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Nardin, Rachel

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Nardin

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Nardin, Rachel
Author's Publications: search.filters.isAuthorOfPublication.3f08d8c5-ef05-4462-ae55-edde8266364c

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Now showing 1 - 6 of 6
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    Clinical utility of electrodiagnostic studies in the inpatient setting
    (Wiley, 2009) Perry, Daryl I.; Tarulli, Andrew W.; Nardin, Rachel; Rutkove, Seward; Gautam, Shiva; Narayanaswami, Pushpa
    Nerve conduction studies and electromyograms (EMGs) are most often performed in the outpatient setting in patients with suspected neuromuscular diseases, where they help the physician confirm the clinical diagnosis, assess the localization and severity of the disease, and plan further evaluation and treat- ment. Not infrequently, EMGs are requested on a relatively urgent basis for patients who are admitted to the hospital. Inpatient electrodiagnostic studies are usually requested in two situations: (1) as part of the diagnostic evaluation of patients who present with symptoms of a neuromuscular disorder; or (2) in patients who are admitted to the hospital with non-neuromuscular illnesses but develop symptoms suggestive of a neuromuscular disorder during the course of their illness. The second scenario com- monly occurs in patients who are in the intensive care unit and are unable to be weaned from the ven- tilator. This raises the possibility of a neuromuscular disorder as a cause of respiratory muscle weakness and ventilator dependence. The role of EMG in the evaluation of neuro- muscular disorders in the inpatient setting has not been studied previously. In this study, we evaluated the contribution of EMG to the diagnosis and man- agement of hospital inpatients. We hypothesized that inpatient EMGs (IP-EMGs) would frequently find clinically meaningful diagnoses that would affect the subsequent management of patients. The aims of this study were to compare the results of IP-EMGs with the referring physicians’ clinical diag- noses and to assess how often results of IP-EMGs changed the clinical diagnosis and altered further diagnostic evaluation and treatment.
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    Experiences applying for and understanding health insurance under Massachusetts health care reform
    (BioMed Central, 2016) Nardin, Rachel; Zallman, Leah; Sayah, Assaad; McCormick, Danny
    Background: The Affordable Care Act was modeled on the Massachusetts Health Reform of 2006, which reduced the number of uninsured largely through a Medicaid expansion and the provision of publicly subsidized insurance obtained through a Health Benefits Exchange. Methods: We surveyed a convenience sample of 780 patients seeking care in a safety-net system who obtained Medicaid or publicly subsidized insurance after the Massachusetts reform, as well as a group of employed patients with private insurance. Results: We found that although most patients with Medicaid or publicly subsidized exchange-based plans were able to obtain assistance with applying for and choosing an insurance plan, substantial proportions of respondents experienced difficulties with the application process and with understanding coverage and cost features of plans. Conclusions: Under the Affordable Care Act, efforts to simplify the application process and reduce the complexity of plans may be warranted, particularly for vulnerable patient populations cared for by the medical safety net.
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    Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients
    (BioMed Central, 2015) Zallman, Leah; Nardin, Rachel; Malowney, Monica; Sayah, Assaad; McCormick, Danny
    Introduction: The Affordable Care Act (ACA) and the 2006 Massachusetts (MA) health reform law, on which the ACA was based, aimed to improve the affordability of care largely by expanding publicly sponsored insurances. Both laws also aimed to promote consumer understanding of how to acquire, maintain and use these public plans. A prior study found an association between the level of cost-sharing required in these plans and the affordability of care. Preparatory to a quantitative study we conducted this qualitative study that aimed to examine (1) whether cost sharing levels built into the public insurance types that formed the backbone of the MA health reform led to unaffordability of care and if so, (2) how insurances with higher cost sharing levels led to unaffordability of care in this context. Methods: We interviewed 12 consumers obtaining the most commonly obtained insurances under MA health reform (Medicaid and Commonwealth Care) at a safety net hospital emergency department. We purposefully interviewed a stratified sample of higher and low cost sharing recipients. We used a combination of inductive and deductive codes to analyze the data according to degree of cost-sharing required by different insurance types. Results: We found that higher cost sharing plans led to unaffordability of care, as evidenced by unmet medical needs, difficulty affording basic non-medical needs due to expenditures on medical care, and reliance on non-insurance resources to pay for care. Participants described two principal mechanisms by which higher cost sharing led to unaffordability of care: (1) cost sharing above what their incomes allowed and (2) poor understanding of how to effectively acquire, maintain and utilize insurance new public plans. Conclusions: Further efforts to investigate the relationship between perceived affordability of care and understanding of insurance for the insurance types obtained under MA health reform may be warranted. A potential focus for further work may be quantitative investigation of how the level of calibration of cost-sharing to income and understanding of insurances under the MA reform was associated with perceived affordability of care. Electronic supplementary material The online version of this article (doi:10.1186/s12939-015-0240-5) contains supplementary material, which is available to authorized users.
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    Perceived affordability of health insurance and medical financial burdens five years in to Massachusetts health reform
    (BioMed Central, 2015) Zallman, Leah; Nardin, Rachel; Sayah, Assaad; McCormick, Danny
    Introduction: Under the Massachusetts health reform, low income residents (those with incomes below 150 % of the Federal Poverty Level [FPL]) were eligible for Medicaid and health insurance exchange-based plans with minimal cost-sharing and no premiums. Those with slightly higher incomes (150 %-300 % FPL) were eligible for exchange-based plans that required cost-sharing and premium payments. Methods: We conducted face to face surveys in four languages with a convenience sample of 976 patients seeking care at three hospital emergency departments five years after Massachusetts reform. We compared perceived affordability of insurance, financial burden, and satisfaction among low cost sharing plan recipients (recipients of Medicaid and insurance exchange-based plans with minimal cost-sharing and no premiums), high cost sharing plan recipients (recipients of exchange-based plans that required cost-sharing and premium payments) and the commercially insured. Results: We found that despite having higher incomes, higher cost-sharing plan recipients were less satisfied with their insurance plans and perceived more difficulty affording their insurance than those with low cost-sharing plans. Higher cost-sharing plan recipients also reported more difficulty affording medical and non-medical health care as well as insurance premiums than those with commercial insurance. In contrast, patients with low cost-sharing public plans reported higher plan satisfaction and less financial concern than the commercially insured. Conclusions: Policy makers with responsibility for the benefit design of public insurance available under health care reforms in the U.S. should calibrate cost-sharing to income level so as to minimize difficulty affording care and financial burdens. Electronic supplementary material The online version of this article (doi:10.1186/s12939-015-0235-2) contains supplementary material, which is available to authorized users.
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    Infective Endocarditis in the U.S., 1998–2009: A Nationwide Study
    (Public Library of Science, 2013) Bor, David; Woolhandler, Steffie; Nardin, Rachel; Brusch, John; Himmelstein, David
    Background: Previous studies based on local case series estimated the annual incidence of endocarditis in the U.S. at about 4 per 100,000 population. Small-scale studies elsewhere have reported similar incidence rates. However, no nationally-representative population-based studies have verified these estimates. Methods and findings: Using the 1998–2009 Nationwide Inpatient Sample, which provides diagnoses from about 8 million U.S. hospitalizations annually, we examined endocarditis hospitalizations, bacteriology, co-morbidities, outcomes and costs. Hospital admissions for endocarditis rose from 25,511 in 1998 to 38, 976 in 2009 (12.7 per 100,000 population in 2009). The age-adjusted endocarditis admission rate increased 2.4% annually. The proportion of patients with intra-cardiac devices rose from 13.3% to 18.9%, while the share with drug use and/or HIV fell. Mortality remained stable at about 14.5%, as did cardiac valve replacement (9.6%). Other serious complications increased; 13.3% of patients in 2009 suffered a stroke or CNS infection, and 5.5% suffered myocardial infarction. Amongst cases with identified pathogens, Staphylococcus aureus was the most common, increasing from 37.6% in 1998 to 49.3% in 2009, 53.3% of which were MRSA. Streptococci were mentioned in 24.7% of cases, gram-negatives in 5.6% and Candida species in 1.0%. We detected no inflection in hospitalization rates after changes in prophylaxis recommendations in 2007. Mean age rose from 58.6 to 60.8 years; elderly patients suffered higher rates of myocardial infarction and death, but slightly lower rates of Staphylococcus aureus infections and neurologic complications. Our study relied on clinically diagnosed cases of endocarditis that may not meet strict criteria. Moreover, since some patients are discharged and readmitted during a single episode of endocarditis, our hospitalization figures probably slightly overstate the true incidence of this illness. Conclusions: Endocarditis is more common in the U.S. than previously believed, and is steadily increasing. Preventive efforts should focus on device-associated and health-care-associated infections.
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    Impaired Distal Thermoregulation in Diabetes and Diabetic Polyneuropathy
    (American Diabetes Association, 2009) Rutkove, Seward; Veves, Aristidis; Mitsa, Theophano; Nie, Rui; Fogerson, Patricia M.; Garmirian, Lindsay P.; Nardin, Rachel
    Objective: To determine how thermoregulation of the feet is affected by diabetes and diabetic polyneuropathy in both wakefulness and sleep. Research Design and Methods: Normal subjects, diabetic subjects without neuropathy, diabetic subjects with small-fiber diabetic polyneuropathy, and those with advanced diabetic polyneuropathy were categorized based on neurological examination, nerve conduction studies, and quantitative sensory testing. Subjects underwent foot temperature monitoring using an iButton device attached to the foot and a second iButton for recording of ambient temperature. Socks and footwear were standardized, and subjects maintained an activity diary. Data were collected over a 32-h period and analyzed. Results: A total of 39 normal subjects, 28 patients with diabetes but without diabetic polyneuropathy, 14 patients with isolated small-fiber diabetic polyneuropathy, and 27 patients with more advanced diabetic polyneuropathy participated. No consistent differences in foot temperature regulation between the four groups were identified during wakefulness. During sleep, however, multiple metrics revealed significant abnormalities in the diabetic patients. These included reduced mean foot temperature (P < 0.001), reduced maximal temperature (P < 0.001), increased rate of cooling (P < 0.001), as well as increased frequency of variation (P = 0.005), supporting that patients with diabetic polyneuropathy and even those with only diabetes but no diabetic polyneuropathy have impaired nocturnal thermoregulation. Conclusions: Nocturnal foot thermoregulation is impaired in patients with diabetes and diabetic polyneuropathy. Because neurons are highly temperature sensitive and because foot warming is part of the normal biology of sleep onset and maintenance, these findings suggest new potentially treatable mechanisms of diabetes-associated nocturnal pain and sleep disturbance.