CUF), on LEC have been analyzed. A comparative study of the plants is done by varying these parameters. Operation and maintenance cost has been assumed 1% of the capital cost. It has been observed that LEC increases with increase in both inflation rate and interest rate. However, the influence of inflation rate on LEC is more. LEC decreases with increase in plant life and cumulative utilization factor. SPV plants established earlier have higher LEC compared to that of plants established later due to reduction in cost of SPV module prices over the years.

A framework for quantifying environmental sustainability

Recent concepts of environmental sustainability have focused on narrative economic and societal aspects rather than quantitative ones. Many key sustainability indicators also lack a consistent definition of sustainability, have perspectives that are too short-term, and are unable to model the dynamics of complex environmental utilization which can then result in inappropriate projection of long-term sustainability and/or sustainability indication. Here I propose a generalized quantitative framework of environmental sustainability requiring that (1) environmental capacities and utilization rates are identified, (2) their complex temporal dynamics are quantitatively modeled or estimated (3) while also adjusting for uncertainties, and finally, (4) using one of three options, determining which cumulative utilization pathways can be sustained for a (usually well-defined) period of time. Using the example of wood volume and its growth as capacities and harvest as utilization, and the example of global greenhouse gas emissions as the utilization component and the capacity of the air to absorb these emissions, I demonstrate how the proposed framework can be applied in practice, how sustainability indicators could be developed, and also how they can inform policies and measures to ensure sustainability.

Impact of a comprehensive pharmacist medication-therapy management service

Objective:This proof of concept study aimed to determine whether a pharmacist-managed medication therapy management (MTM) program in a private endocrinologist physician’s practice reduced healthcare services utilization and related costs 6 months after patients’ discharge from an institution with a transition of care service.Methods:Patients were included in the study if they were English-speaking, ages >18 years, had type 1 or 2 diabetes, and had a recent transition of care experience (inpatient hospital stay or emergency department/urgent care/paramedic or other acute care visit). The study had a non-randomized design where intervention patients, enrolled July 1, 2012–September 30, 2013, were administered MTM at four visits over 6 months and were compared to historical control patients with available electronic medical records from August 8, 2008 to March 15, 2012. The primary study end-point was the rate of 30-day hospital readmissions, as related to the reason for the index admission. Secondary end-points included the cumulative rate of all-cause hospitalizations, emergency department, paramedic and urgent care visits at 30, 60, 90, and 180 days post-discharge as well as imputed total costs, including prescription medication costs, at 180 days. Propensity score weights were constructed to balance covariate characteristics between the intervention and control groups. Weighted multivariate negative binomial and generalized linear regressions were used to model cumulative utilization rates and log-transformed costs, respectively.Results:The intervention (n = 28) and control (n = 73) groups had 0% hospital readmissions at 30 days post-discharge. In propensity score weighted multivariate analyses, cumulative utilization rate was not different between the two groups (IRR = 1.61, p = 0.72 at 180 days) while costs in the intervention group were lower but not statistically different (cost ratio = 0.65, p = 0.13 at 180 days).Conclusions:Further studies should investigate whether the integration of pharmacists in transition of care models could reduce readmission and healthcare utilization rates post-discharge.

The positive influences of increasing age at diagnosis of inflammatory bowel disease on disease prognostication in asian perspective.

The positive influences of increasing age at diagnosis of inflammatory bowel disease on disease prognostication in asian perspective.

Cumulative human impacts on marine predators

Stressors associated with human activities interact in complex ways to affect marine ecosystems, yet we lack spatially explicit assessments of cumulative impacts on ecologically and economically key components such as marine predators. Here we develop a metric of cumulative utilization and impact (CUI) on marine predators by combining electronic tracking data of eight protected predator species (n=685 individuals) in the California Current Ecosystem with data on 24 anthropogenic stressors. We show significant variation in CUI with some of the highest impacts within US National Marine Sanctuaries. High variation in underlying species and cumulative impact distributions means that neither alone is sufficient for effective spatial management. Instead, comprehensive management approaches accounting for both cumulative human impacts and trade-offs among multiple stressors must be applied in planning the use of marine resources.

Evaluating components of dental care utilization among adults with diabetes and matched controls via hurdle models

BackgroundAbout one-third of adults with diabetes have severe oral complications. However, limited previous research has investigated dental care utilization associated with diabetes. This project had two purposes: to develop a methodology to estimate dental care utilization using claims data and to use this methodology to compare utilization of dental care between adults with and without diabetes.MethodsData included secondary enrollment and demographic data from Washington Dental Service (WDS) and Group Health Cooperative (GH), clinical data from GH, and dental-utilization data from WDS claims during 2002–2006. Dental and medical records from WDS and GH were linked for enrolees continuously and dually insured during the study. We employed hurdle models in a quasi-experimental setting to assess differences between adults with and without diabetes in 5-year cumulative utilization of dental services. Propensity score matching adjusted for differences in baseline covariates between the two groups.ResultsWe found that adults with diabetes had lower odds of visiting a dentist (OR = 0.74, p < 0.001). Among those with a dental visit, diabetes patients had lower odds of receiving prophylaxes (OR = 0.77), fillings (OR = 0.80) and crowns (OR = 0.84) (p < 0.005 for all) and higher odds of receiving periodontal maintenance (OR = 1.24), non-surgical periodontal procedures (OR = 1.30), extractions (OR = 1.38) and removable prosthetics (OR = 1.36) (p < 0.001 for all).ConclusionsPatients with diabetes are less likely to use dental services. Those who do are less likely to use preventive care and more likely to receive periodontal care and tooth-extractions. Future research should address the possible effectiveness of additional prevention in reducing subsequent severe oral disease in patients with diabetes.

A DOUBLE-BLIND RANDOMIZED, CONTROLLED TRIAL OF PROTEIN ENERGY–ENRICHED FORMULA ADMINISTERED TO CRITICALLY ILL INFANTS

INTRODUCTION: Nutritional support is an important aspect of clinical management of critically ill infants, but the nutritional requirements of these infants are not well defined. OBJECTIVE: Our goal was to compare tolerance, nutritional, and metabolic effects of 2 different infant formulas in critically ill infants in a double-blind, randomized way. METHODS: Eighteen ventilated infants with respiratory insufficiency caused by respiratory syncytial virus infection were included and received an energy- and protein-enriched (PE) infant formula (Infatrini [Nutricia B. V. Zoetermeer, Zoetermeer, Netherlands]; n = 8) or standard infant formula (Nutrilon 1 [Nutricia B. V. Zoetermeer]; n = 10). Daily intake and tolerance (gastric retention, diarrhea) were recorded. Resting energy expenditure, respiratory quotient, L-amino acid concentrations, and metabolic parameters were measured, and cumulative energy balance, nitrogen balance, and substrate utilization were calculated. RESULTS: Baseline characteristics were similar in both groups. Both formulas were well tolerated with similar volumes of intake. Results from day 4 are presented in Table 1. Levels of several amino acids (His, Val, Met, Phe, Lys, and ornithine; P &amp;lt; .05) were significantly higher in the infants who received the PE-enriched formula. CONCLUSIONS: PE-enriched infant formula was well tolerated in critically ill infants and effective in achieving higher nutritional intakes in the first days of admission. PE-enriched formula improved energy balance and plasma amino acid profile, and a trend toward increased nitrogen balance was found. TABLE 1.Results on Day 4 of AdmissionFormulaProtein Intake, g/kg per dayEnergy Intake, kcal/kg per dayaResting Energy Expenditure, kcal/kg per dayaRespiratory QuotientCumulative Energy Balance, kcal/kg per dayaCumulative Nitrogen Balance, mg/kg per dayPE-enriched (n = 8)2.61 ± 0.24111 ± 1059 ± 50.98 ± 0.02589 ± 115162 ± 32Standard (n = 10)1.46 ± 0.1178 ± 449 ± 40.91 ± 0.01350 ± 5068 ± 16 P &amp;lt;.01&amp;lt;.01.26&amp;lt;.01&amp;lt;.05.08a1 kcal = 4.2 kJ.

Anemia management with erythropoietic stimulating therapies (ESTs) in patients (pts) with gastrointestinal (GI) malignancies: Results from a prospective observational study

19614 Background: Chemotherapy-induced anemia is a common problem for pts with GI malignancies. To assess dosing patterns and outcomes in GI malignancy pts treated with ESTs (epoetin alfa (EPO) and darbepoetin alfa (DARB), a subset analysis of an ongoing registry was conducted. Methods: Data drawn between1/04 and 10/06 from 41 U.S. oncology clinics from the Dosing and Outcomes Study of Erythropoietic Stimulating Therapies (D.O.S.E.) registry were assessed. Pts were included in this analysis if they were diagnosed with a GI malignancy (colon, rectal, gastric, esophageal, or pancreatic), = 18 years, and received = 2 doses of either EPO or DARB. Outcomes assessed included mean baseline (BL) characteristics, transfusion utilization, hemoglobin (Hb) at Weeks 4, 8, and 12 after initiation of EPO or DARB, and cumulative EST doses with associated cost (based on 9/2006 wholesale acquisition cost). Results: 186 pts (82 EPO, 104 DARB) were identified. BL characteristics were similar between treatment groups: age 64 years, 45% women, and Hb 10.5g/dL. Both groups had a similar treatment duration (7 weeks) and number of Hb determinations (7.6); however, the DARB group had significantly more office visits (EPO 7, DARB 9.8, p=.0006). The proportion of pts transfused from Week 5 to end of study and number of units transfused/pt were similar between both groups. Hb values were similar at Weeks 4 (11.1 g/dL), 8 (11.1 g/dL), and 12 (11.0 g/dL). The mean administered dose per injection was 42,143 Units for EPO and 225 mcg for DARB. Mean cumulative administered dose during the treatment episode was 296,476 Units for EPO and 1,131 mcg for DARB, resulting in a dose ratio of 262:1 (Units EPO:mcg DARB). Overall EST cost was significantly lower in the EPO group compared to the DARB group (EPO $3,608, DARB $5,028, p=.0024). Conclusions: Similar hematological outcomes for EPO- and DARB-treated pts with GI malignancies were observed. Based on observed dosing patterns and cumulative EST utilization from this prospective observational study, EST costs were 28% lower in the EPO group than the DARB group. The observed dose ratio is consistent with previously reported clinical studies. No significant financial relationships to disclose.

Evaluation of Breast Cancer Care under Puerto Rico's Health Care Reform

Puerto Rico has implemented Health Care Reform legislation that shifted medically indigent and underserved persons from direct care by public sector institutions to managed care arrangements through the private sector. Our aim is to assess how previously underserved women with breast cancer have fared during the first three years of the Reform. Medical claims data were obtained on breast cancer cases in San Juan who were either enrolled in the capitated Reform plan or in a commercial policy offered by the same insurer. A set of indicators reflecting initial therapy, use of key services, and cumulative utilization rates of various medical procedures were constructed. Statistical tests were conducted to assess whether these indicators differed between Reform- and commercially-insured patients. Failure to reject null hypotheses of indicator differences were then used to judge Reform progress. We found some differences, but they were neither pervasive nor unidirectional. On balance, we conclude that previously underserved women are being treated for breast cancer roughly on par with other patients. This conclusion, however, is preliminary and subject to important qualifications.

The challenges associated with the capitalization of managerial skills and competencies

Drawing on the theoretical framework of the institutional competency-based perspective, this paper develops a model to explain the process of capitalizing managerial competencies and skills into intangible capital stocks of an organization. It is argued that the effective and cumulative utilization of human, social, political, and cross-cultural capitals can help an organization sustain its competitive advantage, ultimately exerting a positive influence on organizational performance.