The Relationship Between the Patient-Centered Medical Homes, Healthcare Expenditures, and Quality of Care Among Children with Special Health Care Needs

Abstract

Objectives To examine the association between having a patient-centered medical home (PCMH) and healthcare expenditures and quality of care for children with special health care needs (CSHCN). Methods We conducted a cross-sectional analysis of 8802 CSHCN using the 2008–2012 Medical Expenditure Panel Survey. A PCMH indicator was constructed from survey responses. Inverse probability treatment weighting was applied to balance the cohort. CSHCN's annual health care expenditures and quality were analyzed using two-part and logistic models, respectively. Results Covariate-adjusted annual total expenditures were similar between CSHCN with and without a PCMH ($4267 vs. $3957, p = 0.285). CSHCN with a PCMH had higher odds of incurring expenditure (OR 1.66, 95% CI 1.22–2.25)—in particular, office-based services and prescriptions (OR 1.46 and 1.36, 95% CI 1.24–1.72 and 1.17–1.58, respectively)—compared to those without a PCMH, without shifting expenditures. When examined in detail, PCMH was associated with lower odds of accessing office-based mental health services (OR 0.80, 95% CI 0.66–0.96), leading to lower expenditures ($106 vs. $137; p = 0.046). PCMH was associated with higher odds of post-operation and immunization visits (OR 1.23 and 1.22, 95% CI 1.05–1.45 and 1.004–1.48, respectively) without changing expenditures. Parents of CSHCN with a PCMH were more likely to report having the best health care quality (OR 2.33, p < 0.001). Conclusions CSHCN who had a PCMH experienced better health care quality and were more likely to access preventive services, with unchanged expenditures. However, they were less likely to use mental health services in office-based settings. As the effects of PCMH varied across services for CSHCN, more research is warranted.

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Best Practices for the Design, Implementation and Evaluation of Prenatal Health Programs

Abstract

Introduction Prenatal health programs provide health education, reproductive care and related services to women. Programs may be administered individually or collaboratively by agencies including public health units, hospitals, health clinics, community and non-governmental organizations. Prenatal health disparities among populations at-risk may be reduced through the provision of accessible health education, services and resources to help women mitigate modifiable risks to pregnancy. Although standardized guidelines inform clinical screening, testing and maternity care, gaps exist regarding the design, implementation and evaluation for comprehensive prenatal health programs. Methods Using a multijurisdictional approach, prenatal health guidance documents released by clinical associations and regional governments across Canada, Australia, the United States, the United Kingdom and Ireland were systematically evaluated to identify standards and practices regarding the design, implementation and evaluation of prenatal health programs. Results Evidence-based, surveillance/monitoring, and expert/stakeholder collaborations were principles affirmed by guidance documents across all jurisdictions. Each jurisdiction described tailored strategies to optimize prenatal health in their respective communities. Divergence between jurisdictions was noted for patient care models and promotion of providers and companions of choice. Discussion A best practices model is proposed describing recommendations as follows: prenatal health programs should be grounded in a theoretical approach, fundamentally woman-centered and designed to address interacting prenatal health determinants across the lifespan. Accessible and inclusive prenatal health care can be achieved through provider training and community stakeholder collaborations. Identification of best practices for prenatal health program design, implementation and evaluation ensures that service standards are harmonized across communities, thereby optimizing maternal and child health.

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A quantification of calcaneal lateral plantar process position with implications for bipedal locomotion in Australopithecus

Publication date: Available online 31 July 2018

Source: Journal of Human Evolution

Author(s): Eve K. Boyle, Ellison J. McNutt, Tomohiko Sasaki, Gen Suwa, Bernhard Zipfel, Jeremy M. DeSilva

Abstract

The evolution of bipedalism in the hominin lineage has shaped the posterior human calcaneus into a large, robust structure considered to be adaptive for dissipating peak compressive forces and energy during heel-strike. A unique anatomy thought to contribute to the human calcaneus and its function is the lateral plantar process (LPP). While it has long been known that humans possess a plantarly positioned LPP and apes possess a more dorsally positioned homologous structure, the relative position of the LPP and intraspecific variation of this structure have never been quantified. Here, we present a method for quantifying relative LPP position and find that, while variable, humans have a significantly more plantar position of the LPP than that found in the apes. Among extinct hominins, while the position of the LPP in Australopithecus afarensis falls within the human distribution, the LPP is more dorsally positioned in Australopithecus sediba and barely within the modern human range of variation. Results from a resampling procedure suggest that these differences can reflect either individual variation of a foot structure/function largely shared among Australopithecus species, or functionally distinct morphologies that reflect locomotor diversity in Plio-Pleistocene hominins. An implication of the latter possibility is that calcaneal changes adaptive for heel-striking bipedalism may have evolved independently in two different hominin lineages.

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Serratus Plane Block: A Cadaveric Study to Evaluate Optimal Injectate Spread

Background and Objectives Although serratus plane block reportedly provides satisfactory analgesia for breast and thoracic surgeries, the optimal technique for consistent success has not been studied. The goal of this anatomical study was to evaluate the impact of volume, level, and site of injection on the extent of injectate spread that can influence anesthetic coverage. Methods Ultrasound-guided dye injection and subsequent dissection were performed in 39 cadaveric hemithoraces. Methylene blue was injected according to 1 of 4 injection protocols as follows: one 20-mL bolus, either superficial or deep to the serratus anterior muscle (SAM), at the fifth rib level (groups SUP-20 and DEEP-20, respectively), or two 20-mL boluses, either superior or deep to the SAM, one at the third rib and one at the fifth rib level (group SUP-40 and group DEEP-40, respectively). Following injection, dissection and 3-dimensional digitization were performed to map the area of dye spread. Results We found that the extent of dye spread was mostly influenced by the volume of injection rather than the plane of injection (superficial vs deep to SAM). Increasing the volume from 20 to 40 mL doubled the area of injectate spread and promoted dye spread preferentially to the anterior chest wall, with some impact on cephalad-to-caudad spread and no impact on posterior spread. Dye was found most consistently in the axilla when a separate injection was performed at the third rib level. Conclusions Our data showed that a high-volume double-injection technique provides extensive and consistent dye spread in the anterior chest wall and axilla, regardless of the plane of injection relative to the SAM. This technique likely provides more reliable analgesic coverage for breast procedures especially those that involve the axilla, pending confirmation in future clinical studies. Accepted for publication April 22, 2018. Address correspondence to: Vincent Chan, MD, FRCPC, FRCA, Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, MCL 2-405, Toronto, Ontario M5T 2S8, Canada (e-mail: vincent.chan@uhn.ca). V.C. has received honorarium from SonoSite, BBraun, and Aspen Pharma. He also sat on the Medical Advisory Board of Smiths Medical. A.P. has a research grant from Fisher and Pykel for an unrelated study. She is associate editor of Regional Anesthesia and Pain Medicine. A.A. is an anatomy faculty at Allergan Academy of Excellence. The other authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Pericapsular Nerve Group (PENG) Block for Hip Fracture

Fascia iliaca block or femoral nerve block is used frequently in hip fracture patients because of their opioid-sparing effects and reduction in opioid-related adverse effects. A recent anatomical study on hip innervation led to the identification of relevant landmarks to target the hip articular branches of femoral nerve and accessory obturator nerve. Using this information, we developed a novel ultrasound-guided approach for blockade of these articular branches to the hip, the PENG (PEricapsular Nerve Group) block. In this report, we describe the technique and its application in 5 consecutive patients. Accepted for publication April 14, 2018. Address correspondence to: Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Med), Department of Anesthesia, McL 2-405, TWH, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8 (e-mail: philip.peng@uhn.ca). A.P. has a research grant from Fisher and Pykel. P.W.H.P. has equipment support from Fujifilm/Sonosite Canada. The other authors declare no conflict of interest. The authors have no sources of funding to declare for this article. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Comparison of the ED50 and ED95 of Intrathecal Bupivacaine in Parturients Undergoing Cesarean Delivery With or Without Prophylactic Phenylephrine Infusion: A Prospective, Double-Blind Study

Background and Objectives While prophylactic phenylephrine infusions during cesarean delivery are often used to counteract the sympathectomy associated with spinal anesthesia, their use has been associated with decreased rostral spread of local anesthetic. The purpose of this study was to determine the median effective dose (ED50) and 95% effective dose (ED95) of intrathecal hyperbaric bupivacaine for cesarean delivery in the presence and absence of prophylactic phenylephrine infusion. Methods One hundred healthy parturients undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blind, dose-finding study to determine ED50 and ED95. Subjects were randomly assigned to receive prophylactic phenylephrine or control (saline) infusion with injection of 6, 7.5, 9, 10.5, or 12 mg intrathecal hyperbaric bupivacaine. An effective dose was defined as achieving a T5 sensory level within 10 minutes of intrathecal drug administration without the need for epidural supplementation. Results The ED50 of intrathecal hyperbaric bupivacaine was 10.0 mg (95% confidence interval [CI], 5.9–11.4 mg) with prophylactic phenylephrine infusion and 7.9 mg (95% CI, 2.3–9.4 mg) in the control group. The ED95 of intrathecal hyperbaric bupivacaine was 14.1 mg (95% CI, 12.3–37.6 mg) with prophylactic phenylephrine infusion and 11.7 mg (95% CI, 9.9–22.8 mg) in the control group. Conclusions The administration of prophylactic phenylephrine infusion results in higher intrathecal hyperbaric bupivacaine dosing requirements in parturients undergoing cesarean delivery. Clinical Trial Registration This study was registered at the Chinese Clinical Trial Registry, identifier ChiCTR-TRC-16008938. Accepted for publication April 14, 2018. Address correspondence to: Xinzhong Chen, MD, Department of Anesthesia, Women's Hospital, School of Medicine, Zhejiang University, No. 1, Xueshi Road, 310006 Hangzhou, China (e-mail: chenxinz@zju.edu.cn). The authors declare no conflict of interest. This study was supported by the funds from National Natural Science Foundation of China (no. 81271237 and no. 81471126). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review

Background and Objectives Postdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. Methods We conducted a chart review of the first authors' obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. Results A greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P

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