• Effectiveness of practice guidelines for disease modifying therapy in multiple sclerosis within the Veteran's Health Administration

      Culpepper, William; Magder, Laurence S. (2009)
      Background: Multiple Sclerosis (MS) is a chronic, degenerative neurologic disorder and is the most common neurologic disorder in young adults; however, its etiology has yet to be fully elucidated. The efficacy of disease modifying therapy (DMT) has been documented, but compliance is an issue and only one study appears in the literature that specifically assessed the effectiveness of DMT. Objectives: This study had four objectives: 1) enroll a large cohort of veterans with MS into the VHA MS Surveillance Registry (MSSR); 2) assess the representativeness of the MSSR as compared with other published MS cohorts; 3) assess how well DMT practice guidelines are applied across the VHA system; and 4) assess the effectiveness of DMT in the treatment of MS. Methods: A cross-sectional, mail-based survey was administered to a stratified, random sample of 3,905 VHA users with MS. Detailed demographic and clinical data were collected as well as patient-reported outcomes assessing disability and QOL. Results: There were 1,227 respondents (31% response rate) that were enrolled into the VHA MS Surveillance Registry (MMSR). Respondents did not differ from non-respondents or from the larger VHA MS population with regard to demographics or region and the MSSR cohort was very similar in demographic and clinical characteristics when compared with other published MS cohorts. Overall, 86% of eligible patients had tried at least one DMT and 72% were compliant with therapy. In general, a dose-response type of association was found such that low DMT compliance was associated with increased disability, more MS-related symptoms, and poorer physical QOL compared with high DMT-compliance. DMT-use was not associated with the psychological QOL scale. Conclusions: The MSSR provides a representative cohort of veterans with MS that reflects the larger VHA MS population and adequately represents the general MS population as well. The DMT-use rates observed in this study exceeded those in other studies and provide a system-wide assessment that could contribute to the development of a national benchmark criterion. This study is only the second to provide empirical support for the effectiveness of DMT in a "real world" cohort of MS patients and highlights the importance of patient compliance. Additional research is needed regarding the factors associated with compliance to ensure therapeutic benefit in all DMT users.
    • Evaluation of Factors Related to Long-term Healing in Endodontic Treatment

      Orgel, Adam William; Fouad, Ashraf F. (2012)
      Introduction: This study sought to determine the effects of residual root canal bacteria and treatment factors on endodontic treatment outcomes up to 6 years post-operatively using traditional radiography (PA radiographs) and limited cone beam computed tomography (CBCT). Methods: Root canal samples were obtained from 50 patients with pulp necrosis and a periapical lesion, following two-visit treatment using contemporary chemomechanical preparation techniques. PCR, with broad range 16S rDNA bacterial primers, was performed followed by cloning and sequencing on pre-obturation specimens. Periapical and CBCT radiographs were taken at 10 months to 6 years post-treatment. Images were scored by two blinded, calibrated endodontists using the conventional periapical index (PAI) and a CBCT index. Statistical analysis was performed using bivariate and multivariate regression analysis for treatment factors. Kaplan-Meier survival analysis and Pearson's regression analysis was used for year-over-year changes. Results: 41 patients were included in the final data analysis. Recall decreased from 98% at 10-17 months to 51% at 33+ months. The percentage of patients healed at 10-17 months, 18-32 months and 33+ months and overall was 65%, 63%, and 66% respectively. Factors influencing outcomes were presence of bacteria at time of obturation (56% when present, 81% absent), primary versus persistent disease (71% vs. 39%), tooth type (85% anterior,23% molar), obturation to the radiographic apex (100% to the apex, 56% not to the apex), and larger master apical file sizes (73%MAF>45 vs. 36% MAF<45).. Short-term outcomes had a strong positive relationship with final outcome (Pearson's, r2=0.56, p=<0.01). Conclusions: Bacterial DNA presence at the time of obturation adversely affects short-term and intermediate-term endodontic treatment outcomes, but this effect is not found in the long-term. Various patient factors such as tooth type and treatment factors such as master apical file size influence outcomes. Short-term treatment outcomes are good predictors of long-term outcomes.
    • The Impact of Maryland Care Management Entity on Quality of Antipsychotic Medication Use and Clinical Outcomes

      Tai, Ming-Hui; dosReis, Susan; 0000-0002-3540-5425 (2016)
      Background: Care Management Entity (CME) using the wraparound practice is a type of care delivery model for youth with severe mental/behavioral disorders. The CME provides coordinated, child-centered services that aim to improve youth's clinical and functional outcomes. The impact of this care management on the quality of psychotropic medication treatment and outcomes following discharge is unknown. The goals of this dissertation are to examine the quality of antipsychotic use and mental health-related outcomes between CME-enrolled and non-CME youth. Methods: Data comprised Medicaid claims linked with the CME administrative records anytime from December 2009 through December 2013. A difference-in-difference design was used to estimate the odds ratio (OR) and the average marginal effect (AME) of antipsychotic use, concomitant antipsychotic use, higher-than-recommended antipsychotic dose, and metabolic monitoring among inverse probability of treatment weighting-adjusted CME and non-CME youth. To avoid loss of the sample due to missing information on length of stay (LOS) in CME services, methods for imputing LOS in CME care were conducted and cross-validated. Building on the data imputation, two-part models were used to examine the mental health-related emergency department (ED) visits, hospitalizations, and outpatient visits within one-year post discharge between CME and non-CME youth. Results: Among the 3,493 IPTW-adjusted cohort (679 CME and 2,814 non-CME youth), the CME-served youth had a significant decrease in any concomitant antipsychotic use relative to non-CME youth (AME= -3.28%, 95% CI= -4.19% to -2.38%). However, there was no difference in antipsychotic dosing or metabolic monitoring between the two groups. In the methodological study, the multiple imputation was preferred over single imputation because it produced smaller errors and similar LOS distribution. In the outcome analyses, the CME care model resulted in a lower likelihood of receiving any mental health-related service (mental health-related ED visits: OR=0.65, 95%CI=0.46 to 0.93; hospitalizations: OR=0.60, 95%CI=0.40 to 0.89; outpatient visits OR=0.46, 95%CI= 0.32 to 0.66) post discharge. Conclusions: Future optimization of this care model may benefit from 1) greater attention to improving antipsychotic monitoring, 2) stronger prescriber engagement in the wraparound practice, and 3) further research to identify potential risk factors that associated with mental health services utilization among youth in public health insurance programs.
    • Outcomes of Older Adults Admitted to a Level I Trauma Center

      Tang, Ying; Smith, Gordon S., M.B., Ch.B., M.P.H. (2013)
      Background: The outcomes of injury and the associated risk factors among older adults are poorly understood. Objective: To examine the associations of pre-existing medical conditions (PMCs) and mechanism of injury (MOI) with the outcomes and to estimate the impact of injury upon long-term mortality of older adults. Methods: Injured older adults admitted to the Shock Trauma Center, University of Maryland Medical Center, between July 1, 1995 and November 30, 2008 were followed until the end of 2008. Logistic regression and Cox proportional hazard models were fit to analyze the outcomes. Standardized mortality ratios (SMRs) and relative survival ratios (RSRs), comparing the observed to the expected proportion of Maryland older adult population were calculated. Results: Among 6,162 injured older adults, 27% developed in-hospital complications, 15% (N=918) died within 30 days of admission, and 43% (N=2,323) of those who were discharged died during the follow-up. Hypertension, prior myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease (COPD) were associated with increased odds of in-hospital complications, with adjusted ORs ranging from 1.2 (95% confidence interval (CI): 1.1-1.5) to 2.2 (95% CI: 1.6-3.0). Hypertension was associated with lower odds (OR=0.7, 95% CI: 0.6-0.8) while COPD with increased odds of 30-day mortality (OR=1.5, 95% CI: 1.1-2.1). All PMCs, except hypertension, were associated with increased hazard of death after discharge (adjusted hazard ratios range: 1.1-1.7). MVC injuries were associated with higher odds of complications than fall injuries (adjusted ORs range: 1.3-2.2). Older adults with MVC injuries had lower odds of 30-day mortality (OR=0.8, 95% CI: 0.6-0.9) and a lower hazard of death after discharge (HR=0.6, 95% CI: 0.6-0.7). SMR was 4.5 (95% CI: 4.1-4.8) at 6 months and 1.4 (95% CI: 1.2-1.5) between 5-10 years after discharge. The RSR was 91.0% (95% CI: 90.1%-91.9%) at 6 months and 72.6% (95% CI: 69.3%-75.8%) at 10 years after discharge. Conclusions: The associations between PMCs and outcomes are disease-specific. Older adults sustaining MVC injuries have a better survival compared to those sustaining fall injuries. The impact of injury on mortality is most evident during the first 6 months after discharge and can last as long as 10 years.
    • The Relationship Between Short Term Healing of Periapical Lesions and Glycemic Control: A Pilot Study

      Zhou, Zuwu; Chand, Priya; Tordik, Patricia (2019)
      The aim of this study was to evaluate the relationship between HbA1c level and short-term healing of periapical lesions after non-surgical root canal treatment (NSRCT). After NSRCT, digital periapical radiographs were taken and blood samples were drawn for HbA1c analysis. To assess short-term healing (PAI difference), subjects returned after six months for a radiograph and blood draw. A calibration exercise established the reliability of the PAI scoring process. Thirty-eight subjects returned for the recall. The relationship between HbA1c level and also the co-variables, with healing was explained using Spearman’s rho and logistic regression. There was a significant correlation between healing and HbA1c level (rs = -.52, p ≤.0001), age (rs = -.44, p ≤.003), recall days (rs =.29, p ≤.036), and cardiovascular status (rs = -.34, p ≤.018). A final logistic regression showed a significant relationship between HbA1c level and short-term healing of periapical lesions (R = .62, p≤ .05).
    • Unit-level staffing, workload, and adverse events in Army Acute Care Hospitals: 2003-2006

      Breckenridge-Sproat, Sara Todd; Johantgen, Mary E. (2009)
      Background: A sequence of reports from the Institute of Medicine revealed quality and patient safety issues in hospitals. The crucial role of nurses was recognized, although much of the research has addressed staffing and, more recently, the work environment. Moreover, most of this research has been at the hospital level where attribution of care processes to adverse events is difficult. The Army, Air Force and Navy's hospitals have faced the same economic and quality challenges. However, military medical institutions also have the increased demands of supporting a nation at war. Purpose: This study examined unit level impact of nursing staffing and workload on medication errors and patient falls in Army hospitals between 2003 and 2006. Methods: A descriptive correlational longitudinal design was used to conduct a secondary analysis of 23 Army inpatient units from the Military Nursing Outcomes Database (MilNOD). Relationships among staffing, workload, and quality of care were examined from 2003 to 2006. A cross sectional design using only 2006 data examined the influence of practice environment on outcomes. Generalized Linear modeling (GZLM) was used to accommodate nested data. Results: Large turbulence was expected in the Army inpatient units from 2003-2006. Although some years were significantly higher, turbulence was far less than expected. Staff complement (measure of percent mix of military, civilian and contractor staff) was a significant predictor of medication errors. Patient census was a significant predictor of falls. The professional nursing Practice Environment Scale (PES) was a partial mediator of medication errors in all types of units. Although tested as both, the practice environment did not significantly mediate or moderate falls. Conclusion: This study supports the growing literature on nurse staffing and the influence on patient outcomes. This study was unique in that data was collected at the unit/shift level, outcomes assessed are considered nurse-sensitive, and statistical techniques accounted for the nested data. Despite these advantages, limitations of the measurement of nursing-related acuity and patient turnover are acknowledged. Well-defined and consistent measures are necessary to enhance interpretability and application across nursing settings.