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Background and Objectives The Affordable Care Act intended to “extend affordable coverage” and “ensure access” for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, BlueCross, cash pay) carried by trauma patients influences access to pain management specialty care. Methods Investigators phoned 443 board certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient that sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. Results 53% of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash paying patients, 39.6% for those with Medicare, and 41.3% with BlueCross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. Conclusions Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.

Proactive control allows us to maneuver a changing environment and individuals are distinct in how they anticipate and approach such changes. Here, we examined how individual differences in personality traits influence cerebral responses to conflict anticipation, a critical process of proactive control. We explored this issue in an fMRI study of the stop signal task, in which the probability of stop signal – p(Stop) – was computed trial by trial with a Bayesian model. Higher p(Stop) is associated with prolonged go trial reaction time, indicating conflict anticipation and proactive control of motor response. Regional brain activations to conflict anticipation were correlated to novelty seeking (NS), harm avoidance (HA), reward dependence, as assessed by the Tridimensional Personality Questionnaire, with age and gender as covariates, in a whole-brain linear regression. Results showed that increased anticipation of the stop signal is associated with activations in the bilateral inferior parietal lobules (IPL), right lateral orbitofrontal cortex (lOFC), middle frontal gyrus (MFG), anterior pre-supplementary motor area (pre-SMA), and bilateral thalamus, with men showing greater activation in the IPL than women. NS correlated negatively to activity in the anterior pre-SMA, right IPL, and MFG/lOFC, and HA correlated negatively to activity in the thalamus during conflict anticipation. In addition, the negative association between NS and MFG/lOFC activity was significant in men but not in women. Thus, NS and HA traits are associated with reduced mobilization of cognitive control circuits when enhanced behavioral control is necessary. The findings from this exploratory study characterize the influence of NS and HA on proactive control and provide preliminary evidence for gender differences in these associations.

Objective: The purpose of this study was to characterize and compare risk behaviors between motorcyclists and motor vehicle drivers who were involved in accidents and required hospitalization. The study focused on patients who were recently involved in motorcycle collisions (MCCs) and motor vehicle collisions (MVCs). Methods: We identified 63 patients involved in MCCs and 39 patients involved in MVCs who were admitted to our level-1 trauma center from April 2014 to September 2015. These 102 patients completed a questionnaire designed to evaluate risky driving behaviors. Pearson’s chi-squared tests and unpaired two-tailed t-tests were used to evaluate categorical and normally distributed continuous variables, respectively. Multivariable linear regression was used to analyze predictors of risk behavior. Significance was set at p < 0.05. Results: When compared to patients involved in an MCC, patients involved in MVCs were more likely to be female (p = 0.007), drive more frequently (p < 0.001), and never perceive the risk of an accident (p = 0.036). MVC patients were more likely to have admitted to substance use on the day of the accident (p = 0.030), historically drive under the influence of drugs (p = 0.031), drive while tired (p < 0.001), drive while text messaging (p < 0.001), and speed while overtaking vehicles (p = 0.011). Overall, MVC patients engaged in more risk behaviors (3.3 ± 1.3 vs. 2.0 ± 1.5; p < 0.001) and were more likely to engage in multiple risk behaviors (p < 0.001). MVCs were associated with increased risk behavior, even after controlling for protective behaviors, driving history, and demographics (p = 0.045). Conclusions: Within our cohort of trauma patients at our institution, motor vehicle drivers were more likely than motorcyclists to engage in any one risk behavior and engage in a higher number of risk behaviors. In addition, motor vehicle drivers perceived their risk of a potential accident as lower than riding a motorcycle. Education initiatives should focus on motor vehicle driver safety interventions that reduce risk behaviors.

Family caregivers play an important role in the healthcare of older adults, but their circumstances, needs, and risks are often unknown to medical professionals. Standardizing how caregivers’ needs are assessed in healthcare delivery can help clinicians design care plans that take caregivers’ capabilities into account and provide targeted recommendations for caregiver support. Despite the potential of caregiver assessment, little is known about its use in primary care practice. The present study surveyed a national random sample of 1,000 U.S. primary care clinicians (physicians, nurses, social workers) to characterize current practices, barriers, and facilitators of caregiver assessment. A total of 231 completed responses were received. A minority of respondents (11%) reported that their practice or clinic had a standardized procedure for caregiver assessment; one in ten (10%) reported that they had personally conducted a caregiver assessment using a standardized instrument in the past year. The most common barriers to caregiver assessment were lack of time (65%), inability to have private discussions with caregivers (36%), lack of access to referral options (30%), inadequate reimbursement (30%), and reluctance of caregivers to discuss their needs (30%). The most frequently endorsed facilitators to aid future implementation included better availability of referral options (77%), easier referral mechanisms (67%), co-location of mental health specialists, care managers, or social workers (65%), and training in how to address caregiver issues (61%). Findings are discussed within the context of emerging healthcare policies and practice initiatives designed to promote caregiver assessment in health care settings.