Background: Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations. Objective: The objective of this study was to evaluate a care coordination program designed to provide combined “whole-person care,” integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants. Research Design: Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis. Subjects: A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare. Measures: Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome’s time trend after program enrollment. Results: Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: −6.6%; 95% confidence interval: −11.2%, −2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: −5.8%; 95% confidence interval: −11.4%, −0.2%). Conclusion: A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.
Background High-cost high-need patients are typically defined by risk or cost thresholds which aggregate clinically diverse subgroups into a single ‘high-need high-cost’ designation. Programs have had limited success in reducing utilization or improving quality of care for high-cost high-need Medicaid patients, which may be due to the underlying clinical heterogeneity of patients meeting high-cost high-need designations. Methods Our objective was to segment a population of high-cost high-need Medicaid patients (N = 676,161) eligible for a national complex case management program between January 2012 and May 2015 to disaggregate clinically diverse subgroups. Patients were eligible if they were in the top 5 % of annual spending among UnitedHealthcare Medicaid beneficiaries. We used k-means cluster analysis, identified clusters using an information-theoretic approach, and named clusters using the patients’ pattern of acute and chronic conditions. We assessed one-year overall and preventable hospitalizations, overall and preventable emergency department (ED) visits, and cluster stability. Results Six clusters were identified which varied by utilization and stability. The characteristic condition patterns were: 1) pregnancy complications, 2) behavioral health, 3) relatively few conditions, 4) cardio-metabolic disease, and complex illness with relatively 5) low or 6) high resource use. The patients varied by cluster by average ED visits (2.3–11.3), hospitalizations (0.3–2.0), and cluster stability (32–91%). Conclusions We concluded that disaggregating subgroups of high-cost high-need patients in a large multi-state Medicaid sample identified clinically distinct clusters of patients who may have unique clinical needs. Segmenting previously identified high-cost high-need populations thus may be a necessary strategy to improve the effectiveness of complex case management programs in Medicaid.
северо-Западный государственный медицинский университет им. И.И. Мечникова 2 Всероссийский центр экстренной и радиационной медицины имени А.М. Никифорова 3 Первый санкт-Петербургский государственный медицинский университет им. акад. И.П. Павлова санкт-Петербург, Российская Федерация Резюме Актуальность. SARS-CoV-2 стал причиной пандемии новой коронавирусной инфекции (COVID-19) в мире. Вирус относится к семейству РНК-содержащих коронавирусов и является представителем линии Beta-CoV B. Эпидемиологический анализ показывает, что болезнь передается воздушно-капельным, воздушно-пылевым и контактным путями. Во время стоматологического лечения пациенты находятся лицом к лицу с врачом. Может произойти кашель, чихание, выделение слюны и крови при использовании ультразвукового или высокоскоростного наконечника. Если пациент заражен, то стандартные защитные меры в повседневной клинической работе недостаточно эффективны для предотвращения распространения COVID-19, даже если пациенты и находятся в бессимптомном инкубационном периоде.Цель. Обобщение знаний коллег и собственного практического опыта необходимо для правильной организации оказания стоматологической помощи пациентам и минимизации риска заражения в условиях пандемии новой коронавирусной инфекции.Материалы и методы. Нами проанализированы данные коллег -стоматологов разных стран. Также представлено собственное понимание вопросов оказания стоматологической помощи во время пандемии новой коронавирусной инфекции.Результаты. Таким образом, основными важными шагами в проведении стоматологической практики в период пандемии являются: соблюдение врачом рекомендаций Министерства здравоохранения Российской Федерации по профилактике, диагностике и лечению новой коронавирусной инфекции (COVID-19); строгое соблюдение стоматологом и челюстно-лицевым хирургом правил собственной безопасности; получение дополнительной информации из анамнеза о возможных факторах риска у пациента; правильное использование диагностического алгоритма в зависимости от патологии больного; использование преимущественно одноразовых материалов; безупречная стерилизация и дезинфекция материалов, которые используются повторно; грамотная асептическая обработка рук и обязательная работа в перчатках; рачительное и правильное использование средств индивидуальной защиты; проведение дезинфекционных мероприятий; утилизация медицинских отходов класса В.Заключение. Знание клинических проявлений новой коронавирусной инфекции и методов профилактики заражения больных и медицинского персонала необходимо для каждого стоматолога и челюстно-лицевого хирурга для предупреждения новых эпизодов распространения и оказания качественной медицинской помощи.Ключевые слова: COVID-19, стоматология, челюстно-лицевая хирургия, стоматологическая практика, КТ-диагностика.Для цитирования: Маковская Н. И., Васильев А. В. Особенности работы врача-стоматолога и челюстно-лицевого хирурга в условиях пандемии новой коронавирусной инфекции . Мировой опыт и собственная практика.
Relevance. Hamartomas are common in the lungs, liver, spleen, pancreas, and kidneys. Head and neck hamartomas are rare and oral hamartomas are still rarer. The feature of hamartoma is that it consists of the same tissue elements as the affected organ; however, it is characterized by an abnormal structure. Hamartomas are most often benign tumours though there were described episodes of malignancy and development of hamartoblastomas, so the maxillofacial surgeon and the dentist should be cancer alert in this case. A small number of diagnosis cases may reflect the true rarity of the disease or may be missed, which can lead to mismanagement of the patient.Purpose. To study the literature on oral hamartomas and present a clinica l case of hard palate hamartoma.Materials and methods. We analyzed the world medical literature about oral hamartomas and hard palate hamartomas in particular and presented a clinical case of hard palate hamartoma diagnosis in a thirty-four-year-old woman. The immunohistochemical test evaluated the markers reflecting the tumour proliferation level.Results. We analyzed the world literature on oral hamartomas and presented a clinical case of the diagnosis and treatment of hard palate hamartoma identified in a thirty-four-year-old woman at an appointment with a maxillofacial surgeon. After the surgical treatment, a histological examination verified the hamartoma.Conclusion. Hard palate hamartomas are rare in the practice of the maxillofacial surgeon and dentist. Learning specific features of hamartomatous lesions is essential to understand how to plan the necessary treatment for a patient with such pathology. Immunohistochemical research methods allow for accurate histological diagnosis, which further determines the patient management strategy.
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