Marijuana use disorder among adults with functional disabilities-A US population-based cross-sectional study

BACKGROUND AND OBJECTIVES

Recent studies suggest a growing trend in marijuana use, compared to a stable prevalence of marijuana use disorder among US adults over the first 15 years of the 21st century. This study investigated the recent patterns of marijuana use disorder among people with disabilities (PWD).

METHODS

We extracted a nationally representative sample (N = 209,058) from the 2015-2019 National Survey on Drug Use and Health data set and examined associations by functional disability status (any disability, disability by type, and number of disabling limitations) with marijuana use disorder using a series of independent multivariable logistic regression models. We also performed trend analyses during the study period.

RESULTS

The prevalence of marijuana use disorder (from 1.7% to 2.3%) increased significantly among PWD between 2015 and 2019 (p-trend < .001). PWD were significantly more likely to report marijuana use disorder (odds ratio [OR], 1.37, 95% confidence interval [CI], 1.24-1.52) than people without disability (PWoD). Those with cognitive limitation only (OR, 1.78, 95% CI, 1.53-2.06) and ≥2 limitations (OR, 1.29, 95% CI, 1.10-1.51) were more likely to report marijuana use disorder than PWoD.

DISCUSSION AND CONCLUSIONS

PWD had a consistently higher prevalence of marijuana use disorder than PWoD. Additionally, the level of risk for marijuana use disorder varied by disability type and number of disabling limitations.

SCIENTIFIC SIGNIFICANCE

Our study provided new nuance on disparities in marijuana use disorder between PWD and PWoD and further revealed the varied risks for marijuana use disorder across different disability statuses.

Sociodemographic factors associated with major depressive episodes and suicidal ideation among emerging adults with diabetes in the U.S

Background

Research focused on disparities related to mental health comorbidities, especially among emerging adults with diabetes, is limited. Identifying associated factors of disparities could inform policy decisions to make diabetes-related interdisciplinary care more accessible for vulnerable groups.

Method

Using data from the National Survey on Drug Use and Health (2015-2019), we examined disparities in presence of major depressive episode (MDE) and suicidal ideation among emerging adults with diabetes. Survey design-adjusted bivariate and multivariable logistic regression models were used for statistical analyses.

Results

The study included 1,125 emerging adults (18-25 years old), with a history of type 1 diabetes (T1D) or type 2 diabetes (T2D). After controlling for sociodemographic and health-related characteristics, we found lower odds of having past-year major MDE for non-Hispanic Black (AOR, 0.42, p=0.032) compared to their non-Hispanic White counterparts. Females were 3.02 times more likely to have past-year MDE than males (AOR, 3.02, p=0.004). The odds of having past-year MDE were 1.96 times higher among individuals who identified as LGB (lesbian, gay, bisexual) (AOR, 1.96, P=0.038). There were no statistically significant disparities in suicidal ideation related to race/ethnicity, sex, education, and family income. However, individuals who identified as LGB had significantly higher likelihood of suicidal ideation than their heterosexual counterparts (AOR, 2.47, P=0.004).

Conclusion

Significant disparities related to MDE and suicidal ideation exist based on race/ethnicity, gender, and sexual orientation. Integration of a mental health professional into the multidisciplinary diabetes care team is critical for effective management of comorbid mental health conditions in younger patients with diabetes.

Telehealth Utilization During the COVID-19 Pandemic Among People With Functional Disabilities in the U.S.: A Preliminary Analysis of National Health Interview Survey 2020 Data

Introduction

Telehealth has been widely promoted and adopted at multiple levels in the U.S. healthcare system during the COVID-19 pandemic. However, this rapid expansion of telehealth services may have further exacerbated health inequities among marginalized groups.

Methods

Using the 2020 National Health Interview Survey, this study compared patterns of telehealth use between people with functional disabilities and people without disabilities during the first year of the pandemic.

Results

In the multivariable-adjusted logistic regression models, respondents with moderate disabilities were significantly more likely to report telehealth use, not pandemic related (OR=1.25, 95% CI=1.03, 1.52) and telehealth use, pandemic related (OR=1.43, 95% CI=1.28, 1.60) than people without disabilities. Similarly, respondents with severe disabilities were significantly more likely to report telehealth use, not pandemic related (OR=1.46, 95% CI=1.07, 2.00) and telehealth use, pandemic related (OR=2.06, 95% CI=1.72, 2.46). In addition, telehealth use varied by the number of limitations and disability type.

Conclusions

People with functional disabilities were more likely to report telehealth use than people without disabilities. Furthermore, these associations strengthened with increasing disability severity and number of limitations while varying by disability type. Additional studies are warranted to explore ways of providing patient-centered telehealth to responsively meet various healthcare needs of people with functional disabilities and improve their health outcomes.

Suicide Ideation, Plans, and Attempts Among Military Veterans vs Nonveterans With Disability

Importance

People with disability are at heightened risk for suicide ideation, planning, and attempt, with risk growing as the number of disabling limitations increases. Military veterans have higher rates of suicide deaths and disability relative to nonveterans.

Objective

To evaluate whether veteran status is associated with greater risk for suicide in those with disability.

Design, Setting, and Participants

This survey study used cross-sectional self-reported data from US adults who participated in the 2015-2020 National Survey on Drug Use and Health. Data were weighted to represent the population. Data analysis was conducted from July to August 2022.

Main Outcomes and Measures

Suicide ideation, planning, and attempt served as primary outcomes. Disability status (present or absent) and number of disabling limitations (1, 2, or ≥3) served as factors. Veteran status was determined based on self-report (veteran or nonveteran). Multivariable logistic regression examined suicide ideation, planning, and attempt as a function of veteran status and disability variables.

Results

Participants included 231 099 US veterans and nonveterans, representing 236 551 727 US adults, of whom 20.03% (weighted n = 47 397 876) reported a disabling limitation, 8.92% were veterans (weighted n = 21 111 727; 16.0% aged 35-49 years; 91.0% men; 6.7% Hispanic; 10.9% non-Hispanic Black; and 78.4% non-Hispanic White) and 91.08% were nonveterans (weighted n = 215 440 000; 25.4% aged 35-49 years; 44.0% male; 16.5% Hispanic; 11.7% non-Hispanic Black; and 63.3% non-Hispanic White). Overall, 4.39% reported suicide ideation, planning, or attempt (weighted n = 10 401 065). Among those with no disability, veteran status was associated with higher risk of suicide planning (adjusted odds ratio [AOR], 1.71; 95% CI, 1.17-2.49). Among those with 1 or 2 disabling limitations, being a veteran was associated with a lower risk of suicide planning (AOR, 0.57; 95% CI, 0.34-0.95) and history of attempt (AOR, 0.46; 95% CI, 0.24-0.88).

Conclusions and Relevance

In this study of how suicide risk differs as a function of disability and veteran status, risk for death by suicide was lower among veterans with disability relative to nonveterans with disability. Veteran status may mitigate risk for suicide given increased receipt of more disability-related care through the Department of Veterans Affairs. Further research would extend this line of inquiry by examining the cause and type of disability as well as perceptions of disability on self-worth. It is possible that physical wounds of war are protective because of the meaning and value of service to one's country.

Drivers of Individual and Regional Variation in CMS Hierarchical Condition Categories Among Florida Beneficiaries

Objective

To explore hierarchical condition categories (HCC) risk score variation among Florida Fee for Service (FFS) Medicare beneficiaries between 2016 and 2018.

Data Sources

This study analyzed HCC risk score variation using Medicare claims data for Florida beneficiaries enrolled in Parts A & B between 2016 and 2018.

Study Design

The CMS methodology analyzed HCC risk score variation using annual mean county- and beneficiary-level risk score changes. The association between variation and beneficiary characteristics, diagnoses, and geographic location was characterized using mixed-effects negative binomial regression models.

Data Collection

Not applicable.

Principal Findings

Counties in the Northeast [marginal effect (ME)=-0.003], Central (ME=-0.021), and Southwest (ME=-0.009) Florida have relatively lower mean risk scores. A higher number of lifetime (ME=0.246) and treatable (ME=0.288) conditions were associated with higher county-level risk scores, while more preventable conditions (ME=-0.249) were associated with lower risk scores. Counties with older beneficiaries (ME=0.015) and more Blacks (ME=0.070) have higher risk scores, while having female beneficiaries reduced risk scores (ME=-0.005). Individual risk scores did not vary by age (ME=0.000), but Blacks (ME=0.001) had higher rates of variation relative to Whites, while other races had comparatively lower variation (ME=-0.003). In addition, individuals diagnosed with more lifetime (ME=0.129), treatable (ME=0.235), and preventable (ME=0.001) conditions had higher risk score variation. Most condition-specific indicators showed small associations with risk score changes; however, metastatic cancer/acute leukemia, respirator dependence/tracheostomy, and pressure ulcers of the skin were significantly associated with both types of HCC risk score variation.

Conclusion

Results showed demographics, HCC condition classifications (ie, lifetime, preventable, and treatable), and some specific conditions were associated with higher variation in mean county-level and individual risk scores. Results suggest consistent coding and reductions in the prevalence of certain treatable or preventable conditions could reduce the county and individual HCC risk score year-to-year change.

Hearing Impairment, Mental Health Services Use, and Perceived Unmet Needs Among Adults With Serious Mental Illness: A Cross-Sectional Study

PURPOSE

Individuals with hearing impairment have higher risks of mental illnesses. We sought to develop a richer understanding of how the presence of any hearing impairment affects three types (prescription medication, outpatient services, and inpatient services) of mental health services utilization (MHSU) and perceived unmet needs for mental health care; also, we aimed to identify sociodemographic factors associated with outpatient mental health services use among those with hearing impairment and discuss potential implications under the U.S. health care system.

METHOD

Using secondary data from the 2015-2019 National Survey on Drug Use and Health, our study included U.S. adults aged ≥ 18 years who reported serious mental illnesses (SMIs) in the past year. Multivariable logistic regression was used to examine associations of hearing impairment with MHSU and perceived unmet mental health care needs.

RESULTS

The study sample comprised 12,541 adults with SMIs. Prevalence of MHSU (medication: 55.5% vs. 57.5%; outpatient: 37.1% vs. 44.2%; inpatient: 6.6% vs.7.1%) and unmet needs for mental health care (47.5% vs. 43.3%) were estimated among survey respondents who reported hearing impairment and those who did not, respectively. Those with hearing impairment were significantly less likely to report outpatient MHSU (OR = 0.73, 95% CI [0.60, 0.90]).

CONCLUSIONS

MHSU was low while perceived unmet needs for mental health care were high among individuals with SMIs, regardless of hearing status. In addition, patients with hearing impairment were significantly less likely to report outpatient MHSU than their counterparts. Enhancing communication is essential to improve access to mental health care for those with hearing impairment.

Association between functional disability type and suicide-related outcomes among U.S. adults with disabilities in the National Survey on Drug Use and Health, 2015-2019

While research on suicidal behavior for people with disability (PWD) suggests they experience higher risk than people without disability, less is known about variations among individuals with different disability types. This nationally representative, cross-sectional study compared differences in suicide-related outcomes (ideation, planning, attempts) among PWD by functional disability type (hearing, vision, cognitive, mobility, complex activity) and number. Secondary analysis of adult PWD in the 2015-2019 National Survey on Drug Use and Health (unweighted N = 35,544; representing 47,723,378 PWD, weighted) was used to estimate relationships between suicide-related outcomes and disability type and number. Most respondents were female (55.9%), and 36.0% were aged ≥65 years. Adjusted odds ratios (AORs) from multivariable logistic regression indicated that suicidal ideation and suicide attempt, respectively, were significantly more likely among individuals with cognitive (AOR = 1.71, 95% CI = 1.24-2.35; AOR = 2.54, 95% CI = 1.31-4.91), complex activity (AOR = 1.96, 95% CI = 1.37-2.81; AOR = 2.67, 95% CI = 1.32-5.41), and ≥2 limitations (AOR = 2.02, 95% CI = 1.52-2.69; AOR = 3.46, 95% CI = 1.84-6.50) than hearing limitation. Also, relative to other disability types, suicide-related outcomes were significantly more likely among individuals with cognitive limitation and complex activity limitation (p < 0.001). Additionally, suicide-related outcomes elevated in likelihood as the number of limitations increased, with the largest associations among those with ≥5 limitations for suicidal ideation (AOR = 2.31, 95% CI = 1.46-3.66), suicide planning (AOR = 3.34, 95% CI = 1.97-5.68), and suicide attempt (AOR = 6.37, 95% CI = 3.76-10.79). Subgroup analyses showed that presence of cognitive limitation and multiple limitations differentiated between suicidal ideators and suicide attempters. Further research is needed to identify causes of these risks and develop suicide prevention efforts for these particularly vulnerable groups.

Association of functional disability with mental health services use and perceived unmet needs for mental health care among adults with serious mental illness

BACKGROUND

Approximately 13.1 million U.S. adults experienced serious mental illness (SMI) in 2019. Persons with disability (PWD) have higher risks of SMI. Ensuring adequate access to mental health (MH) services for PWD is imperative to ameliorate this burden.

METHODS

Using the 2015-2019 National Survey on Drug Use and Health, we obtained study variables for U.S. adults with SMI in the past year and used multivariable logistic regression models to examine the association of disability with MH services and perceived unmet needs.

RESULTS

The sample comprised 12,532 respondents, representing 11,143,650 U.S. adults with SMI. Overall, PWD had higher proportions of using prescription medications (64.7% vs. 46.2%), outpatient treatment (48.4% vs. 36.5%) and inpatient treatment (8.6% vs. 4.7%) compared to persons without disability; however, the prevalence of perceived unmet MH service needs was also higher (46.3% vs. 39.4%) among PWD. Multivariable logistic regression models showed presence of any disability, cognitive and ≥2 limitations were significantly associated with MH services use (all p<0.01). However, PWD were significantly more likely to report perceived unmet MH service needs (p<0.01 for any disability as well as cognitive, complex activity, and ≥2 limitations).

LIMITATIONS

Due to data limitations, disability status and SMI may be misclassified for some respondents, and the results may not be generalized to all individuals with SMI.

CONCLUSION

While PWD were more likely to use MH services, they also had higher odds of unmet MH needs. These results call for more effective and tailored mental health services for PWD.

Association Between Disability and Suicide-Related Outcomes Among U.S. Adults

INTRODUCTION

Although research has analyzed the sociodemographic and socioeconomic risks for suicide, only recently has suicide risk for people with disabilities been examined. This study investigates the associations between disability and distinct suicide-related outcomes, including suicidal ideation, suicide planning, and suicide attempt.

METHODS

This nationally representative, cross-sectional study comprised secondary analyses of the 2015-2019 National Survey on Drug Use and Health conducted in 2020 (N=198,640, representing 229,556,289 U.S. adults). Disability status comprised the presence of any disability; hearing, vision, mobility, cognitive, complex activity, or ≥2 limitations; and 1, 2, 3, 4, or ≥5 limitations. Suicide-related outcomes in the past year included none, suicidal ideation only, suicide planning, and suicide attempt. Multivariable logistic regression was applied to estimate the AORs.

RESULTS

Overall, 19.8% reported any disability. Results showed that people with disabilities were significantly more likely than those without disabilities to report suicidal ideation (AOR=2.13, 95% CI=1.93, 2.36), suicide planning (AOR=2.66, 95% CI=2.27, 3.11), and suicide attempt (AOR=2.47, 95% CI=2.05, 2.98). Furthermore, individuals within each limitation count group were significantly more likely than people without disabilities to report suicide-related outcomes (p<0.001), with the largest magnitudes among those with ≥5 limitations for suicidal ideation (AOR=3.80, 95% CI=2.32, 6.23), suicide planning (AOR=6.45, 95% CI=3.52, 11.80), and suicide attempt (AOR=8.19, 95% CI=4.45, 15.07).

CONCLUSIONS

People with various types of functional disabilities had an elevated risk for suicide-related outcomes, compared with people without disabilities. The more limitations a person had progressively increased their risk. These findings call for focused attention to the mental health of people with disabilities, including suicide prevention efforts that accommodate their needs.

Comorbidity Subgroups Among Medicare Beneficiaries Seeking Health Care for Musculoskeletal Pain

BACKGROUND

Treatment of musculoskeletal pain in older adults may be more effective if it incorporates integrated management of comorbid health conditions. The purpose of this study was to define empirically derived comorbidity subgroups among Medicare beneficiaries with an index condition of osteoarthritis (OA) or low back pain (LBP) as a precursor to the development of comorbidity-specific pain treatment pathways.

METHODS

This study included Medicare beneficiaries participating in the Medicare Current Beneficiary Survey (MCBS) and seeking care for OA (n = 723) or LBP (n = 617) with data available for 3 years after entry into the survey. We identified 30 comorbidity diagnoses using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes in claims data during beneficiaries' first year in the survey. Latent class analysis defined comorbidity subgroups, and posterior probabilities were used to assign subgroup classification. Self-reported disability was compared over three consecutive years for each subgroup.

RESULTS

We identified similar comorbidity subgroups for OA and LBP. The subgroups included (range of percent prevalence) low comorbidity (47.6%-54.4%), nonvascular (21.8%-28.6%), diabetes (12.2%-15.0%), renal disease with complicated hypertension (5.5%-5.8%), and complex cardiac disease/high comorbidity (3.3%-5.8%). OA and LBP subgroups with more complex comorbidity burden generally demonstrated higher disability over 3 years.

CONCLUSIONS

Five comorbidity subgroups were identified, with a large proportion of older adults classified into the subgroup defined by a low probability of most comorbidities. These findings provide direction for the development of pain treatment pathways that are tailored to address common comorbidity profiles among older adults.

Factors associated with persistently high-cost health care utilization for musculoskeletal pain

BACKGROUND

Musculoskeletal pain conditions incur high costs and produce significant personal and public health consequences, including disability and opioid-related mortality. Persistence of high-cost health care utilization for musculoskeletal pain may help identify system inefficiencies that could limit value of care. The objective of this study was to identify factors associated with persistent high-cost utilization among individuals seeking health care for musculoskeletal pain.

METHODS

This was a retrospective cohort study of Medical Expenditure Panel Survey data (2008-2013) that included a non-institutionalized, population-based sample of individuals seeking health care for a musculoskeletal pain condition (n = 12,985). Expenditures associated with musculoskeletal pain conditions over two consecutive years were analyzed from prescribed medicine, office-based medical provider visits, outpatient department visits, emergency room visits, inpatient hospital stays, and home health visits. Persistent high-cost utilization was defined as being in the top 15th percentile for annual musculoskeletal pain-related expenditures over 2 consecutive years. We used multinomial regression to determine which modifiable and non-modifiable sociodemographic, health, and pain-related variables were associated with persistent high-cost utilization.

RESULTS

Approximately 35% of direct costs for musculoskeletal pain were concentrated among the 4% defined as persistent high-cost utilizers. Non-modifiable variables associated with expenditure group classification included age, race, poverty level, geographic region, insurance status, diagnosis type and total number of musculoskeletal pain diagnoses. Modifiable variables associated with increased risk of high expenditure classification were higher number of missed work days, greater pain interference, and higher use of prescription medication for pain, while higher self-reported physical and mental health were associated with lower risk of high expenditure classification.

CONCLUSIONS

Health care delivery models that prospectively identify these potentially modifiable factors may improve the costs and value of care for individuals with musculoskeletal pain prone to risk for high-cost care episodes.

EXAMINING LONGITUDINAL HEALTHCARE UTILIZATION, OUTCOMES, AND SATISFACTION IN PRE-FRAIL OLDER ADULTS

Frailty is a medical syndrome occurring in nearly 60% community dwelling older adults and could have insidious origins in middle-adulthood that manifest predominantly as decline and multi-morbidity. Identification of pre-frail states in adults could potentially reduce its impact in late-life. The study used data from the Health and Retirement Study (HRS) to: 1) compare long-term healthcare utilization between pre-frail and non-frail patients, 2) compare risk of pain progression, functional decline, and mortality between pre-frail and non-frail patients, and (3) compare satisfaction with healthcare, self-perceptions of aging and satisfaction with life between pre-frail and non-frail patients. The primary predictor, pre-frailty phenotype, was based on the Paulson-Lichtenberg Frailty Index (PLFI), a validated HRS-version of the Fried criteria. Additional covariates included sociodemographics, comorbidities, smoking status, sleep quality, health status, and body mass index. Statistical analyses consisted of descriptive statistics, univariate analysis, negative binomial regression with log-link function, logistic regression, generalized linear modeling and Cox regression. Pre-frailty status increased the incidence of hospitalizations (IRR: 1.23; 95%CI: 1.18-1.28) and doctor’s visits (IRR: 1.18; 95%CI: 0.15-1.22); increased the risk of pain progression (HR: 1.61, 95%CI: 1.53-1.69), functional decline (HR: 1.77, 95%CI: 1.67-1.87), and all-cause mortality (HR: 1.09, 95%CI:1.03-1.16); lowered odds of healthcare satisfaction (OR: 0.79, 95%CI: 0.62-0.99) and lowered satisfaction with aging ((β: -0.23 95%CI: -0.36- (-0.10)) and satisfaction with life (β: -0.27 95%CI: -0.44- (-0.11)). Frailty syndrome is highly prevalent and having a better understanding of its influence on health outcomes at intermediate pre-frail states could provide insight into reducing manifestations in later life.

Patient-provider communication quality for persons with disabilities: A cross-sectional analysis of the Health Information National Trends Survey

BACKGROUND

It is unclear how perceived patient-provider communication quality (PPPCQ) varies according to disability status. Lack of adequate patient-provider communication may prevent providers from considering healthcare issues that are relevant and important to persons with disabilities (PWD), potentially contributing to poorer health outcomes.

OBJECTIVE/HYPOTHESIS

To examine PPPCQ by disability status using current U.S. Department of Health and Human Services standards for surveillance of functional disabilities.

METHODS

This cross-sectional study used nationally-representative data from the 2012-2013 Health Information National Trends Survey (HINTS). Participants were categorized as having any disability (hearing, vision, mobility, cognitive, self-care, and/or independent living limitations). PPPCQ was assessed using seven HINTS questions about communication with healthcare professionals. Linear regression was used to estimate mean differences in composite PPPCQ scores, and logistic regression was used to estimate odds ratios (OR) for a provider "always or usually" performing PPPCQ.

RESULTS

The study population comprised 5301 participants, representing 180,442,731 U.S. adults. Overall, 22.1% (weighted) reported any disability. Adjusted mean PPPCQ scores were significantly lower for PWD (72.8, 95% CI: 68.2-77.4) than persons without disability (78.3, 95% CI: 76.5-80.2), p = 0.021. More specifically, PWD were significantly less likely to be given attention needed to address feelings and emotions (OR = 0.6, 95% CI: 0.4, 0.9, p = 0.017), to have next steps understood (OR = 0.4, 95% CI: 0.2, 0.8, p = 0.019), and to receive a clear explanation (OR = 0.3, 95% CI: 0.1, 0.8, p = 0.018).

CONCLUSIONS

PWD are less likely to report key elements of effective patient-provider communication. Implementing patient-centered care may improve patient-provider communication for this vulnerable population.

Risk for Medication Nonadherence Among Medicaid Enrollees With Fibromyalgia: Development of a Validated Risk Prediction Tool

OBJECTIVE

To develop and validate a risk assessment tool called the Prescription Medication Non-Adherence Prediction Tool (Rx-NAPT) to predict medication nonadherence in patients with fibromyalgia.

METHODS

This was a retrospective cohort study using claims data from South Carolina Medicaid. Patients with fibromyalgia who were ≥18 years old and who had filled at least 1 prescription medication for pregabalin, duloxetine, or milnacipran from January 1, 2005, through June 30, 2011 were included. Medication possession ratios (MPRs) were calculated to classify patients as adherent (MPR ≥ 80%) or nonadherent (MPR < 80%). Multivariable logistic models using 100 bootstrap replications (with replacement) were used to identify factors associated with medication nonadherence, including age, gender, race, days' supply, medication type, and fibromyalgia-related comorbidity score. Weighted β coefficients of the predictors were used to create the Rx-NAPT. Youden's J statistic was used to classify nonadherent patients into different levels of risk.

RESULTS

The study sample comprised 6,626 patients with fibromyalgia, where 4,804 (72.50%) were non-adherent and 1,822 (27.50%) were adherent to their prescribed medication(s). Logistic regression models showed that 7 predictors (gender, age, race, fibromyalgia-related comorbidity score, medication type, health maintenance organization coverage, emergency room visit) were statistically significant in ≥50% of the bootstrapped samples. The final model demonstrated reasonable discrimination (area under the curve [AUC] = 0.6224) and calibration (Hosmer-Lemeshow goodness-of-fit; P > 0.05) statistics and was validated internally (AUC = 0.6372).

CONCLUSION

Poor adherence with medication remains an important barrier to providing optimal care. Our risk prediction model provides an easy tool to help clinicians better identify patients with fibromyalgia who may not take their medications as prescribed.

Healthcare Costs and Medication Adherence Among Patients with Fibromyalgia: Combination Medication vs. Duloxetine, Milnacipran, Venlafaxine, and Pregabalin Initiators

OBJECTIVE

To examine medication adherence and healthcare costs for combination prescription initiators (duloxetine/milnacipran/venlafaxine with pregabalin) vs. monotherapy initiators (duloxetine, milnacipran, venlafaxine, and pregabalin) among patients with fibromyalgia syndrome (FMS).

METHODS

Our retrospective cohort study used claims data for the South Carolina Blue Cross Blue Shield State Health Plan (SHP). Patients with FMS ≥ 18 years of age, with prescription initiation from July 1, 2007, through June 30, 2010, and SHP enrollment for 12 months pre- and post-index periods were included (combination: n = 100; pregabalin: n = 665; duloxetine: n = 713; milnacipran: n = 131; venlafaxine: n = 272). Medication adherence measures included high adherence (medication possession ratio ≥ 80%) and total supply days. Healthcare costs comprised direct medical expenditures. Propensity score methods of inverse probability of treatment weights were used to control for selection bias due to differing pre-index characteristics.

RESULTS

Odds ratios for high adherence were significantly increased (P < 0.05) among the combination cohort vs. the venlafaxine (2.15), duloxetine (1.39), and pregabalin (2.20) cohorts. Rate ratios for total supply days were significantly higher (P < 0.05) for combination vs. venlafaxine (1.23), duloxetine (1.08), and pregabalin (1.32) cohorts. Expenditures for total health care were significantly higher (P < 0.05) for combination vs. duloxetine ($26,291 vs. $17,190), milnacipran ($33,638 vs. $22,886), and venlafaxine ($26,586 vs. $16,857) cohorts.

CONCLUSIONS

Medication adherence was considerably better for combination prescription initiators; however, expenditures for total health care were higher. Still, our findings suggest important clinical benefits with the use of combination prescription therapy, and prospective studies of medication adherence are warranted to examine causal relationships with outcomes not captured by healthcare claims databases.

Association between race/ethnicity and disability status and receipt of vaccines among older adults in Florida

BACKGROUND

Individuals living with a disability or are a member of a certain racial/ethnic group may be at heightened risk for not receiving important vaccinations.

OBJECTIVE

This study examined whether race/ethnicity and disability status are associated with the receipt of two vaccines (influenza and pneumococcal) among older adults living in Florida.

METHODS

Using the 2011-2015 Florida Behavioral Risk Factor Surveillance System, a cross-sectional survey, we ran bivariate and multivariate analyses to determine the associations for race/ethnicity and disability status with receipt of vaccinations among individuals 65 years and older. Interactions between race/ethnicity and disability status were tested in each model.

RESULTS

Among our study sample, 68% received the pneumococcal vaccine in their lifetime and 54% of them received influenza vaccine in the past 12 months. Multivariate logistic regression indicated that Non-Hispanic Blacks and Hispanics were less likely to receive both vaccines compared to Non-Hispanic Whites. Older adults with a disability were more likely to receive influenza and pneumococcal vaccines compared to those without. A significant interaction was observed between race/ethnicity and disability status for predicting pneumococcal vaccination receipt.

CONCLUSIONS

Large proportions of older adults in Florida continue to go without needed vaccinations. Although race/ethnicity and disability status were shown to have some association with receipt of vaccines, having a regular source of care, employment and income also were shown to be important predictors.

Comparative effectiveness of dual-action versus single-action antidepressants for the treatment of depression in people living with HIV/AIDS

BACKGROUND

Depression is the most common psychiatric comorbidity among people living with HIV/AIDS (PLWHA). Little is known about the comparative effectiveness between different types of antidepressants used to treat depression in this population. We compared the effectiveness of dual-action and single-action antidepressants in PLWHA for achieving remission from depression.

METHODS

We used data from the Centers for AIDS Research Network of Integrated Clinic Systems to identify 1175 new user dual-action or single-action antidepressant treatment episodes occurring from 2005 to 2014 for PLWHA diagnosed with depression. The primary outcome was remission from depression defined as a Patient Health Questionnaire-9 (PHQ-9) score <5. Mean difference in PHQ-9 depressive symptom severity was a secondary outcome. The main approach was an intent-to-treat (ITT) evaluation complemented with a per protocol (PP) sensitivity analysis. Generalized linear models were fitted to estimate treatment effects.

RESULTS

In ITT analysis, 32% of the episodes ended in remission for both dual-action and single-action antidepressants. The odds ratio (OR) of remission was 1.02 (95%CI=0.63,1.67). In PP analysis, 40% of dual-action episodes ended in remission compared to 32% in single-action episodes. Dual-action episodes had 1.33 times the odds of remission (95%CI=0.55,3.21), however the result was not statistically significant. Non-significant differences were also observed for depressive symptom severity.

LIMITATIONS

Missing data was common but was addressed with inverse probability weights.

CONCLUSIONS

Results suggest that single-action and dual-action antidepressants are equally effective in PLWHA. Remission was uncommon highlighting the need to identify health service delivery strategies that aid HIV providers in achieving full remission of their patients' depression.

Hearing Impairment and Undiagnosed Disease: The Potential Role of Clinical Recommendations

PURPOSE

The objective of this study was to use cross-sectional, nationally representative data to examine the relationship between self-reported hearing impairment and undetected diabetes, hypertension, hypercholesterolemia, and chronic kidney disease.

METHOD

We analyzed the National Health and Nutrition Examination Survey for the years 2007-2012 for individuals 40 years of age and older without previously diagnosed cardiovascular disease. Analyses were conducted examining hearing impairment and undiagnosed disease.

RESULTS

The unweighted sample size was 9,786, representing 123,444,066 Americans. Hearing impairment was reported in 10.2% of the individuals. In unadjusted analyses, there was no significant difference between adults with hearing impairment and adults with typical hearing for undiagnosed diabetes, hypertension, or hypercholesterolemia. A higher proportion of adults with hearing impairment than adults with typical hearing had undiagnosed chronic kidney disease (20.1% vs. 10.7%; p = .0001). In models adjusting for demographics and health care utilization, hearing impairment was associated with a higher likelihood of having undiagnosed chronic kidney disease (odds ratio = 1.53, 95% CI [1.23, 1.91]).

CONCLUSIONS

Individuals with hearing impairment are more likely to have undiagnosed chronic kidney disease. Hearing impairment may affect disclosure of important signs and symptoms as well as the comprehension of medical conversations for chronic disease management. General practitioners can play a critical role in improving medical communication by responding with sensitivity to the signs of hearing impairment in their patients.

The effect of EHR-integrated patient-reported outcomes on satisfaction with chronic pain care

OBJECTIVES

Given its complexity, chronic noncancer pain presents an opportunity to use health information technology (IT) to improve care experiences. The objective of this study was to assess whether integrating patient-reported outcomes (PROs) data in an electronic health record (EHR) affects provider and patient satisfaction with chronic noncancer pain care.

STUDY DESIGN

We conducted a pragmatic cluster randomized trial involving 4 family medicine clinics.

METHODS

We enrolled primary care providers (PCPs) and their patients with chronic noncancer pain. In the first 7 months (education phase), PCPs in intervention practices received education on how to use PROs for pain care. In the second 7 months (PRO phase), patients in intervention practices reported pain-related outcomes on arrival at their visits. PROs were immediately reported to PCPs through the EHR. Control group PCPs provided usual care. We compared intervention and control practices in terms of provider and patient satisfaction with care.

RESULTS

During the education phase, patients' mean ratings of their visits did not differ between control and intervention (9.33 vs 9.08; P = .20). During the PRO phase, patients' mean ratings did not differ between control and intervention (9.28 vs 9.01; P = .20). Similarly, there were no differences between the intervention and control groups in terms of provider satisfaction.

CONCLUSIONS

Delivering EHR-integrated PROs did not consistently improve patient or provider satisfaction. Positively, we found no evidence that the PRO tools negatively affected satisfaction. Future studies and technological innovations are needed to translate point-of-care health IT tools into improvements in patient and provider experiences.

A patient navigator and education program for increasing potential living donors: a comparative observational study

BACKGROUND AND OBJECTIVES

Person-centered clinical environments may promote living donation for patients with end-stage renal disease (ESRD). We implemented an observational study design to explore whether a patient navigator (PN) program with person-centered education in nephrology practice settings could increase potential living donors (PLDs) and, subsequently, increase living transplantation.

DESIGN, SETTING, PARTICIPANTS, AND MEASURES

Patients referred to (N = 4621) and/or transplanted at (N = 950) our transplant center during 2007-2012 were eligible for inclusion. Two analytical study populations were derived from propensity score matched patient groups. Outcomes comprised total PLDs per candidate and living vs. deceased transplantation for recipients.

RESULTS

Multivariable generalized estimating equations logistic regression showed that PN practice candidates were significantly more likely to have an initial inquiry PLD (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.01-1.44) and a preliminary screening PLD (OR = 1.27, 95% CI = 1.05-1.54), while there were no significant differences observed in evaluated PLD (OR = 0.94, 95% CI = 0.61-1.45).

CONCLUSIONS

Our results suggest that our person-centered PN program stimulated willingness to seek living transplantation and was associated with a trend toward increased LD.

Accuracy of dental torque wrenches

The aim of this in vitro study was to compare the actual torque of 2 manual wrench systems to their stated (target) torque. New spring- (Nobel Biocare USA, LLC) and friction-style (Zimmer Dental, Inc.) manual dental torque wrenches, as well as spring torque wrenches that had undergone sterilization and clinical use, were tested. A calibrated torque gauge was used to compare actual torque to target torque values of 15 and 35 N/cm. Data were statistically analyzed via mixed-effects regression model with Bonferroni correction. At a target torque of 15 N/cm, the mean torque of new spring wrenches (13.97 N/cm; SE, 0.07 N/cm) was significantly different from that of used spring wrenches (14.94 N/cm; SE, 0.06 N/cm; P < 0.0001). However, the mean torques of new spring and new friction wrenches (14.10 N/cm; SE, 0.07 N/cm; P = 0.21) were not significantly different. For torque measurements calibrated at 35 N/cm, the mean torque of new spring wrenches (35.29 N/cm; SE, 0.10 N/cm) was significantly different (P < 0.0001) from the means of new friction wrenches (36.20 N/cm; SE, 0.08 N/cm) and used spring wrenches (36.45 N/cm; SE, 0.08 N/cm). Discrepancies in torque could impact the clinical success of screw-retained dental implants. It is recommended that torque wrenches be checked regularly to ensure that they are performing to target values.

Variations in coping stages for individuals with chronic kidney disease: Results from an exploratory study with patient navigators

Using a cross-sectional design, we examined coping stages (Kübler-Ross) among patients with end-stage renal disease at nephrology practices incorporating professional social workers as patient navigators, providing person-centered education and support (N = 420). We evaluated associations with behavioral counseling constructs (assess-advise-agree-assist-arrange). Coping stages comprised denial = 35.24 percent, acceptance = 24.05 percent, depression = 21.43 percent, bargaining = 12.86 percent, and anger = 6.43 percent. Compared to denial, other coping stages showed increased odds ratios for transplant referral agreement, transplant referral evaluations, understanding treatments, understanding donation procedures, plans to recruit donors, active donor recruitment, and potential living donor(s). Assessment of coping stages, and strategies to influence these, may be key factors in guiding patients to living donor kidney transplantation.

An evidenced-based scoring index to determine the periodontal prognosis on molars

BACKGROUND

This retrospective study evaluates and assigns scores to six prognostic factors and derives a quantitative scoring index used to determine the periodontal prognosis on molar teeth.

METHODS

Data were gathered on 816 molars in 102 patients with moderate-to-severe periodontitis. The six factors evaluated (age, probing depth, mobility, furcation involvement, smoking, and molar type) were assigned a numeric score based on statistical analysis. The sum of the scores for all factors was used to determine the prognosis score for each molar. Only patients with all first and second molars at the initial examination qualified for the study. All patients were evaluated a minimum of 15 years after treatment.

RESULTS

The post-treatment time ranged from 15 to 40 years and averaged 24 years. When the study was completed, 639 molars survived (78%), and, of those surviving molars, 588 survived and were periodontally healthy (92%). In molars with lower scores (scores 1-3), the 15-year survival rates ranged from 98% to 96%. In molars with middle scores (scores 4-6), the 15-year survival rates ranged from 95% to 90%, and, for molars with higher scores (scores 7-10), the survival rates ranged from 86% to 67%.

CONCLUSION

The present results indicate that the periodontal prognosis of molars diagnosed with moderate-to-severe periodontitis can be calculated using an evidence-based scoring index.

Metabolic syndrome and periodontitis in Gullah African Americans with type 2 diabetes mellitus

AIM

To assess associations of metabolic syndrome, and its individual components, with extent of severe periodontitis among patients with type 2 diabetes mellitus (T2DM).

MATERIALS & METHODS

We performed a secondary data analysis (N = 283) using a cross-sectional study population of Gullah African Americans with T2DM. Extent of severe periodontitis was assessed as total diseased tooth-sites/person [evaluated as separate outcomes: 6+mm clinical attachment level (CAL), 5+mm periodontal probing depth (PPD)] using negative binomial regression techniques. Primary independent variables assessed in separate models included metabolic syndrome (yes/no), each metabolic syndrome component (low HDL, hypertension, high triglycerides, large waist circumference) and glycemic control (poor/good).

RESULTS

Multivariable CAL-model results showed a significant association for metabolic syndrome status with extent of severe periodontitis (RR = 2.77, p = 0.03). The separate multivariable CAL-model including each metabolic syndrome component showed marginally increased rates among those with large waist circumference (RR = 2.33, p = 0.09) and those with HbA1c ≥ 7% (RR = 1.73, p = 0.06). Multivariable PPD-models showed marginally increased rates among those with metabolic syndrome (RR = 2.18, p = 0.06).

CONCLUSION

Metabolic syndrome is associated with the extent of severe periodontitis in this Gullah population with T2DM.

E4D compare software: an alternative to faculty grading in dental education

The traditional method of evaluating student tooth preparations in preclinical courses has relied on the judgment of experienced clinicians primarily utilizing visual inspection. At times, certain aids such as reduction matrices or reduction instruments of known dimension are used to assist the evaluator in determining the grade. Despite the skill and experience of the evaluator, there is still a significant element of uncertainty and inconsistency in these methods. Students may perceive this inconsistency as a form of subjective, arbitrary, and empirical evaluation, which often results in students' focusing more on the grade than the actual learning or developing skills necessary to accomplish the preparation properly. Perceptions of favoritism, discrimination, and unfairness (whether verbalized or not) may interfere with the learning process. This study reports the use of a new experimental scanning and evaluation software program (E4D Compare) that can consistently and reliably scan a student's tooth preparation and compare it to a known (faculty-determined) standardized preparation. An actual numerical evaluation is generated by the E4D Compare software, thereby making subjective judgments by the faculty unnecessary. In this study, the computer-generated result was found to be more precise than the hand-graded method.

Associations between health insurance and generalized periodontal disease in a study population of Gullah African Americans with type-2 diabetes

OBJECTIVES

To explore the relationship between health insurance status (Medicare, Medicaid, private, and uninsured) and generalized periodontal disease (GPD) among a study population (N = 245) of adult Gullah African Americans with type-2 diabetes mellitus (T2DM) ages <65 years.

METHODS

We used multivariable logistic regression to assess GPD [using three different and increasingly severe clinical assessments: 3, 4, and 5 mm clinical attachment level (CAL) at 30% of sites] according to health insurance status.

RESULTS

Prevalence of GPD was 33.06% for 3, 18.78% for 4, and 9.80% for 5 mm CAL. Age ranged 26-64 years (mean = 52.11, SD = 8.53, median = 53). Private insurance was most prevalent (39.59%), followed by uninsured (30.61%), Medicaid (16.33%), and Medicare (13.47%). Results showed increased odds (versus private insurance) for GPD at 3 mm among Medicaid (OR = 1.82, P = 0.2404), Medicare (OR = 3.34, P = 0.0103), and uninsured (OR = 1.96, P = 0.0956) groups; GPD at 4 mm among Medicaid (OR = 1.97, P = 0.3303), Medicare (OR = 5.02, P = 0.0121), and uninsured (OR = 3.38, P = 0.0319) groups; and GPD at 5 mm among Medicaid (OR = 1.21, P = 0.8507), Medicare (OR = 12.62, P = 0.0038), and uninsured (OR = 4.00, P = 0.0763) groups.

CONCLUSIONS

We observed substantial disparities for GPD severity among those without private health insurance even after adjusting for glycemic control, income, dental health behaviors, and other covariates. Improved insurance benefits as well as individualized oral health educational interventions may decrease GPD severity for this study population of younger (ages <65 years) Gullah African Americans with T2DM, particularly those with Medicare insurance.

Efficacy of transcranial direct current stimulation and repetitive transcranial magnetic stimulation for treating fibromyalgia syndrome: a systematic review

OBJECTIVE

 To systematically review the literature to date applying repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) for patients with fibromyalgia syndrome (FMS).

METHOD

 Electronic bibliography databases screened included PubMed, Ovid MEDLINE, PsychINFO, CINAHL, and Cochrane Library. The keyword "fibromyalgia" was combined with ("transcranial" and "stimulation") or "TMS" or "tDCS" or "transcranial magnetic stimulation" or "transcranial direct current stimulation".

RESULTS

 Nine of 23 studies were included; brain stimulation sites comprised either the primary motor cortex (M1) or the dorsolateral prefrontal cortex (DLPFC). Five studies used rTMS (high-frequency-M1: 2, low-frequency-DLPFC: 2, high-frequency-DLPFC: 1), while 4 applied tDCS (anodal-M1: 1, anodal-M1/DLPFC: 3). Eight were double-blinded, randomized controlled trials. Most (80%) rTMS studies that measured pain reported significant decreases, while all (100%) tDCS studies with pain measures reported significant decreases. Greater longevity of significant pain reductions was observed for excitatory M1 rTMS/tDCS.

CONCLUSION

 Studies involving excitatory rTMS/tDCS at M1 showed analogous pain reductions as well as considerably fewer side effects compared to FDA apaproved FMS pharmaceuticals. The most commonly reported side effects were mild, including transient headaches and scalp discomforts at the stimulation site. Yearly use of rTMS/tDCS regimens appears costly ($11,740 to 14,507/year); however, analyses to apapropriately weigh these costs against clinical and quality of life benefits for patients with FMS are lacking. Consequently, rTMS/tDCS should be considered when treating patients with FMS, particularly those who are unable to find adequate symptom relief with other therapies. Further work into optimal stimulation parameters and standardized outcome measures is needed to clarify associated efficacy and effectiveness.

Impact of maternal diabetes on birthweight is greater in non-Hispanic blacks than in non-Hispanic whites

AIMS/HYPOTHESIS

To determine the impact of maternal diabetes during pregnancy on racial disparities in fetal growth.

METHODS

Using linked birth certificate, inpatient hospital and prenatal claims data we examined live singleton births of mothers resident in South Carolina who self-reported their race as non-Hispanic white (NHW; n = 140,128) or non-Hispanic black (NHB; n = 82,492) and delivered at 28-42 weeks' gestation between 2004 and 2008.

RESULTS

Prepregnancy diabetes prevalence was higher in NHB (3.0%) than in NHW (1.7%), while the prevalence of gestational diabetes mellitus (GDM) was similar in NHB (6.1%) and NHW (6.3%). At a delivery BMI of 35 kg/m(2), GDM exposure was associated with an average birthweight only 17 g (95% CI 4, 30) higher in NHW, but 78 g (95% CI 61, 95) higher in NHB (controlling for gestational age, maternal age, infant sex and availability of information on prenatal care). Figures for prepregnancy diabetes were 58 g (95% CI 34, 81) in NHW and 60 g (95% CI 37, 84) in NHB. GDM had a greater impact on birthweight in NHB than in NHW (60 g racial difference [95% CI 39, 82]), while prepregnancy diabetes had a large but similar impact. Similarly, the RR for GDM of having a large- relative to a normal-weight-for-gestational-age infant was lower in NHW (RR 1.41 [95% CI 1.34, 1.49]) than in NHB (RR 2.24 [95% CI 2.05, 2.46]).

CONCLUSIONS/INTERPRETATION

These data suggest that the negative effects of GDM combined with obesity during pregnancy may be greater in NHB than in NHW individuals.

Methamphetamine abuse and oral health: a pilot study of "meth mouth"

Abuse of methamphetamine (meth), a potent central nervous system stimulant, has been associated with significant dental disease. Current descriptions of "meth mouth" are limited in their scope and fail to illuminate the potential pathogenic mechanisms of meth for oral disease. The purpose of this pilot study was to characterize the oral health of subjects with a history of meth abuse as compared to nonabusing control subjects. A total of 28 meth abusers and 16 control subjects were enrolled. Interviews and surveys regarding meth abuse, dental history, oral hygiene, and diet were collected. A comprehensive oral cavity examination including salivary characterization was completed. We observed significantly higher rates of decayed surfaces, missing teeth, tooth wear, plaque, and calculus among meth abusers. No significant difference in salivary flow rates were noted, yet results showed significant trends for lower pH and decreased buffering capacity. These findings suggest that salivary quality may play a more important role in meth mouth than previously considered. Salivary analysis may be useful when managing a dental patient with history of methamphetamine abuse.

Effect of orofacial exercises on oral aperture in adults with systemic sclerosis

PURPOSE

To examine the effect of a home orofacial exercise program on increasing oral aperture among adults with systemic sclerosis (SSc).

METHOD

Forty-eight adults with SSc were assigned randomly to the multifaceted oral-health intervention or usual dental care control group. Participants with an oral aperture of <40 mm in the intervention group received an orofacial exercise program, which included daily manual mouth-stretching and oral-augmentation exercises twice a day with a total of 6 minutes for 6 months. The outcome measure was oral aperture which was measured at baseline, 3-months, and 6-months intervals.

RESULTS

A significantly larger increase in oral aperture for participants received the orofacial exercise program was found when compared to those in the usual care at 3 months (P = 0.01), but not at 6-months evaluation. Participants' adherence rate to the exercise program was low (48.9%).

CONCLUSIONS

The orofacial exercise program intervention for adults with SSc and microstomia did not show significant improvement at 6 months. In addition to the low exercise adherence rate, insufficient frequencies, repetitions, and durations of the orofacial exercises may contribute to these results.

Race and ethnicity are associated with delays in breast cancer treatment (2003-2006)

Access to timely treatment may be one contributing factor to survival differences by race/ethnicity among breast cancer patients. In this study, we examined the relationship between race and treatment delay among breast cancer patients diagnosed between 2003 and 2006 with Stage I-III breast cancer from the National Cancer Database (n=250,007). We evaluated factors associated with receipt of initial treatment more than 30, 60, and 90 days after biopsy using multivariable log binomial models to estimate risk ratios (RR) and 95% confidence intervals (CI). The average time to treatment was 34.30 days (±31.77). Independent of health insurance, stage at diagnosis, and age, Black and Hispanic patients had higher risks of 30, 60, and 90-day treatment delay compared with White patients. Further studies are needed to define the role of structural, health system, physician, clinical and patient factors in treatment delay among Black and Hispanic women and appropriate interventions.

Health insurance status is associated with periodontal disease progression among Gullah African-Americans with type 2 diabetes mellitus

OBJECTIVES

Assess periodontal disease progression among GullahAfrican Americans with type 2 diabetes mellitus (T2DM) according to health insurance coverage.

METHODS

From an ongoing clinical trial among T2DM Gullah, we extracted a cohort that was previously enrolled in a cross-sectional study (N=93). Comparing prior exam to trial initiation, total tooth sites/person with periodontal disease progression events [evaluated separately: 2+ mm of clinical attachment loss (CAL), 2+ mm increased periodontal probing depths (PPD), bleeding on probing (BOP) emergence] were evaluated according to health insurance coverage using regression techniques appropriate for data with different counts of potential events per subject (varying tooth sites available). We used negative binomial regression techniques to account for overdispersion and fit multivariable models that also included baseline glycemic control (poor: glycated hemoglobin > OR =7 percent, well: glycated hemoglobin <7 percent), history of established periodontitis, age, gender, body mass index, annual income, and oral hygiene behaviors. Final models included health insurance status, other significant predictors, and any observed confounders.

RESULTS

Privately insured were most prevalent (41.94 percent), followed by uninsured (23.66 percent), Medicare (19.35 percent), and Medicaid (15.05 percent). Those with poor glycemic control (65.59 percent) were more prevalent than well-controlled (34.41 percent). CAL events ranged from 0 to 58.8 percent tooth sites/ person (11.83 +/- 12.44 percent), while PPD events ranged from 0 to 44.2 percent (8.66 +/- 10.97 percent) and BOP events ranged from 0 to 95.8 percent (23.65 +/- 17.21 percent). Rates of CAL events were increased among those who were uninsured [rate ratio (RR) = 1.75, P = 0.02], Medicare-insured (RR = 1.90, P = 0.03), and Medicaid-insured (RR = 1.89, P = 0.06).

CONCLUSIONS

Increased access to health care, including dental services, may achieve reduction in chronic periodontal disease progression (as determined by CAL) for this study population. These results are very timely given the March 2010 passing of the US healthcare reform bills.

Oral health content in diabetes self-management education programs

Oral health information was included in 89.5% of diabetes education programs in states with high diabetes prevalence compared to 85.9% in low prevalence states (P = 0.22). Comparing the high to low diabetes prevalence states, there were significant differences in odds for responding "yes" to the topics "show patients proper tooth brushing (and flossing) techniques" and "managing dry mouth" (Ps = 0.02). However, management of dry mouth, demonstrations and return demonstrations of oral hygiene techniques were covered by 27.0%, 10.1% and < 1% programs, respectively.

An evaluation of serum albumin, root caries, and other covariates in Gullah African Americans with type-2 diabetes

OBJECTIVES

Associations between dental conditions and overall health have been previously reported. Investigators have also shown significant inverse relationships between serum albumin (a general health status marker) and root caries. This relationship was explored among a study population of Gullah African Americans (who have a considerably lower level of non-African genetic admixture when compared to other African American populations) with type-2 diabetes (T2DM) and self-reported history of normal kidney function (N=280).

METHODS

Root caries indices were defined as total decayed and/or filled root surfaces. The coronal caries index [total decayed, missing, and/or filled coronal surfaces (DMFS)], level of glycemic control, total number of teeth, and other covariates were also evaluated. Logistic regression models were used to evaluate the associations between these factors and hypoalbuminemia (serum albumin concentrations <4 g/dl).

RESULTS

Serum albumin concentrations ranged 2.4-4.5 g/dl (mean=3.8, SD=0.3), with 70.4% exhibiting hypoalbuminemia. Root caries totals ranged 0-38 (mean=1.3, SD=4.5) surfaces decayed/filled, while total teeth ranged 1-28 (mean=19.4, SD=6.2). DMFS totals ranged 2-116 (mean=55.2, SD=28.0). We failed to detect significant associations for root caries; however, the final multivariable logistic regression models showed significant associations between hypoalbuminemia and total teeth [odds ratio (OR)=0.93, P=0.01], poor glycemic control (OR=2.49, P<0.01), elevated C-reactive protein (OR=1.57, P<0.01), glomerular filtration rates ≥60 (OR=0.31, P=0.03), and age (OR=0.97, P=0.03).

CONCLUSIONS

Previously reported inverse relationships between serum albumin and root caries were not evident in our study population. We propose that these null findings are because of the considerably lower level of root caries as well as other differing characteristics (including oral health status, the chronic presence of T2DM, and predominantly younger age) within our study population compared to these previously assessed groups.

Periodontal disease progression and glycaemic control among Gullah African Americans with type-2 diabetes

AIM

To evaluate associations between glycaemic control and periodontitis progression among Gullah African Americans with type-2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

From an ongoing clinical trial among T2DM Gullah, we extracted a cohort previously in a cross-sectional study (N=88). Time from baseline (previous study) to follow-up (trial enrollment, before treatment interventions) ranged 1.93-4.08 years [mean=2.99, standard deviation (SD)=0.36]. We evaluated tooth site-level periodontitis progression [clinical attachment loss (CAL) worsening of > or =2 mm, periodontal probing depth (PPD) increases of > or =2 mm and bleeding on probing (BOP) from none to present] by glycaemic control status (well-controlled=HbA(1c)<7%, poorly-controlled=HbA(1c)> or =7%) using multivariable generalized estimating equations logistic regression, nesting tooth sites/person.

RESULTS

Poorly-controlled T2DM (68.18%) was more prevalent than well-controlled T2DM (31.82%). Proportions of tooth sites/person with CAL progression between baseline and follow-up ranged 0.00-0.59 (mean=0.12, SD=0.12), while PPD and BOP progression ranged 0.00-0.44 (mean=0.09, SD=0.11) and 0.00-0.96 (mean=0.24, SD=0.18), respectively. Site-level PPD at baseline was a significant effect modifier of associations between poorly-controlled T2DM and site-level CAL and PPD progression [adjusted odds ratios (OR) according to poorly-controlled T2DM among PPD at baseline=3, 5 and 7 mm, respectively: CAL progression=1.93, 2.64, and 3.62, PPD progression=1.98, 2.76, and 3.84; p<0.05 for all]. Odds of site-level BOP progression were increased (OR=1.24) for poorly-controlled T2DM, yet the results were not significant (p=0.32).

CONCLUSIONS

These findings from a distinct, homogenous population further support the clinical relevance of identifying patients with poor glycaemic control and periodontitis, particularly among those with disparities for both diseases.

Disparities associated with advanced prostate cancer stage at diagnosis

This study expands on a previous report (focusing on health insurance status and race/ethnicity) to present effects of age, socioeconomic status, hospital type, and other factors (e.g., type of Medicaid and Medicare coverage, insurance-by-race/ethnicity interactions) on advanced-stage (III/IV) at prostate cancer diagnosis. Invasive (Stages I-IV) prostate cancer cases diagnosed during 1998-2004 were extracted from the National Cancer Database (N=687,464). Independent of health-insurance and race/ethnicity, socioeconomic status was a significant predictor of advanced stage at diagnosis, with patients residing in areas with lower socioeconomic characteristics having significantly increased odds. Those treated at community-cancer-centers had significantly decreased odds (versus teaching/research-facilities). Significantly increased odds were also observed among uninsured-Blacks, Medicare-insured-Blacks, Medicaid-insured-Blacks, Medicare-insured-Hispanics, and Medicare-insured-other-racial/ethnic-minorities 65 years old and older (versus corresponding White-populations). The impact of prostate cancer screening on reducing mortality remains debatable. Still, our results suggest improvements in multiple factors that affect access-to-care may achieve earlier diagnosis and, therefore, a potentially more treatable disease.

Differential induction of CYP1A1 and CYP1B1 by benzo[a]pyrene in oral squamous cell carcinoma cell lines and by tobacco smoking in oral mucosa

Polyaromatic hydrocarbons, including benzo[a]pyrene (BP), are major tobacco carcinogens. Their carcinogenic effects require metabolic activation by cytochrome p450 (CYP) enzymes. Relative CYP isoform expression is related to tissue-specific tobacco-related squamous cell carcinoma (SCC) susceptibility. There have been conflicting reports regarding relative CYP1A1 and CYP1B1 oral expression, and information regarding CYP1B1 expression in oral tissues is limited. To quantify BP- and tobacco-induced CYP1A1 and CYP1B1 expression in oral SCC cells and oral mucosa.

STUDY DESIGN

Real-time qPCR was performed to measure (1) BP-induced CYP1A1 and CYP1B1 mRNA expression in seven oral/other head and neck SCC cell lines (2) CYP1A1 and CYP1B1 mRNA expression in gingiva from 22 smokers and 24 nonsmokers. SCC lines exhibited either similar induction of both isoforms or preferential CYP1A1 induction (CYP1A1-to-CYP1B1 ratios 0.8-4.3). In contrast, gingival tissues from smokers exhibited preferential CYP1B1 induction. Marked interindividual variation in CYP1A1 and CYP1B1 expression was observed among smokers. In vitro conditions may not account for factors that modulate expression in vivo. Interindividual variation in inducible CYP1A1 and CYP1B1 expression may account in part for variation in tobacco-related oral SCC risk.