Faculty Bibliography

Over the past decade, hearing loss has emerged as a key issue for aging and health. We describe why hearing loss may be especially disabling in nursing home settings and provide an estimate of prevalence using the Minimum Data Set (MDS v.3.0). We outline steps to mitigate hearing loss. Many solutions are inexpensive and low-tech, but require significant awareness and institutional commitment.

BACKGROUND AND OBJECTIVE: In utero exposure to perfluorooctanoic acid (PFOA) has been associated with decreases in birth weight. We aimed to estimate the proportion of PFOA-attributable low birth weight (LBW) births and associated costs in the US from 2003 to 2014, a period during which there were industry-initiated and regulatory activities aimed at reducing exposure. METHODS: Serum PFOA levels among women 18-49 years were obtained from the National Health and Nutrition Examination Survey (NHANES) for 2003-2014; birth weight distributions were obtained from the Vital Statistics Natality Birth Data. The exposure-response relationship identified in a previous meta-analysis (18.9g decrease in birth weight per 1ng/mL of PFOA) was applied to quantify PFOA-attributable LBW (reference level of 3.1ng/mL for our base case, 1 and 3.9ng/mL for sensitivity analyses). Hospitalization costs and lost economic productivity were also estimated. RESULTS: Serum PFOA levels remained approximately constant from 2003-2004 (median: 3.3ng/mL) to 2007-2008 (3.5ng/mL), and declined from 2009-2010 (2.8ng/mL) to 2013-2014 (1.6ng/mL). In 2003-2004, an estimated 12,764 LBW cases (4% of total for those years) were potentially preventable if PFOA exposure were reduced to the base case reference level (10,203 cases in 2009-2010 and 1,491 in 2013-2014). The total cost of PFOA-attributable LBW for 2003 through 2014 was estimated at $13.7 billion, with $2.97 billion in 2003-2004, $2.4 billion in 2009-2010 and $347 million in 2013-2014. CONCLUSIONS: Serum PFOA levels began to decline in women of childbearing age in 2009-2010. Declines were of a magnitude expected to meaningfully reduce the estimated incidence of PFOA-attributable LBW and associated costs.

Hearing loss is remarkably prevalent in the geriatric population: one-quarter of adults aged 60-69 and 80% of adults aged 80 years and older have bilateral disabling loss. Only about one in five adults with hearing loss wears a hearing aid, leaving many vulnerable to poor communication with healthcare providers. We quantified the extent to which hearing loss is mentioned in studies of physician-patient communication with older patients, and the degree to which hearing loss is incorporated into analyses and findings. We conducted a structured literature search within PubMed for original studies of physician-patient communication with older patients that were published since 2000, using the natural language phrase "older patient physician communication." We identified 409 papers in the initial search, and included 67 in this systematic review. Of the 67 papers, only 16 studies (23.9%) included any mention of hearing loss. In six of the 16 studies, hearing loss was mentioned only; in four studies, hearing loss was used as an exclusion criterion; and in two studies, the extent of hearing loss was measured and reported for the sample, with no further analysis. Three studies examined or reported on an association between hearing loss and the quality of physician-patient communication. One study included an intervention to temporarily mitigate hearing loss to improve communication. Less than one-quarter of studies of physician-elderly patient communication even mention that hearing loss may affect communication. Methodologically, this means that many studies may have omitted an important potential confounder. Perhaps more importantly, research in this field has largely overlooked a highly prevalent, important, and remediable influence on the quality of communication.

The surgical robot, a costly technology for treatment of prostate cancer with equivocal marginal benefit, rapidly diffused into clinical practice. We sought to evaluate the role of teaching in the early adoption phase of the surgical robot. Teaching hospitals were the primary early adopters: data from the Healthcare Cost and Utilization Project showed that surgical robots were acquired by 45.5% of major teaching, 18.0% of minor teaching and 8.0% of non-teaching hospitals during the early adoption phase. However, teaching hospital faculty produced little comparative effectiveness research: By 2008, only 24 published studies compared robotic prostatectomy outcomes to those of conventional techniques. Just ten of these studies (41.7%) were more than minimally powered, and only six (25%) involved cross-institutional collaborations. In adopting the surgical robot, teaching hospitals fulfilled their mission to innovate, but failed to generate corresponding scientific evidence.

OBJECTIVE: To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. DATA SOURCES/STUDY SETTING: Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. STUDY DESIGN: We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. DATA COLLECTION/EXTRACTION METHODS: Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. PRINCIPAL FINDINGS: In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. CONCLUSIONS: Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.

Importance: The increasing use of cesarean delivery is an emerging global health issue. Prior estimates of China's cesarean rate have been based on surveys with limited geographic coverage. Objective: To provide updated information about cesarean rates and geographic variation in cesarean use in China. Design, Setting, and Data Sources: Descriptive study, covering every county (n = 2865) in mainland China's 31 provinces, using county-level aggregated information on the number of live births, cesarean deliveries, maternal deaths, and perinatal deaths, collected by the Office for National Maternal & Child Health Statistics of China, from 2008 through 2014. Exposures: Live births. Main Outcomes and Measures: Annual rate of cesarean deliveries. Results: Over the study period, there were 100873051 live births, of which 32947229 (32.7%) were by cesarean delivery. In 2008, there were 13160634 live births, of which 3788029 (28.8%) were by cesarean delivery and in 2014 there were 15123276 live births, of which 5280124 (34.9%) were by cesarean delivery. Rates varied markedly by province, from 4.0% to 62.5% in 2014. Despite the overall increase, by 2014 rates of cesarean delieries in 14 of the nation's 17 "super cities" had declined by 4.1 to 17.5 percentage points from their earlier peak values (median, 11.4; interquartile range, 6.3-15.4). In 4 super cities with the largest decreases, there was no increase in maternal or perinatal mortality. Conclusions and Relevance: Between 2008 and 2014, the overall annual rate of cesarean deliveries increased in China, reaching 34.9%. There was major geographic variation in rates and trends over time, with rates declining in some of the largest urban areas.

Hearing loss is a leading cause of disability among older people. Yet only one in seven US adults who could benefit from a hearing aid uses one. This fraction has not increased over the past 30 years, nor have hearing aid prices dropped, despite trends of steady improvements and price reductions in the consumer electronics industry. The President's Council on Science and Technology has proposed changes in the regulation of hearing aids, including the creation of a "basic" low-cost over-the-counter category of devices. We discuss the potential to reduce disability as well as to improve public health, stakeholder responses to the president's council's proposal, and public health efforts to further mitigate the burden of disability stemming from age-related hearing loss. (Am J Public Health. Published online ahead of print April 14, 2016: e1-e4. doi:10.2105/AJPH.2016.303176).