US Health Care Research Articles

Venous thromboembolism performance measurement in the United States: An evolving landscape with many stakeholders.

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a life-threatening, costly, and common preventable complication associated with hospitalization. Although VTE prevention strategies such as risk assessment and prophylaxis are available, they are not applied uniformly or systematically across US hospitals and healthcare systems. Hospital-level performance measurement has been used nationally to promote standardized approaches for VTE prevention and incentivize the adoption of guideline-based care management. Though most measures reflect care processes rather than outcomes, certain domains including diagnosis, treatment, and continuity of care remain unmeasured. In this article, we describe the development of VTE prevention measures from various stakeholders, measure strengths and limitations, publicly reported rates, the impact of technology and health policy on measure use, and perspectives on future options for surveillance and performance monitoring.

Analysis of trends in radiofrequency ablation in a tertiary care center practice.

Radiofrequency ablation (RFA) for thyroid nodules has recently been introduced into the United States healthcare system landscape. Little is known about the process of incorporating this procedure into existing clinical practice. A retrospective chart review of a single institution was conducted to examine referral patterns and decision-making after the introduction of RFA into an endocrine surgery-focused practice. Patient demographics and thyroid-specific data were recorded. Two reviewers abstracted and coded reasons for the noncompletion of RFA. Two-sample t tests were used to compare groups; linear regression was used to assess trends and practice patterns. Chart review identified 451 patients referred for consideration of RFA from January 2020 to December 2022. Only 255 (56.5%) went on to receive the treatment. There was no significant difference in nodule volume between treated and nontreated groups (18.5 vs. 14.9 cm3, p = 0.07). Concern for malignancy on genetic testing, size (too large/too small), recommendation for Ethanol ablation, and multinodular disease without target nodules were the most common reasons for physician deferral. Of patients who declined to proceed, 46% opted to undergo surgical excision. Linear regression showed that referral numbers significantly increased with time; however, the proportion of patients receiving treatment decreased yearly, primarily because of higher rates of physician deferral. This study reflects the complex decision-making in offering minimally invasive thyroid nodule ablation. Despite a greater number of referrals over time, physician criteria became increasingly selective. Optimal candidacy in RFA is an evolving determination requiring patient and physician input to guide ideal practice patterns.

Vasectomy incidence in the military health system after the reversal of Roe v. Wade.

Dobbs v. Jackson Women's Health Organization (Dobbs decision) has already had profound impact on reproductive health care in the United States. Some studies have reported increased incidence of vasectomy after the Dobbs decision. The Military Health System (MHS) provides a unique opportunity to evaluate this relationship in a universally insured, geographically representative population. We conducted a retrospective cross-sectional study of vasectomies among all male beneficiaries in the MHS, ages 18 to 64, from 2018 to 2022. Beneficiaries receiving a vasectomy were identified via billing data extraction from the MHS Data Repository (MDR). Descriptive statistics of demographic factors of all those receiving a vasectomy in the study period were evaluated. Crude and multivariate logistic regression models were used to evaluate for differences in demographic variables in those receiving a vasectomy pre-Dobb's decision as compared to after the Dobb's decision. The total number of men receiving a vasectomy each month over the study period was analyzed, as were the numbers in a state immediately implementing abortion access restrictions (Texas), and one without any restrictions on abortion access (Virginia). Our analysis found that men receiving a vasectomy post-Dobbs decision were more likely to be younger, unmarried, and of junior military rank than prior to the Dobbs decision. In the months following the Dobbs decision in 2022 (June-December), there was a 22.1% increase in vasectomy utilization as compared to the averages of those months in 2018-2021. Further, it was found that the relative increase in vasectomy after the Dobbs decision was greater in Texas (29.3%) compared to Virginia (10.6%). Our findings highlight the impact of the Dobbs decision on reproductive health care utilization outside of abortion.

Implications of trial eligibility in patients with heart failure with mildly reduced or preserved ejection fraction.

Clinical trials in heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) commonly have detailed eligibility criteria. This may contribute to challenges with efficient enrolment and questions regarding the generalizability of trial findings. Patients with HFmrEF/HFpEF from a large US healthcare system were identified through a computable phenotype applied in linked imaging and electronic health record databases. We evaluated shared eligibility criteria from five recent/ongoing HFmrEF/HFpEF trials (PARAGON-HF, EMPEROR-Preserved, DELIVER, FINE-ARTS, and SPIRRIT-HFpEF) and compared clinical and echocardiographic features as well as outcomes between trial-eligible and trial-ineligible patients. Among 5552 patients with HFpEF/HFmrEF, 792 (14%) were eligible for trial consideration, having met all criteria assessed. Causes of ineligibility included lack of recent loop diuretics (37%), significant pulmonary disease (24%), reduced estimated glomerular filtration rate (17%), recent stroke/transient ischaemic attack (13%), or low natriuretic peptides (12%); 53% of ineligible patients had >1 reason for exclusion. Compared with eligible patients, ineligible patients were younger (age 71 vs. 75years, P<0.001) with higher rates of coronary artery disease (66% vs. 59%, P<0.001) and peripheral vascular disease (40% vs. 33%, P<0.001), but less mitral regurgitation, lower E/e' ratio, and smaller left atrial sizes. Both eligible and ineligible patients demonstrated high rates of structural heart disease consistent with HFpEF [elevated left atrial size or left ventricular (LV) hypertrophy/increased LV mass], although this was slightly higher among eligible patients (95% vs. 92%, P=0.001). The two cohorts demonstrated similar LV global longitudinal strain along with a similar prevalence of atrial fibrillation/flutter, hypertension, and obesity. Ineligible patients had similar all-cause mortality (33% vs. 33% at 3years) to those eligible but lower rates of heart failure hospitalization (20% vs. 28% at 3years, P<0.001). Among patients with HFmrEF/HFpEF from a large health system, approximately one in seven were eligible for major trials based on key criteria applied through a clinical computable phenotype. These findings highlight the large proportion of patients with HFmrEF/HFpEF ineligible for contemporary trials for whom the generalizability of trial findings may be questioned and further investigation would be beneficial.

Cost-effectiveness analysis of CYP3A5 genotype-guided tacrolimus dosing in solid organ transplantation using real-world data.

The objective of this study was to estimate the cost-effectiveness of CYP3A5 genotype-guided tacrolimus dosing in kidney, liver, heart, and lung transplant recipients relative to standard of care (SOC) tacrolimus dosing, from a US healthcare payer perspective. We developed decision-tree models to compare economic and clinical outcomes between CYP3A5 genotype-guided and SOC tacrolimus therapy in the first six months post-transplant. We derived inputs for CYP3A5 phenotype frequencies and physician use of genotype test results to inform clinical care from literature; tacrolimus exposure [high vs low tacrolimus time in therapeutic range using the Rosendaal algorithm (TAC TTR-Rosendaal)] and outcomes (incidences of acute tacrolimus nephrotoxicity, acute cellular rejection, and death) from real-world data; and costs from the Medicare Fee Schedule and literature. We calculated cost per avoided event and performed sensitivity analyses to evaluate the robustness of the results to changes in inputs. Incremental costs per avoided event for CYP3A5 genotype-guided vs SOC tacrolimus dosing were $176,667 for kidney recipients, $364,000 for liver recipients, $12,982 for heart recipients, and $93,333 for lung recipients. The likelihood of CYP3A5 genotype-guided tacrolimus dosing leading to cost-savings was 19.8% in kidney, 32.3% in liver, 51.8% in heart, and 54.1% in lung transplant recipients. Physician use of genotype results to guide clinical care and the proportion of patients with a high TAC TTR-Rosendaal were key parameters driving the cost-effectiveness of CYP3A5 genotype-guided tacrolimus therapy. Relative to SOC, CYP3A5 genotype-guided tacrolimus dosing resulted in a slightly greater benefit at a higher cost. Further economic evaluations examining intermediary outcomes (e.g., dose modifications) are needed, particularly in populations with higher frequencies of CYP3A5 expressers.

US County-Level Variation in Availability and Prevalence of Black Physicians in 1906

Black physicians are substantially underrepresented in the US health care workforce, with detrimental effects on the health and health care experiences of Black individuals. These contemporary gaps can be traced to the early days of the medical profession using the first edition of the American Medical Directory (AMD). To identify state- and county-level patterns related to the training and availability of Black physicians relative to their White counterparts in the 1906 AMD. For this cross-sectional study, data for 41 828 physician entries in 18 US states in or adjacent to the South as well as the District of Columbia were extracted from the 1906 AMD and aggregated to 1570 counties. Data analysis was performed between September 2023 and January 2024. County-level exposure variables included population density, racial composition, and illiteracy rate among US-born White residents as well as an index of terrain ruggedness and the number of lynchings in the previous decade. Median values of physicians' distance from place of practice to place of medical training (by race of physician) were also used as an exposure variable. There were 4 county-level outcomes: (1) presence of any Black physician, (2) proportion of Black physicians per Black population, (3) proportion of White physicians per White population, and (4) community representativeness (reported as the community representativeness ratio). The cross-sectional analysis used generalized additive mixed models with state-level random effects. Across 1570 counties, Black physicians comprised 746 (1.8%) of the 41 828 physicians in the dataset. Black physicians tended to train further from their place of practice than their White counterparts. The proportion of Black physicians per 1000 Black residents was 0.08 compared with 1.62 for White physicians; these proportions varied substantially by state. At the county level, the presence of any Black physician was associated with percentage Black population (odds ratio [OR], 28.94 [95% CI, 9.77 to 85.76]; P ≤ .001), population density (OR, 2.63 [95% CI, 2.03 to 3.40]; P ≤ .001), and distance to the nearest Black medical school (OR, 0.62 [95% CI, 0.42 to 0.92]; P = .02). A variety of structural disadvantages are illustrated in this cross-sectional study of county-level sociodemographic and geographic characteristics associated with the prevalence of Black physicians in the earliest days of the profession. To demonstrate its broader utility for health disparities research, the dataset has been made publicly available with a visualization platform.

Depression Symptoms Linked to Multiple Oral Health Outcomes in US Adults.

Individuals with mental illness have poor oral health compared to those without mental health conditions. However, the literature is still lacking regarding the specifics of this relationship. This study aims at examining the relationship between depression and oral health problems such as oral conditions, access to dental care, and oral hygiene measures. A cross-sectional study using a secondary data analysis of 9,693 participants from the 2017 to March 2020 prepandemic National Health and Nutrition Examination Survey (NHANES). The independent variable was severity of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9). Proportional odds and binary logistic regression were used to calculate crude and adjusted odds ratios (AORs) between depression and 8 oral health outcomes and oral hygiene-related behaviors. After adjusting for sociodemographics, health conditions, and behaviors, individuals with depression were significantly more likely to have dental aches in the past year (AOR = 1.70; 95% confidence interval [CI], 1.13-2.56), difficulty getting dental care when needed (AOR = 1.93; 95% CI, 1.45-2.58), and difficulty at their jobs due to a problem in their mouth (AOR = 1.63; 95% CI, 1.07-2.49) compared to individuals without depression. Individuals with depressive symptoms often neglect oral hygiene and self-care practices and are less likely to seek medical care for oral health problems, making them at increased risk of poor oral health outcomes. These findings can be applied by dentists, psychologists, and therapists to increase awareness of links between depression and oral health and to encourage patients with depression to seek oral hygiene preventative care. Health care professionals can be on the frontline in creating awareness in the general public about the links between depression and oral health and hygiene. Applying the findings from this study can help communicate about the relationship between depression and poor oral health and relieve some burden on the American health care sector, which often struggles to provide medical care to patients with depression and oral health issues.

Brodalumab: 5-Year US Pharmacovigilance Report.

Brodalumab is a human interleukin-17 receptor A antagonist indicated for the treatment of moderate-to-severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies. Although the US prescribing information for brodalumab includes a boxed warning regarding suicidal ideation and behavior, no causal association has been demonstrated. Here, we summarize 5years of pharmacovigilance data, from August 15, 2017, through August 14, 2022, reported to Ortho Dermatologics by US patients and healthcare providers. Prevalence of the most common adverse events (AEs) listed in the brodalumab package insert (incidence ≥ 1%) and AEs of special interest are described. Brodalumab exposure was estimated as the time from the first to last prescription-dispensing authorization dates. Data were collected from 4744 patients in the USA, with an estimated exposure of 5815 patient-years. Over 5years, 11 cases of adjudicated major adverse cardiovascular events were reported (0.23 events/100 patients), a rate lower than that experienced by patients in the international Psoriasis Longitudinal Assessment and Registry. There were 106 serious infections. No serious fungal infections were reported. There were 40 confirmed and 2 suspected COVID-19 cases, with no new COVID-19-related deaths. Of 49 reported malignancies among 42 patients, 3 were deemed possibly related to brodalumab. No completed suicides and no new suicidal attempts were reported. Five-year pharmacovigilance data are consistent with the established safety profile reported in long-term clinical trials and previous pharmacovigilance reports, with no new safety signals.

Alcohol-Related Deaths of US Health Care Workers

This cohort study investigates the risk of alcohol-related death among US health care workers compared with non–health care workers.

Evaluating the cost-effectiveness of voclosporin for the treatment of lupus nephritis in the United States.

Lupus nephritis (LN) is a severe manifestation of systemic lupus erythematosus; up to 30% of patients with LN will develop end-stage kidney disease (ESKD). One of the main treatment goals for LN is preservation of kidney function, with early decreases in proteinuria associated with improved long-term outcomes. Voclosporin, a second-generation calcineurin inhibitor, was approved in the United States in 2021 for the treatment of active LN combined with background immunosuppression. The AURORA 1 study found that the use of voclosporin with low doses of mycophenolate mofetil and glucocorticoids yielded significant reductions in proteinuria. The AURORA 2 study showed long-term efficacy and safety of voclosporin over a 3-year period with kidney function preservation. The Institute for Clinical and Economic Review (ICER) is a nonprofit organization that evaluates medical evidence to help improve patient outcomes and control costs. In 2021, ICER published an economic model to estimate the impact and cost-effectiveness of LN therapies. From a US health care perspective, voclosporin was cost-effective at $149,260 per quality-adjusted life-year (QALY) and $131,528 per equal value of life-years gained (evLYG). At the time of the LN cost-effectiveness model (CEM) development, voclosporin was not yet approved in the United States and the cost of treating patients with LN with ESKD was not captured in the literature. To evaluate the cost-effectiveness of voclosporin given the emergence of new data. The LN CEM uses a short-term trial-based Markov model and long-term extrapolation using partitioned survival modeling data assuming adults with LN start with active disease, transitioning to complete or partial renal response, kidney failure, or death. In the current analysis, clinical data for voclosporin, duration of voclosporin treatment for nonresponders, and drug costs reflecting the 2023 price of voclosporin were updated. Additionally, health care payer costs of disease management were incorporated based on real-world claims data on the costs of treating patients with LN. Using the LN CEM with inputs reflecting the latest and most relevant evidence, the incremental cost of voclosporin per QALY was $88,076 and per evLYG was $77,643. For a subpopulation of Black, Hispanic, and Latino patients, the incremental cost of voclosporin per QALY was $77,435 and per evLYG was $67,828. Following the inclusion of updated data in the cost-effectiveness analysis, voclosporin remains a cost-effective therapy for the treatment of active LN including in a Black, Hispanic, and Latino subpopulation, substantially below the ICER willingness-to-pay threshold of $150,000/QALY.

Abstract PO2-12-07: Risk of anaphylaxis associated with the use of pertuzumab or other biologics with potential for use outside the hospital

Abstract BACKGROUND Intravenous (IV) pertuzumab (P) and trastuzumab (H) are approved in the US for the treatment of HER2-positive breast cancer. P and H are also approved as a fixed-dose combination for SC injection (pertuzumab, trastuzumab, and hyaluronidase-zzxf; PH FDC SC). PH FDC SC may offer the possibility of treatment outside a hospital setting by a healthcare professional. Anaphylactic reactions can be a concern with the use of biologics. PH is also frequently initiated with six to eight cycles of taxanes, which can also be associated with anaphylaxis. We used administrative claims data to evaluate the risk of anaphylaxis associated with the real-world administration of PH or other biologic drugs in the real world. Our objective was to evaluate the risk of anaphylaxis associated with the administration of P and to contextualize the risk estimate by using other biologics that can be used outside the hospital as a benchmark. METHODS Cohorts of incident users were selected using retrospective records from a US healthcare claims database (IQVIA). Patients included were privately insured in the US, aged 16 to 65 years, and initiated a treatment of interest between 2012 and 2021. Possible and severe anaphylactic events (PAEs) were identified using the algorithm developed by the US Food and Drug Administration (FDA) Sentinel Initiative and updated with ICD10 codes (PMID: 34181291). PAEs were attributed to a drug if it occurred on the day of administration or the day after. The prevalence proportion (PP) of PAE was used to approximate the risk of anaphylaxis at each cycle. A sensitivity analysis using the proportion of prior P use amongst the cases of PAE beyond cycle 1 in the H cohort was conducted to approximate how many cases of PAE could have been missed at cycle 1 of P due to a depletion of susceptibles (as P IV and H may be administered sequentially in any order, patients with a PAE from H would not receive scheduled P and thus be excluded from the P cohort). RESULTS A total of 1,919,748 patients constituted 27 cohorts. Of them, 184,414 patients initiated monoclonal antibodies (mAbs) in 12 cohorts of which 12,264 and 184 initiated P IV and PH FDC SC, respectively. In the P IV cohort, seven PAE events were observed up to cycle 6 and none after. The PP at cycle 1 of P was 1.63 per 10,000 patients (95% confidence interval [CI] = 0.45, 5.94). The risk was comparable to that of other mAbs where anaphylaxis risk is described as uncommon/rare (Table). Accounting for a potential depletion of susceptibles increased the PP at cycle 1 of P to 2.45/10,000 (95% CI = 0.83, 7.19). No PAEs were reported in patients treated with PH FDC SC. CONCLUSIONS Using one of the largest datasets available, results suggest the risk of PAE with P administration could be within the range of what is observed with other mAbs that can be administered outside of the hospital. All events were observed when patients are expected to receive treatment at the hospital due to taxane administration. No PAE events were identified for PH FDC SC, but there were few patients in this cohort. Efforts are ongoing to identify a larger cohort treated with PH FDC SC. Risk of anaphylaxis by mAb * According to summary of product characteristics. † ≥1/1,000 to &amp;lt;1/100. ‡ ≥1/10,000 to &amp;lt;1/1,000. CI = confidence interval; H = trastuzumab; IV = intravenous; P = pertuzumab; PH FDC SC = pertuzumab, trastuzumab, and hyaluronidase-zzxf. Citation Format: Thibaut Sanglier, Tom Chambers, Joanna Harton, Laurentia Wahyudi, Magali Genevray, Eleonora Restuccia, Cécile Droz-Perroteau, Chau Dang. Risk of anaphylaxis associated with the use of pertuzumab or other biologics with potential for use outside the hospital [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-12-07.

Effectiveness and safety in non-valvular atrial fibrillation patients switching from warfarin to direct oral anticoagulants in US healthcare claims.

There is a paucity of real-world studies examining the risks of stroke/systemic embolism (SE) and major bleeding (MB) among non-valvular atrial fibrillation (NVAF) patients switching from warfarin to a direct oral anticoagulant (DOAC). This retrospective study was conducted to compare the stroke/SE and MB risks between patients switched from warfarin to apixaban, dabigatran, or rivaroxaban in real-world clinical practice. This study used data from four United States commercial claims databases from January 1, 2012 to June 30, 2019. The study population included NVAF patients initially treated with warfarin and switched to apixaban, dabigatran, or rivaroxaban within 90 days of their warfarin prescription ending. Patients were matched 1:1 between the DOACs in each database using propensity scores and then pooled for the final analysis. Cox proportional hazards models were used to calculate the risk of stroke/SE and MB. The final population consisted of 2,611 apixaban-dabigatran, 12,165 apixaban-rivaroxaban, and 2,672 dabigatran-rivaroxaban pairs. Apixaban vs. dabigatran was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.39-0.96) and MB (HR: 0.67; 95% CI: 0.50-0.91). Apixaban vs. rivaroxaban was associated with a similar risk of stroke/SE (HR: 0.88; 95% CI: 0.73-1.07) and a lower risk of MB (HR: 0.60; 95% CI: 0.52-0.68). There was no significant difference in either risk between dabigatran and rivaroxaban. These results provide important insights into how the risks of stroke/SE and MB for NVAF patients vary when switching from warfarin to different DOACs.

Transgender health care in the United States: legal, ethical and practical concerns for gastroenterologists in a changing landscape.

Transgender health care in the United States: legal, ethical and practical concerns for gastroenterologists in a changing landscape.

Cost-Effectiveness of Medical Therapy for HeartFailure With Mildly Reduced and Preserved Ejection Fraction.

Three medications are now guideline-recommended treatments for heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), however, the cost-effectiveness of these agents in combination has yet to be established. The purpose of this study was to determine the cost-effectiveness of mineralocorticoid receptor antagonists (MRA), angiotensin receptor-neprilysin inhibitors (ARNIs), and sodium glucose co-transporter 2 inhibitors (SGLT2is) in individuals with HFmrEF/HFpEF. Using a 3-state Markov model, we performed a cost-effectiveness study using simulated cohorts of 1,000 patients with HFmrEF and HFpEF. Treatment with 1-, 2-, and 3-drug combinations was modeled. Based on a United States health care sector perspective, outcome data was used to calculate incremental cost-effectiveness ratios (ICERs) in 2023 United States dollars based on a 30-year time horizon. Treatment with MRA, MRA+SGLT2i, and MRA+SGLT2i+ARNI therapy resulted in an increase in life years of 1.04, 1.58, and 1.80 in the HFmrEF subgroup, respectively, and 0.99, 1.54, and 1.77 in the HFpEF subgroup, respectively, compared with placebo. At a yearly cost of $18, MRA therapy resulted in ICERs of $10,000 per quality-adjusted life year (QALY) in both subgroups. The ICER for the addition of SGLT2i therapy ($4,962 per year) was $113,000 per QALY in the HFmrEF subgroup and $141,000 in the HFpEF subgroup. The addition of ARNI therapy ($5,504 per year) resulted in ICERs >$250,000 per QALY in both subgroups. If SGLT2i and ARNI were available at generic pricing the ICERs become <$10,000 per QALY in both EF subgroups. Outcomes were highly sensitive to assumed benefit in cardiovascular death. For patients with heart failure, MRA was of high value, SGLT2i was of intermediate value, and ARNI was of low value in both HFmrEF and HFpEF subgroups. For patients with HFmrEF/HFpEF increased use of MRA and SGLT2i therapies should be encouraged and be accompanied with efforts to lower the cost of SGLT2i and ARNI therapies.

Addressing Disparities in Vision Health and Eye Care in the US

Health disparities are a prevalent issue that continues to affect health outcomes. In ophthalmology, these disparities affect eye care utilization increasing the burden of eye care disorders and vision impairment/loss. Various factors contribute to disparities in vision care. They include age, gender, socioeconomic status, geographic location, and race and ethnicity. These factors make it difficult for people affected by eye conditions to access care. Addressing these disparities can help to increase eye care utilization and improve patient outcomes. Some measures that can address these disparities and increase utilization are providing patient education, increasing insurance coverage, implementing community-based eye care programs, using teleophthalmology, providing transport services, providing reminder alerts, and creating community centres that are federally funded among others. This review seeks to identify measures that can help to address disparities in vision and eye care in the US. The review also identifies drivers of health disparities in vision health and how they affect the ability to access care.

Demographic differences in access to health/therapeutic services over first year of the pandemic: a SPARK COVID-19 impact survey analysis.

This analysis examined changes in services received and service recovery one-year post-pandemic compared to pre-pandemic levels in children with ASD aged between 19 months and 17 years in various subgroups based on factors such as age, income, race/ethnicity, geographic location, and sex. An online, parent report survey was completed by the parents of children with ASD in the SPARK study cohort (N = 6,393). Descriptive statistics, chi-square analyses, and Spearman correlations were performed to study associations between various factors and service access, pre-pandemic and one-year, post-pandemic. One year after pandemic, the lag in service recovery in children with ASD was greatest for PT/OT services followed by SLT. ABA services only recovered in half of the subgroups. In contrast, SES fully recovered and MH and MED services superseded pre-pandemic levels. Across majority of the timepoints, younger children received more SLT, PT/OT, and ABA services whereas older children received more SES, MH, and MED services. Higher income families accessed more SES, SLT, and ABA whereas lower income families received more MH services. White families received less SLT compared to non-white families. Hispanic families received more SLT services compared to non-Hispanic families. Compared to rural families, urban families received more ABA services at baseline which also recovered one year after the pandemic. Certain counterintuitive findings may be attributed to home/remote schooling leading to reduced access to related services. Future research and policy changes are needed to address the American healthcare vulnerabilities when serving children with ASD by enhancing the diversity of healthcare formats for continued service access during future pandemics and other similar crises.

Counting the Cost of Pins and Needles: A Case Study of Paresthesias and the Cost of Healthcare in the United States

Counting the Cost of Pins and Needles: A Case Study of Paresthesias and the Cost of Healthcare in the United States

Neural Interconnections of Extracranial Nerves in Headache Surgery: Anatomical Landmarks and Clinical Implications - A Review of Literature.

Headache disorders (HD) remain a nationwide challenge for the US healthcare system affecting nearly 60% of the US population. Surgical deactivation of the peripheral trigger site, also referred to as headache surgery, represents an effective treatment for patients with refractory HD pain or non-response to pharmacological regimes. Research stemming from other surgical specialties has underlined the clinical relevance of neural interconnections in refining diagnostic algorithms, adapting surgical techniques, and improving overall patient outcomes. While different HD trigger points have been identified, there is a paucity of studies discussing these mostly sensory neural interconnections between these trigger points in a comprehensive fashion. Herein, we aim to provide an overview of the specific nerves involved in HD and synthesize the current literature on HD nerve interconnections to, ultimately, deduce clinical implications. Overall, this line of research may help refine the perioperative workflow and enhance HD patient care.

Trends in RSV testing patterns among infants presenting with bronchiolitis: Results from four United States health systems, 2015-2023

BackgroundBronchiolitis due to respiratory syncytial virus (RSV) is the leading cause of hospitalization among American infants. The overall burden of RSV among infants has been historically under-estimated due to variable testing practices, particularly in the outpatient setting. Universal masking and social distancing implemented during the coronavirus disease 2019 (COVID-19) pandemic altered RSV seasonality, however potential consequences on RSV testing practices across different healthcare settings and sociodemographic groups have not been described. Variable testing practices could also affect accurate assessment of the effects of two recently approved RSV preventative agents targeting infants. MethodsUtilizing real-time clinical and viral surveillance, we examined RSV testing practices among infants with bronchiolitis within four United States healthcare systems across different healthcare settings and sociodemographic groups pre- and post-COVID-19. ResultsRSV testing among infants with bronchiolitis increased since 2015 within each healthcare system across all healthcare settings and sociodemographic groups, with a more dramatic increase since the COVID-19 pandemic. Outpatient testing remained disproportionately low compared to hospital-based testing, although there were no major differences in testing frequency among sociodemographic groups in either setting. ConclusionsAlthough RSV testing increased among infants with bronchiolitis, relatively low outpatient testing rates remain a key barrier to accurate RSV surveillance.

Knowledge, attitudes and perceptions of Latin American healthcare workers relating to antibiotic stewardship and antibiotic use: a cross-sectional multi-country study

BackgroundThe burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers’ (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region.MethodsHCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March–April 2023.FindingsOverall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% “other”). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term “antibiotic stewardship”. Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians’ opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions.ConclusionsAlthough HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.