Inadequate Effort on Neuropsychological Evaluation is Associated With Increased Healthcare Utilization

Patients who exert inadequate effort on neuropsychological examination might not receive accurate diagnoses and recommendations, and might not cooperate fully with other aspects of healthcare. This study examined whether inadequate effort is associated with increased healthcare utilization. Of 355 patients seen for routine, clinical neuropsychological examination at a VA Medical Center, 283 (79.7%) showed adequate effort and 72 (20.3%) showed inadequate effort, as determined at time of evaluation using the Word Memory Test and/or Test of Memory Malingering. Utilization data included number of Emergency Department (ED) visits and inpatient hospitalizations in the year following evaluation. Patients who had shown inadequate effort on examination had more Emergency Department visits, more inpatient hospitalizations, and more days of inpatient hospitalization in the year after evaluation, compared to patients who had exerted adequate effort. This finding was not attributable to group differences in age or medical/psychiatric comorbidities. Thus, patients who exerted inadequate effort showed greater healthcare utilization in the year following evaluation. Such patients might use more resources since diagnostic evaluations are inconclusive. Inadequate effort on examination might also serve as a “marker” for more general failure to cooperate fully in one’s healthcare, possibly resulting in greater utilization.     

Integration of neuropsychology services in a sickle cell clinic and subsequent healthcare use for pain crises

Abstract

Objective: Growing literature has documented the clinical utility of neuropsychological evaluations for predicting functional outcomes, including reduced healthcare service utilization, in a variety of clinical samples. The present study investigates the relationship between the integration of clinical neuropsychology services into an existing outpatient sickle cell clinic and frequency of emergency department (ED) visits and hospitalizations for pain crises.

Method: Participants included 144 adults diagnosed with sickle cell disease (SCD) who either underwent neuropsychological evaluation (NP+), including interview, neuropsychological testing, and feedback, or treatment as usual (NP?). Medical records were reviewed for a two-year period, one year prior to study enrollment (pre-assessment) and one year post-study enrollment (post-assessment), to track the number of ED visits and hospitalizations related to sickle cell pain crises.

Results: When examining pain crises ED visits prior to and following neuropsychological evaluation, there was a significant decrease in ED visits for the NP?+?group, but no change for the NP???group. No significant changes in pain crises hospitalizations were observed for the NP?+?and NP???groups. For the NP?+?group, the decreased incidence of pain crises ED visits and hospitalizations was associated with an estimated total cost savings of $994,821.

Discussion: Results highlight that integration of neuropsychology services into an existing outpatient sickle cell clinic may reduce healthcare costs, particularly use of pain crises ED services, for adults with SCD.     

Is self or caregiver report comparable to Medicare claims indicators of healthcare utilization after stroke?

Background: Claims data from Medicare or other payers might not generalize to other populations regarding service use after stroke especially among younger patients. However, high agreement between self-report and Medicare claims data would support the use of self-reported healthcare utilization data in these populations.

Methods: A population-based sample of 147 stroke participants with traditional fee-for service Medicare and their family caregivers was examined. Concordance with Medicare claims was examined for stroke participant self-report for Emergency Room visits, hospitalizations, and physician visits for a six-month period after stroke, and for both stroke participant and caregiver reports of receipt of Physical Therapy (PT), Speech and Language Pathology (SLP), or Home Health Agency (HHA) visits.

Results: Agreement was good for Emergency Room visits (kappa 0.75), hospitalization (kappa 0.70), and physician visits (Prevalence Adjusted Bias Adjusted Kappa [PABAK] 0.69) but more moderate for physical therapy, speech and language therapy, and home health agency visits (kappa 0.56–0.63). Caregiver agreement with Medicare claims was similar to stroke participant agreement. African Americans were less likely to self-report therapy compared to whites (OR 0.32 PT, 0.38 SLP, 0.29 HHA, p < 0.03). Younger stroke participants reported lower levels of Emergency Room visits than claims (OR 0.81, p = 0.001).

Conclusion: Healthcare utilization after stroke can be reliably assessed from Medicare claims, Stroke participant, or Caregiver report for salient events such as hospitalizations and Emergency Room visits. Self-report and caregiver report appear to be less reliable for identifying use of therapy or home health services. Caution should be used when interpreting disparities based on self-report data alone in these areas.     

Comorbid Parkinson's disease,falls and fractures in the 2010 National Emergency Department Sample

IntroductionParkinson's disease (PD) is a progressive, neurodegenerative disorder of multifactorial etiology affecting ∼1% of older adults. Research focused on linking PD to falls and bone fractures has been limited in Emergency Department (ED) settings, where most injuries are identified. We assessed whether injured U.S. ED admissions with PD diagnoses were more likely to exhibit comorbid fall- or non-fall related bone fractures and whether a PD diagnosis with a concomitant fall or bone fracture is linked to worse prognosis.MethodsWe performed secondary analyses of 2010 Healthcare Utilization Project National ED Sample from 4,253,987 admissions to U.S. EDs linked to injured elderly patients. ED discharges with ICD-9-CM code (332.0) were identified as PD and those with ICD-9-CM code (800.0–829.0) were used to define bone fracture location. Linear and logistic regression models were constructed to estimate slopes (B) and odds ratios (OR) with 95% confidence intervals (CI).ResultsPD admissions had 28% increased adjusted prevalence of bone fracture. Non-fall injuries showed stronger relationship between PD and bone fracture (OR_adj = 1.33, 95% CI: 1.22–1.45) than fall injuries (OR_adj = 1.06, 95% CI: 1.01–1.10). PD had the strongest impact on hospitalization length when bone fracture and fall co-occurred, and total charges were directly associated with PD only for fall injuries. Finally, PD status was not related to in-hospital death in this population.ConclusionAmong injured U.S. ED elderly patient visits, those with PD had higher bone fracture prevalence and more resource utilization especially among fall-related injuries. No association of PD with in-hospital death was noted.     

Rate and Predictors of Acute Care Encounters in the First Month After Stroke

ObjectivesThe purpose of this quality improvement project is to understand the burden of acute care, including inpatient readmission and emergency department (ED) visits, in the month following hospital discharge after stroke.Materials and MethodsWe identified patients discharged from our hospitals between 2015 and 2018 with any stroke diagnosis who had an unplanned readmission or ED visit within the first month after discharge, and those who had primary care (PC) visits before or after their stroke. Patients were compared regarding demographics, clinical characteristics, and PC visits. Independent predictors of acute care encounters were examined using logistic regression.ResultsA total of 166 patients (19%) had an acute care encounter one month after discharge. Eighty-eight (10%) patients were readmitted and 78 (9%) patients had an ED visit. Encounter diagnoses were different between the two groups; inpatient readmission had more frequent acute stroke/TIA and pneumonia/pulmonary indications, while ED visits had more non-specific neurologic symptoms and more frequent cardiovascular complaints. Independent predictors of any acute care encounter and inpatient readmission were younger age, longer length of stay (LOS), and lack of PC visit after discharge. Predictors of ED visits were the same except for LOS.Conclusions30-day acute care encounters after stroke hospitalization are common, affecting 19% of patients and usually occurring in the first week after discharge. Post discharge PC visit was associated with a decreased need for acute care. Efforts should be made to facilitate a PC visit within a week after discharge, especially in high risk patients.     

Influence of psychiatric comorbidities in migraineurs in the emergency department

Objective

To examine how psychiatric comorbidities in migraineurs in the emergency department (ED) affect healthcare utilization and treatment tendencies.

Method

This is a cross-sectional analysis of 2872 patients who visited our ED over a 10-year period and were given a principal diagnosis of migraine.

Results

Compared to migraineurs without a psychiatric comorbidity, migraineurs with a psychiatric comorbidity had about three times more ED visits, six times more inpatient hospital stays and four times more outpatient visits. Migraineurs with psychiatric comorbidities received narcotics in the ED more often than migraineurs without psychiatric comorbidities (P<0.0001). In addition, migraineurs with psychiatric disorders were more likely to have a computed tomography scan of the head [Risk Ratio (RR) 1.42 (95% confidence interval (CI)=1.28–1.56, P<0.001)] or a magnetic resonance image of the brain [RR 1.53 (95% CI=1.33–1.76, P<0.001)] than patients without a psychiatric disorder when visiting our hospital center.

Conclusions

Migraineurs with psychiatric comorbidity who visit the ED have different healthcare utilization tendencies than migraineurs without psychiatric comorbidity who visit the ED. This is seen in the frequency of ED visits, outpatient visits and inpatient stays, in the medications administered to them and in the radiology tests they undergo.     

Impact of nonadherence to antiepileptic drugs on health care utilization and costs: Findings from the RANSOM study

Purpose: To study the impact of nonadherence to antiepileptic drugs (AEDs) on health care utilization and direct medical costs in a Medicaid population. Methods: A retrospective cohort design was employed using state Medicaid claims data from Florida, Iowa, and New Jersey during the period from January 1997 to June 2006. Patients aged ≥18 years with one or more neurologist visit with an epilepsy diagnosis and two or more pharmacy claims for AEDs were included. Medication possession ratio (MPR) was used to evaluate AED adherence with MPR ≥ 0.80 considered adherent and <0.80 considered nonadherent. The association of nonadherence with utilization outcomes [hospitalizations, inpatient days, emergency department (ED), and outpatient visits] was assessed with univariate and multivariate Poisson regressions. Quarterly per‐patient inpatient, outpatient, ED, and pharmacy costs were calculated across nonadherent and adherent quarters for the younger than 65 population (under‐65) and cost differences were computed. Adjusted incremental costs of nonadherence were estimated with multivariate Tobit regression models. Results: A total of 33,658 patients were included (28,470 under‐65), together contributing 388,564 treated quarters (26% nonadherent). In multivariate analyses, AED nonadherence was associated with significantly higher incidence of hospitalizations [incident rate ratio (IRR) = 1.39, 95% confidence interval (CI) = 1.37–1.41], inpatient days (IRR = 1.76, 95% CI = 1.75–1.78), and ED visits (IRR = 1.19, 95% CI = 1.18–1.21). Nonadherence was associated with cost increases related to serious outcomes, including inpatient ($4,320 additional cost per quarter, 95% CI = $4,077–$4,564) and ED services ($303 additional cost per quarter, 95% CI = $273–$334), but lower costs for outpatient and pharmacy services, likely because of nonadherent behavior. Discussion: Nonadherence to AEDs appears to be associated with serious outcomes, as evidenced by increased utilization and costs of inpatient and ED services.     

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations

BackgroundLittle is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services.MethodsWe analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation.ResultsMild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant.ConclusionsHigher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.     

The Burden of Narcolepsy Disease (BOND) study: health-care utilization and cost findings

ObjectivesThe aim of this study was to characterize health-care utilization, costs, and productivity in a large population of patients diagnosed with narcolepsy in the United States.MethodsThis retrospective, observational study using data from the Truven Health Analytics MarketScan® Research Databases assessed 5 years of claims data (2006–2010) to compare health-care utilization patterns, productivity, and associated costs among narcolepsy patients (identified by International Classification of Diseases, Ninth Revision (ICD9) narcolepsy diagnosis codes) versus matched controls. A total of 9312 narcolepsy patients (>18 years of age, continuously insured between 2006 and 2010) and 46,559 matched controls were identified.ResultsCompared with controls, narcolepsy subjects had approximately twofold higher annual rates of inpatient admissions (0.15 vs. 0.08), emergency department (ED) visits w/o admission (0.34 vs. 0.17), hospital outpatient (OP) visits (2.8 vs. 1.4), other OP services (7.0 vs. 3.2), and physician visits (11.1 vs. 5.6; all p < 0.0001). The rate of total annual drug transactions was doubled in narcolepsy versus controls (26.4 vs. 13.3; p < 0.0001), including a 337% and 72% higher usage rate of narcolepsy drugs and non-narcolepsy drugs, respectively (both p < 0.0001). Mean yearly costs were significantly higher in narcolepsy compared with controls for medical services ($8346 vs. $4147; p < 0.0001) and drugs ($3356 vs. $1114; p < 0.0001).ConclusionsNarcolepsy was found to be associated with substantial personal and economic burdens, as indicated by significantly higher rates of health-care utilization and medical costs in this large US group of narcolepsy patients.     

Investigating Medical Cost and Mortality Among Psychiatric Patients Involuntary Admissions: A Nationwide Propensity Score-Matched Study

Objective Involuntary admission to psychiatric inpatient care can protect both patients with severe mental illnesses and individuals around them. This study analyzed annual healthcare costs per person for involuntary psychiatric admission and examined categories of mental disorders and other factors associated with mortality. Methods This retrospective cohort study collected 1 million randomly sampled beneficiaries from the National Health Insurance Database for 2002–2013. It identified and matched 181 patients with involuntary psychiatric admissions (research group) with 724 patients with voluntary psychiatric admissions (control group) through 1:4 propensity-score matching for sex, age, comorbidities, mental disorder category, and index year of diagnosis. Results Mean life expectancy of patients with involuntary psychiatric admissions was 33.13 years less than the general population. Average annual healthcare costs per person for involuntary psychiatric admissions were 3.94 times higher compared with voluntary admissions. The general linear model demonstrated that average annual medical costs per person per compulsory hospitalization were 5.8 times that of voluntary hospitalization. Survival analysis using the Cox proportional hazards model found no significant association between type of psychiatric admission (involuntary or voluntary) and death. Conclusion This study revealed no significant difference in mortality between involuntary and voluntary psychiatric admissions, indicating involuntary treatment’s effectiveness.     

Clinical Equivalence of Generic Clozapine

Objective: To determine if mental health service utilization increases when patients are converted to generic clozapine.Method: About 125 patients taking clozapine in a community mental health clinic were switched from Novartis Clozaril to generic clozapine (Mylan Pharmaceuticals). Serum clozapine levels were obtained 2 weeks before, and 2 weeks after, the switch to generic clozapine. The number of outpatient visits, emergency room visits, and hospitalizations in the year prior to the switch were compared to those in the year following the switch, to determine service utilization.Results: Psychiatric emergency room visits decreased, but clozapine serum levels, inpatient hospital days, partial hospital admissions, and outpatient psychiatrist visits did not change after the switch to generic clozapine.Conclusions: There were no significant increases in mental health service utilization after the conversion to Mylan generic clozapine. The switch to Mylan generic clozapine was cost effective, as the reduction in pharmacy costs was not offset by increased utilization costs.     

A cost-consequence analysis of long-acting injectable risperidone in schizophrenia: a one-year mirror-image study with national claim-based database in Taiwan

ObjectiveThe development of long-acting atypical antipsychotics has provided a new paradigm for schizophrenia treatment. The economic effectiveness of risperidone long-acting injection (RLAI) on service costs has, however, never been studied in the real world with national claim-based database.MethodTo assess the change of service utilization and costs for schizophrenia before and after RLAI treatment, we conducted this 1-year mirror-image study with Taiwanese national claimed-data. Comparison was made for service sectors (the number of visits, acute admissions and relapse events) and cost components (outpatient, inpatient, emergency, medication and non-medication costs).ResultsService uses reduced in the post-RLAI period, along with a reduction of 34% and 32% on total inpatient services costs and inpatient non-medication costs, respectively (p < 0.005). However, overall psychiatric service costs went up by 26%, with an increase of 190% on total outpatient service costs and 177% on overall medication costs (p < 0.0001).ConclusionsThis 1-year mirror-image analysis showed that RLAI treatment was associated with reductions of service uses; however, overall psychiatric service costs were compromised by costs incurred from increased utilization of outpatient service and RLAI medication costs under the context of healthcare in Taiwan.     

An Evaluation of the Clinical and Economic Burden Among Older Adult Medicare-Covered Beneficiaries With Treatment-Resistant Depression

ObjectiveTo compare the clinical and economic burden of treatment-resistant depression (TRD) among older adult patients with major depressive disorder (MDD) to non-TRD MDD and non-MDD patients.MethodsRetrospective cohort study using 5% Medicare data (January 1, 2012–December 31, 2015) for MDD patients aged ≥65 years who were defined as TRD if they received ≥2 antidepressant treatments in the current episode. MDD patients not meeting TRD criteria were deemed non-TRD MDD; those without an MDD diagnosis were categorized as non-MDD. All were required to have continuous health plan enrollment for ≥6 months pre- and ≥12 months postindex date (index: first antidepressant claim/random [non-MDD]). Three cohorts were matched, and generalized linear and Cox proportional hazards models were used to compare medication use, healthcare resource utilization, costs, and risks of initial hospitalization and readmission ≤30 days postdischarge from initial hospitalization.ResultsAfter matching, 178 patients from each cohort were analyzed. During 12 months of follow-up, TRD patients had higher use of different antidepressants and antipsychotics, higher inpatient and emergency room visits, longer inpatient stays, and higher total healthcare costs ($24,543 versus $16,059, $8,058) than non-TRD MDD and non-MDD cohorts, respectively (all p <0.05). Risk of initial hospitalization was higher in the TRD (hazard ratio [HR] = 3.60, 95% confidence interval [CI] = 2.08–6.23) and non-TRD MDD cohorts (HR = 1.82, 95% CI = 1.02–3.25) than the non-MDD cohort.ConclusionsThe burden of MDD among older adult Medicare beneficiaries is substantial, and even greater among those with TRD compared to non-TRD MDD, demonstrating the need for more effective treatments than those currently available.     

Clinical and economic burden of breakthrough seizures

PurposeThe purpose of this study was to measure health-care resource utilization and costs in treatment-adherent, previously seizure-free patients with epilepsy who were treated in the inpatient/emergency room (ER) setting for new-onset seizures, compared with matched controls.MethodsThe study used a retrospective case/control study design using administrative claims from the IMS PharMetrics™ database. We identified adult patients with epilepsy with 1 + ER visit/hospitalization with primary diagnosis of epilepsy between 1/1/2006 and 3/31/2011, preceded by 6 months of seizure-free activity and antiepileptic drug (AED) treatment adherence (≥ 80% of days covered by any AED); the first observed seizure defined the “breakthrough” seizure/index event. Treatment-adherent patients with epilepsy without any ER/hospital admission for seizures served as controls: an outpatient epilepsy-related medical claim within the selection window was chosen at random as the index date. The following were continuous enrollment requirements for all patients: ≥ 12-month pre- and ≥ 6-month postindex. Each case matched 1:1 to a control using propensity score matching. All-cause and epilepsy-related (epilepsy/convulsion diagnosis, AED pharmacy) resource utilization and unadjusted and adjusted direct health-care costs (per person, 2012 US dollars (USD)) were assessed in a 6-month follow-up period.Principal resultsThere were 5729 cases and 14,437 controls eligible. The final sample comprised 5279 matched case/control pairs. In unadjusted analyses, matched cases had significantly higher rates of all-cause hospitalization and ER visits compared to controls and significantly higher total all-cause direct health-care costs (median $12,714 vs. $5095, p < 0.001) and total epilepsy-related costs among cases vs. controls (median $7293 vs. $1712, p < 0.001), driven by higher inpatient costs. Among cases, costs increased with each subsequent seizure (driven by inpatient costs). Cases had 2.3 times higher adjusted all-cause costs and 8.1 times higher adjusted epilepsy-related costs than controls (both p < 0.001).ConclusionInpatient/ER-treated breakthrough seizures occurred among 28.4% of our treatment-adherent study sample and were associated with significant incremental health-care utilization and costs, primarily driven by hospitalizations. Our findings suggest the need for better seizure control via optimal patient management and the use of effective AED therapy, which can potentially lower health-care costs.     

Toward generally accepted forensic assessment practices among clinical neuropsychologists: a survey of professional practice and common test use*

Objective: This study investigated professional practice and common test use among clinical neuropsychologists engaging in forensic assessment. Method: Doctorate-level psychologists active in the practice of neuropsychology and on the INS and NAN membership listings (n = 502) were surveyed about their demographics, professional practice, and common test use. Participants who reported engaging in forensic practice (n = 255) were further surveyed about their forensic practice. Results: Forensic participants were more likely to be male and Caucasian, and reported higher ages, more years of professional experience, and a higher prevalence of board certification. While characteristics of their professional and forensic practice varied, forensic participants reported spending most of their professional time conducting neuropsychological assessments with adult clients in a private or group practice setting, focusing on civil referrals and civil legal questions involving older adult issues, developmental issues, head injury, and psychiatric issues. Common test use across neuropsychological assessment domains is presented for board-certified forensic participants (n = 77). An examination of these results reveals that the current pattern of test use is similar to the results of a more general survey of neuropsychological test use. Conclusions: The findings provide insight into the practice of forensic neuropsychological assessment, and further establish the admissibility of neuropsychological evidence in the United States legal system. Results will be useful for clinical neuropsychologists, field leaders, and legal professionals hoping to gain insight into the role of clinical neuropsychology in civil and criminal legal decision-making.     

Inpatient treatment costs of status epilepticus in adults in Germany

PurposeStatus epilepticus (SE) is an important neurological emergency and a significant source of direct costs related to hospitalization; however, no cost-of-illness (COI) studies have been performed in Europe. The objective of this study was to determine and characterize hospital costs related to the acute inpatient treatment of SE and to provide national estimates of SE hospitalization costs.MethodsAdult inpatient treatment costs related to SE and costs attributable to epilepsy-related hospital admissions were derived from billing data of participating hospitals.ResultsDuring the 4-month study period a total of 96 patients (59.5 ± 21.6 years; 52 male) received inpatient treatment for epilepsy-related reasons, 10 of these (10.4%) were treated for SE. Epilepsy was newly diagnosed in 30/96 patients (31.3%), of whom five presented with SE. The admission costs related to SE (€8347 ± 10,773 per patient per admission) were significantly higher than those related to admissions of patients with newly diagnosed (€1998 ± 1089; p = 0.014) or established epilepsy (€3475 ± 4413; p = 0.026). Of the total inpatient costs (€346,319) 24.4% were attributable to SE, 14.4% to newly diagnosed epilepsy without SE (n = 25) and 61.2% to complications of established epilepsy (n = 61). Extrapolation to the whole of Germany (population 82 million) indicates that SE causes hospital costs of more than €83 million per year while the total of epilepsy-related inpatient treatment costs amounts to €342 million.ConclusionAcute treatment of SE is responsible for a high proportion of hospital costs associated with epilepsy. With a high incidence of SE in the elderly population, the health care systems will face an increasing number of presentations with SE and its associated costs, underlining the necessity to further evaluate the burden and optimize the treatment of SE.     

Healthcare utilization after elective surgery in patients with obstructive sleep apnea – analysis of a nationwide data set

BackgroundObstructive sleep apnea is prevalent among those undergoing elective surgery and likely introduces a risk of adverse outcomes. To understand its impact, we aimed to compare healthcare utilization in postsurgical patients with obstructive sleep apnea compared to controls matched on the surgical care environment.MethodsThis is a retrospective case–control cohort study using a nationwide database. Among patients undergoing elective surgical procedures during 2009–2014, we compared patients with obstructive sleep apnea with those without obstructive sleep apnea. The two cohorts were matched based on age, sex, type of surgery, performing surgeon, the hospital where the procedure was performed, and various All-Patient-Refined Diagnosis-Related-Groups severity indices. The primary effect of interest was short-term healthcare utilization. We also compared long-term hospital admissions, intensive care unit admissions, emergency room visits and outpatient visits.Results47,719 subjects and controls were matched on a 1:1 basis. As the subjects were matched, the two groups did not differ on age, percent female, and various Diagnosis-Related-Groups severity indices. The obstructive sleep apnea group had more comorbid conditions and a higher Elixhauser index. Short-term healthcare utilization measured by the length of stay and mortality related to index procedure did not increase in the sleep apnea group. In hierarchical logistical regression analysis, the presence of sleep apnea predicted higher long-term health care utilization.ConclusionsOur data suggests that the presence of sleep apnea was not associated with increased post elective surgical length of stay and mortality; however, the presence of obstructive sleep apnea was associated with long-term health care utilization.     

Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis

PurposeTo examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization.MethodsWe applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant.Main findingsMedicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75^th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]).Principal conclusionsLikelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.     

Performance validity and processing speed in a VA Polytrauma sample

Objective: While recognition memory has been the primary tool for the assessment of performance validity in neuropsychological evaluations, some consideration has also been given to embedded measures from other cognitive domains, including processing speed. The present study evaluated the classification accuracy of several speed-based measures in a Veterans Affairs Medical Center Polytrauma sample. Method: The present sample consisted of 114 military veterans (Mean age = 35.5, SD = 9.4) referred for a suspected history of mild traumatic brain injury who were administered a full neuropsychological protocol that included several validity checks. Veterans were assigned to Valid (n = 80) or Invalid (n = 34) groups based on outcomes of performance validity measures (PVMs). Results: Several processing speed measures yielded acceptable or excellent classification accuracy; sensitivity values ranged from 29 to 53% with specificity values above 90%. Efforts to identify an improved algorithm that would collapse across multiple processing speed PVMs were unsuccessful compared to classification based on single measures. Conclusions: Processing speed measures can serve as efficient performance validity assessment tools.     

Hospital Service Utilization is Reduced Following Neuropsychological Evaluation in a Sample of U.S. Veterans

The aim of this study was to evaluate the objective value of neuropsychological evaluation (NPE) through reduction in Emergency Room (ER) visits and hospitalizations. Retrospective analysis examined trends in ER visits and hospitalizations in 440 U.S. veterans who completed NPE between the years of 2003 and 2010. Within-subjects comparisons showed significant decreases in incidence of hospitalization and length of hospitalization in the year after evaluation compared to the year prior. Mean number of hospitalizations declined from 0.31 (SD = 0.64) pre-NPE to 0.22 (SD = 0.59) post-NPE; there were a total of 41 fewer hospitalizations in the year following NPE. Mean length of hospitalization decreased from 1.9 days (SD = 5.6) pre-NPE to 1.06 days (SD = 3.9) post-NPE; there were a total of 368 fewer days of hospitalization post-NPE. This reduction was not attributable to age or time. Incidence of ER visits also decreased from pre-NPE (M = 0.74, SD = 1.3) to post-evaluation (M = 0.69, SD = 1.3), though this was not significant. These findings provide preliminary evidence of the clinical and potential economic value of neuropsychological services within a medical setting. Follow-up studies should examine individual and exam-specific factors that may contribute to reduced utilization.