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A Time-Motion Study of Primary Care Physicians' Work in the Electronic Health Record Era.

Richard Young, MD - Wed, 01/30/2019 - 08:32
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A Time-Motion Study of Primary Care Physicians' Work in the Electronic Health Record Era.

Fam Med. 2018 02;50(2):91-99

Authors: Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF

Abstract
BACKGROUND AND OBJECTIVES: Electronic health records (EHRs) have had mixed effects on the workflow of ambulatory primary care. In this study, we update previous research on the time required to care for patients in primary care clinics with EHRs.
METHODS: We directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time.
RESULTS: The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. Multivariable linear regression analysis revealed many factors associated with total visit time including patient, physician, and clinic infrastructure factors.
CONCLUSIONS: Primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.

PMID: 29432623 [PubMed - indexed for MEDLINE]

Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

Richard Robinson, MD - Wed, 01/30/2019 - 08:31
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Risks predicting prolonged hospital discharge boarding in a regional acute care hospital.

BMC Health Serv Res. 2018 01 30;18(1):59

Authors: Shaikh SA, Robinson RD, Cheeti R, Rath S, Cowden CD, Rosinia F, Zenarosa NR, Wang H

Abstract
BACKGROUND: Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow.
METHODS: Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed.
RESULTS: A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35-10.37), to court or law enforcement custody was 2.51 (95% CI 1.84-3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10-2.93). AOR was 0.57 (95% CI 0.47-0.71) if the disposition order was placed during normal office hours (0800-1700). AOR of early case management consultation was 1.52 (95% CI 1.37-1.68) versus 1.73 (95% CI 1.03-2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone.
CONCLUSION: Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.

PMID: 29378577 [PubMed - indexed for MEDLINE]

Isometric handgrip echocardiography: A noninvasive stress test to assess left ventricular diastolic function.

Paul Bhella - Wed, 01/30/2019 - 08:31
Related Articles

Isometric handgrip echocardiography: A noninvasive stress test to assess left ventricular diastolic function.

Clin Cardiol. 2017 Dec;40(12):1247-1255

Authors: Jake Samuel T, Beaudry R, Haykowsky MJ, Sarma S, Park S, Dombrowsky T, Bhella PS, Nelson MD

Abstract
BACKGROUND: Cycle exercise echocardiography is a useful tool to "unmask" diastolic dysfunction; however, this approach can be limited by respiratory and movement artifacts. Isometric handgrip avoids these issues while reproducibly increasing afterload and myocardial oxygen demand.
HYPOTHESIS: Isometric handgrip echocardiography (IHE) can differentiate normal from abnormal diastolic function.
METHODS: First recruited 19 young healthy individuals (mean age, 24 ± 4 years) to establish the "normal" response. To extend these observations to a more at-risk population, we performed IHE on 17 elderly individuals (mean age, 72 ± 6 years) with age-related diastolic dysfunction. The change in the ratio of mitral valve inflow velocity to lateral wall tissue velocity (E/e'), a surrogate for left ventricular filling pressure, was used to assess the diastolic stress response in each group.
RESULTS: In the young subjects, isometric handgrip increased heart rate and mean arterial pressure (25 ± 12 bpm and 26 ± 17 mmHg, respectively), whereas E/e' changed minimally (0.6 ± 0.9). In the elderly subjects, heart rate and mean arterial pressure were similarly increased with isometric handgrip (19 ± 16 bpm and 25 ± 11 mmHg, respectively), whereas E/e' increased more dramatically (2.3 ± 1.7). Remarkably, 11 of the 17 elderly subjects had an abnormal diastolic response (ΔE/e': 3.4 ± 1.1), whereas the remaining 6 elderly subjects showed very little change (ΔE/e': 0.3 ± 0.7), independent of age or the change in myocardial oxygen demand.
CONCLUSIONS: IHE is a simple, effective tool for evaluating diastolic function during simulated activities of daily living.

PMID: 29247511 [PubMed - indexed for MEDLINE]

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Neal Richmond, MD - Wed, 01/30/2019 - 08:30
Related Articles

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

JAMA. 2018 08 28;320(8):769-778

Authors: Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G

Abstract
Importance: Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown.
Objective: To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA.
Design, Setting, and Participants: Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017.
Interventions: Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals.
Main Outcomes and Measures: The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events.
Results: Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%).
Conclusions and Relevance: Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.
Trial Registration: ClinicalTrials.gov Identifier: NCT02419573.

PMID: 30167699 [PubMed - indexed for MEDLINE]

Role of ED crowding relative to trauma quality care in a Level 1 Trauma Center.

Natasha Singh, MD - Wed, 01/30/2019 - 08:30
Related Articles

Role of ED crowding relative to trauma quality care in a Level 1 Trauma Center.

Am J Emerg Med. 2018 Jun 18;:

Authors: Singh N, Robinson RD, Duane TM, Kirby JJ, Lyell C, Buca S, Gandhi R, Mann SM, Zenarosa NR, Wang H

Abstract
OBJECTIVE: Trauma Quality Improvement Program participation among all trauma centers has shown to improve patient outcomes. We aim to identify trauma quality events occurring during the Emergency Department (ED) phase of care.
METHODS: This is a single-center observational study using consecutively registered data in local trauma registry (Jan 1, 2016-Jun 30, 2017). Four ED crowding scores as determined by four different crowding estimation tools were assigned to each enrolled patient upon arrival to the ED. Patient related (age, gender, race, severity of illness, ED disposition), system related (crowding, night shift, ED LOS), and provider related risk factors were analyzed in a multivariate logistic regression model to determine associations relative to ED quality events.
RESULTS: Total 5160 cases were enrolled among which, 605 cases were deemed ED quality improvement (QI) cases and 457 cases were ED provider related. Similar percentages of ED QI cases (10-12%) occurred across the ED crowding status range. No significant difference was appreciated in terms of predictability of ED QI cases relative to different crowding status after adjustment for potential confounders. However, an adjusted odds ratio of 1.64 (95% CI, 1.17-2.30, p < 0.01) regarding ED LOS ≥2 h predictive of ED related quality issues was noted when analyzed using multivariate logistic regression.
CONCLUSION: Provider related issues are a common contributor to undesirable outcomes in trauma care. ED crowding lacks significant association with poor trauma quality care. Prolonged ED LOS (≥2 h) appears to be linked with unfavorable outcomes in ED trauma care.

PMID: 30139579 [PubMed - as supplied by publisher]

Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note.

Michael Warner, DDS - Wed, 01/30/2019 - 08:30
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Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note.

Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):889-93

Authors: Stella JP, Warner MR

Abstract
The zygomaticus dental implant, designed by Nobel Biocare for the Brånemark System, is indicated primarily for the severely resorbed maxilla. Though the zygomaticus implant has had a remarkable success rate in a very difficult patient population, there are some shortcomings to the protocol for placement. The sinus slot technique described herein provides a simplified approach to zygomaticus implant placement, as compared to the currently recommended protocol.

PMID: 11151591 [PubMed - indexed for MEDLINE]

The coming "sepsis boom..." and the available but underutilized diagnostic tools that could avert it.

Mark Oltermann, MD - Wed, 01/30/2019 - 08:29
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The coming "sepsis boom..." and the available but underutilized diagnostic tools that could avert it.

MLO Med Lab Obs. 2012 Feb;44(2):36-7

Authors: Oltermann MH

PMID: 22452167 [PubMed - indexed for MEDLINE]

Tracheal obstruction as a complication of tracheostomy tube malfunction: case report and review of the literature.

Mark Oltermann, MD - Wed, 01/30/2019 - 08:29
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Tracheal obstruction as a complication of tracheostomy tube malfunction: case report and review of the literature.

J Bronchology Interv Pulmonol. 2010 Jul;17(3):253-7

Authors: Lois M, Oltermann M

Abstract
Tracheostomy is a procedure frequently used in the intensive care unit for prolonged ventilatory support, long-term airway maintenance, and to prevent the complications of long-term translaryngeal intubation. It is believed that it eases patient care and improves the process of weaning from mechanical ventilation. The timing of tracheostomy is controversial and most physicians prefer translaryngeal intubation for needs of up to 10 days and a tracheostomy if an artificial airway for more than 21 days is anticipated. Tracheostomy can be associated with numerous acute (perioperative or postoperative) complications. Some of these complications continue to be a problem after the placement of the tracheostomy tube, and there are specific late complications that have clinical relevance. To our knowledge, there has been no description of a malfunctioning tracheostomy tube leading directly to complications and we are reporting the first case.

PMID: 23168895 [PubMed]

Nutrition support in the acutely ventilated patient.

Mark Oltermann, MD - Wed, 01/30/2019 - 08:29
Related Articles

Nutrition support in the acutely ventilated patient.

Respir Care Clin N Am. 2006 Dec;12(4):533-45

Authors: Oltermann MH

Abstract
Although the nutrition support literature is limited and therefore does not provide robust evidence to promote grade A or strong recommendations, there is a "signal" from all of these studies taken a a whole that critically ill patients may benefit from nutritional manipulation. The acutely ventilated patient that is likely to still be intubated by day three is a classic example of the critically ill patient who has the potential to achieve positive outcomes with nutritional support. Initiating nutrition support early improves the chances of benefit. However, nutrition cannot be provided in a vacuum. It is only one part of a multitude of treatments and therapies that must be optimally applied by a multidisciplinary team of professionals dedicated to the care of ICU patients. The exact makeup of the enteral (or parenteral) formula that is most likely to improve survival is unclear. More research is needed. Further study may demonstrate the possibility for nutritional manipulation to be one of the most important treatments physicians can offer to critically ill ventilated patients. Nutrition may have as much survival benefit as activated protein C, a drug costing over $7000 per course of therapy. No longer can it be said that nutrition makes no difference.

PMID: 17150430 [PubMed - indexed for MEDLINE]

Isometric handgrip echocardiography: A noninvasive stress test to assess left ventricular diastolic function.

Mark Nelson, MD - Wed, 01/30/2019 - 08:29
Related Articles

Isometric handgrip echocardiography: A noninvasive stress test to assess left ventricular diastolic function.

Clin Cardiol. 2017 Dec;40(12):1247-1255

Authors: Jake Samuel T, Beaudry R, Haykowsky MJ, Sarma S, Park S, Dombrowsky T, Bhella PS, Nelson MD

Abstract
BACKGROUND: Cycle exercise echocardiography is a useful tool to "unmask" diastolic dysfunction; however, this approach can be limited by respiratory and movement artifacts. Isometric handgrip avoids these issues while reproducibly increasing afterload and myocardial oxygen demand.
HYPOTHESIS: Isometric handgrip echocardiography (IHE) can differentiate normal from abnormal diastolic function.
METHODS: First recruited 19 young healthy individuals (mean age, 24 ± 4 years) to establish the "normal" response. To extend these observations to a more at-risk population, we performed IHE on 17 elderly individuals (mean age, 72 ± 6 years) with age-related diastolic dysfunction. The change in the ratio of mitral valve inflow velocity to lateral wall tissue velocity (E/e'), a surrogate for left ventricular filling pressure, was used to assess the diastolic stress response in each group.
RESULTS: In the young subjects, isometric handgrip increased heart rate and mean arterial pressure (25 ± 12 bpm and 26 ± 17 mmHg, respectively), whereas E/e' changed minimally (0.6 ± 0.9). In the elderly subjects, heart rate and mean arterial pressure were similarly increased with isometric handgrip (19 ± 16 bpm and 25 ± 11 mmHg, respectively), whereas E/e' increased more dramatically (2.3 ± 1.7). Remarkably, 11 of the 17 elderly subjects had an abnormal diastolic response (ΔE/e': 3.4 ± 1.1), whereas the remaining 6 elderly subjects showed very little change (ΔE/e': 0.3 ± 0.7), independent of age or the change in myocardial oxygen demand.
CONCLUSIONS: IHE is a simple, effective tool for evaluating diastolic function during simulated activities of daily living.

PMID: 29247511 [PubMed - indexed for MEDLINE]

Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

Mark Koch, MD - Wed, 01/30/2019 - 08:28
Related Articles

Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

Am J Gastroenterol. 2016 Nov;111(11):1630-1636

Authors: Gupta S, Miller S, Koch M, Berry E, Anderson P, Pruitt SL, Borton E, Hughes AE, Carter E, Hernandez S, Pozos H, Halm EA, Gneezy A, Lieberman AJ, Sugg Skinner C, Argenbright K, Balasubramanian B

Abstract
OBJECTIVES: Offering financial incentives to promote or "nudge" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population.
METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis.
RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups.
CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

PMID: 27481306 [PubMed - indexed for MEDLINE]

Iowa Gambling Task scores predict future drug use in bipolar disorder outpatients with stimulant dependence.

Marija Djokovic, MD - Wed, 01/30/2019 - 08:28
Related Articles

Iowa Gambling Task scores predict future drug use in bipolar disorder outpatients with stimulant dependence.

Psychiatry Res. 2013 Dec 30;210(3):871-9

Authors: Nejtek VA, Kaiser KA, Zhang B, Djokovic M

Abstract
Poor decision-making is associated with poor recovery in persons with bipolar disorder and drug relapse in persons with stimulant dependence. Cognitive predictors of stimulant use in those with comorbid bipolar and stimulant dependence are surprisingly absent. Our goal was to determine if a single baseline assessment of decision-making (Iowa Gambling Task, IGT) would predict future drug use in bipolar disorder outpatients with comorbid stimulant dependence. Ninety-four men and women of multiple race/ethnic origins consented to participate in a 20-week study. Data analyses were performed on 63 comorbid bipolar outpatients completing at least four study weeks and 28 cocaine dependent volunteers without a mood disorder who participated as cocaine controls. There were no significant differences in IGT scores between comorbid patients and cocaine controls. In the comorbid group, IGT scores significantly predicted future drug use during the study. Age, sex, race, years of mental illness, or mood state did not significantly influence IGT scores. This is the first longitudinal study to show that IGT scores obtained at a single baseline assessment predicts future objective drug use in comorbid bipolar disorder outpatients with cocaine or methamphetamine dependence. Evaluating decision-making with the IGT may provide clinicians with valuable insight about the trajectory of their patients' risk for future drug use. These data suggest a need to augment existing treatment with cognitive restructuring to prevent slips and relapses in comorbid bipolar patients. The lack of a bipolar control group and a modest sample size may limit data interpretations.

PMID: 24012163 [PubMed - indexed for MEDLINE]

Do atypical antipsychotics effectively treat co-occurring bipolar disorder and stimulant dependence? A randomized, double-blind trial.

Marija Djokovic, MD - Wed, 01/30/2019 - 08:28
Related Articles

Do atypical antipsychotics effectively treat co-occurring bipolar disorder and stimulant dependence? A randomized, double-blind trial.

J Clin Psychiatry. 2008 Aug;69(8):1257-66

Authors: Nejtek VA, Avila M, Chen LA, Zielinski T, Djokovic M, Podawiltz A, Kaiser K, Bae S, Rush AJ

Abstract
OBJECTIVES: The primary objective was to compare the efficacy and tolerability of quetiapine and risperidone in the treatment of mood symptoms, drug cravings, and drug use in outpatients with concurrent DSM-IV-defined bipolar I or II disorder and cocaine or methamphetamine dependence.
METHOD: Men and women of all ethnic origins, 20 to 50 years of age, were eligible to participate. Persons were excluded if they were inpatients, met DSM-IV criteria for substance-induced mood disorder, had any other substance dependence, were euthymic or suicidal, had any life-threatening illnesses, or were currently receiving antipsychotic medications. Duration of the trial was 20 weeks. Study participants attended weekly visits and were evaluated for mood symptoms, drug cravings, drug use, and medication side effects. Treatment outcomes were analyzed using linear mixed models. Fixed-effects terms for medication group, study week, and group-by-study-week were included in the models. The study was conducted between October 2002 and November 2006.
RESULTS: Of 124 consenting outpatients, an evaluable sample of 80 patients who attended baseline and at least 1 follow-up study visit was formed. The mean +/- SD exit dose for quetiapine was 303.6 +/- 151.9 mg/day and 3.1 +/- 1.2 mg/day for risperidone. Both quetiapine (N = 42) and risperidone (N = 38) significantly improved manic and depressive symptoms and reduced drug cravings (p < .0005) compared to baseline. Decreased drug cravings were related to less frequent drug use (p = .03). The 2 medications did not significantly differ in their effects on mood symptoms, drug craving, or drug use.
CONCLUSIONS: Relative to baseline mood and drug-craving status, both quetiapine and risperidone were associated with manic, mixed, and depressive symptom improvement and reduced drug cravings. Both medications were well tolerated. The interpretation of these results is limited by the absence of a placebo control.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00227123.

PMID: 18681757 [PubMed - indexed for MEDLINE]

Family Medicine and Obstetrics: Let's Stop Pretending.

Levi Sundermeyer, MD - Wed, 01/30/2019 - 08:27
Related Articles

Family Medicine and Obstetrics: Let's Stop Pretending.

J Am Board Fam Med. 2018 May-Jun;31(3):328-331

Authors: Young RA, Sundermeyer RL

PMID: 29743215 [PubMed - in process]

FPIN's clinical inquiries. Prostaglandins to induce labor in women with asthma.

Levi Sundermeyer, MD - Wed, 01/30/2019 - 08:27
Related Articles

FPIN's clinical inquiries. Prostaglandins to induce labor in women with asthma.

Am Fam Physician. 2014 Sep 15;90(6):415

Authors: Sundermeyer RL, Persons RK, Carrillo MJ

PMID: 25251237 [PubMed - indexed for MEDLINE]

Transitioning From a Level II to Level I Trauma Center Increases Resident Patient Exposure.

Lena Levine, DPM - Wed, 01/30/2019 - 08:27
Related Articles

Transitioning From a Level II to Level I Trauma Center Increases Resident Patient Exposure.

J Foot Ankle Surg. 2017 Nov - Dec;56(6):1170-1172

Authors: Carpenter B, Levine L, Niacaris T, Suzuki S

Abstract
Increased patient exposure has been shown to improve residency training as determined by better patient outcomes. The transition of John Peter Smith Hospital from a level II to a level I trauma center in 2009 provided a unique opportunity to investigate the direct effects of increased patient exposure on residency training in a relatively controlled setting. We evaluated the effect of the transition to a level I trauma center on residency training. In 2014, we examined the annual facility reports and separated the data into 2 groups: level II (2001 to 2008) and level I (2010 to 2013). The primary outcome measures were patient volume, surgical volume, patient acuity, and scholarly activity by the residents. The patient volume in all units increased significantly (p < .05 for all) after the transition to a level I center. The surgical volume increased significantly for the general surgery, orthopedics, and podiatry departments (p < .05 for all) but remained unchanged in the gynecology and oral maxillofacial surgery departments. The volume measures were performed on all 98 residents (100%). Patient acuity and scholarly activity increased by 17% and 52%, respectively; however, the differences in these data were not statistically significant. The scholarly activity per resident was measured for the orthopedic and podiatry departments. For those departments, the total number of residents was 30, and scholarly activity was measured for 100% of them. Overall, resident education improved when the hospital transitioned to a level I trauma center, although certain subspecialties benefited more than did others from this transition.

PMID: 28888403 [PubMed - indexed for MEDLINE]

Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit.

Kristina Domanski, MD - Wed, 01/30/2019 - 08:27
Related Articles

Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit.

Crit Pathw Cardiol. 2016 12;15(4):145-151

Authors: Wang H, Watson K, Robinson RD, Domanski KH, Umejiego J, Hamblin L, Overstreet SE, Akin AM, Hoang S, Shrivastav M, Collyer M, Krech RN, Schrader CD, Zenarosa NR

Abstract
OBJECTIVE: To compare and evaluate the performance of the HEART, Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI) scores to predict major adverse cardiac event (MACE) rates after index placement in an emergency department observation unit (EDOU) and to determine the need for observation unit initiation of emergent cardiac imaging tests, that is, noninvasive cardiac stress tests and invasive coronary angiography.
METHODS: A prospective observational single center study was conducted from January 2014 through June 2015. EDOU chest pain patients were included. HEART, GRACE, and TIMI scores were categorized as low (HEART ≤ 3, GRACE ≤ 108, and TIMI ≤1) versus elevated based on thresholds suggested in prior studies. Patients were followed for 6 months postdischarge. The results of emergent cardiac imaging tests, EDOU length of stay (LOS), and MACE occurrences were compared. Student t test was used to compare groups with continuous data, and χ testing was used for categorical data analysis.
RESULTS: Of 986 patients, emergent cardiac imaging tests were performed on 62%. A majority of patients were scored as low risk by all tools (85% by HEART, 81% by GRACE, and 80% by TIMI, P < 0.05). The low-risk patients had few abnormal cardiac imaging test results as compared with patients scored as intermediate to high risk (1% vs. 11% in HEART, 1% vs. 9% in TIMI, and 2% vs. 4% in GRACE, P < 0.05). The average LOS was 33 hours for patients with emergent cardiac imaging tests performed and 25 hours for patients without (P < 0.05). MACE occurrence rate demonstrated no significant difference regardless of whether tests were performed emergently (0.31% vs. 0.97% in HEART, 0.27% vs. 0.95% in TIMI, and 0% vs. 0.81% in GRACE, P > 0.05).
CONCLUSIONS: Chest pain risk stratification via clinical decision tool scores can minimize the need for emergent cardiac imaging tests with less than 1% MACE occurrence, especially when the HEART score is used.

PMID: 27846006 [PubMed - indexed for MEDLINE]

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions.

Kathleen Delaney, MD - Wed, 01/30/2019 - 08:26
Related Articles

Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions.

BMC Health Serv Res. 2016 10 10;16(1):564

Authors: Wang H, Johnson C, Robinson RD, Nejtek VA, Schrader CD, Leuck J, Umejiego J, Trop A, Delaney KA, Zenarosa NR

Abstract
BACKGROUND: Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission.
METHODS: Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated.
RESULTS: A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25-1.38) and 1.09 (ROM: 95 % CI 1.05-1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed.
CONCLUSIONS: SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.

PMID: 27724889 [PubMed - indexed for MEDLINE]

Predictors of mortality among initially stable adult pelvic trauma patients in the US: Data analysis from the National Trauma Data Bank.

Kathleen Delaney, MD - Wed, 01/30/2019 - 08:26
Related Articles

Predictors of mortality among initially stable adult pelvic trauma patients in the US: Data analysis from the National Trauma Data Bank.

Injury. 2015 Nov;46(11):2113-7

Authors: Wang H, Phillips JL, Robinson RD, Duane TM, Buca S, Campbell-Furtick MB, Jennings A, Miller T, Zenarosa NR, Delaney KA

Abstract
OBJECTIVES: Pelvic fractures are associated with increased risk of death among trauma patients. Studies show independent risks predicting mortality among patients with pelvic fractures vary across different geographic regions. This study analyses national data to determine predictors of mortality in initially stable adult pelvic trauma patients in the US.
METHODS: This study is a retrospective analysis of the US National Trauma Data Bank from January 2003 to December 2010 among trauma patients ≥18 years of age with pelvic fractures (including acetabulum). Over 150 variables were reviewed and analysed. The primary outcome was all-cause in-hospital mortality. Logistic regression analysis was used to determine independent risk factors predictive of in-hospital mortality in stable pelvic fracture patients.
RESULTS: 30,800 patients were included in the final analysis. Overall in-hospital mortality rate was 2.7%. Mortality increased twofold in middle aged patients (age 55-70), and increased nearly fourfold in patients with advanced age ≥70. We found patients with advanced age, higher severity of injury, Glasgow Coma Scale (GCS) <8, GCS between 9 and 12, prolonged mechanical ventilation, and/or in-hospital blood product administration experienced higher mortality. Patients transported to level 1 or level 2 trauma centres experienced lower mortality while concomitantly experiencing higher associated internal injuries.
CONCLUSIONS: Geriatric and middle aged pelvic fracture patients experience higher mortality. Predictors of mortality in initially stable pelvic fracture patients are advanced age, injury severity, mental status, prolonged mechanical ventilation, and/or in-hospital blood product administration. These patients might benefit from transport to local level 1 or level 2 trauma centres.

PMID: 26377773 [PubMed - indexed for MEDLINE]

Using the LACE index to predict hospital readmissions in congestive heart failure patients.

Kathleen Delaney, MD - Wed, 01/30/2019 - 08:26
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Using the LACE index to predict hospital readmissions in congestive heart failure patients.

BMC Cardiovasc Disord. 2014 Aug 07;14:97

Authors: Wang H, Robinson RD, Johnson C, Zenarosa NR, Jayswal RD, Keithley J, Delaney KA

Abstract
BACKGROUND: The LACE index has been used to predict the risk of unplanned readmission within 30 days after hospital discharge in both medical and surgical patients. The aim of this study is to validate the accuracy of using the LACE index in CHF patients.
METHODS: This was a retrospective study. The LACE index score was calculated on each patient who was admitted to hospital due to an acute CHF exacerbation. Operational and clinical variables were collected from patients including basic clinical characteristics, length of hospitalization, comorbidities, number of previous ED visits in the past 6 months before the index admission, and the number of post discharge ED revisits at 30, 60, and 90 days. All variables were analyzed by multivariate logistic regression to determine the association between clinical variables and the hospital unplanned readmissions. C-statistic was used to discriminate those patients with high risk of readmissions.
RESULTS: Of the 253 patients included in the study, 24.50% (62/253) experienced unplanned readmission to hospital within 30 days after discharge. The LACE index was slightly higher in patients readmitted versus patients not readmitted (12.17 ± 2.22 versus 11.80 ± 1.92, p = 0.199). Adjusted odds ratios based on logistic regression of all clinical variables showed only the number of previous ED visits (OR 1.79, 95% CI 1.30-2.47, p < 0.001), history of myocardial infarction (OR 2.51, 95% CI 1.02-6.21, p = 0.045), and history of peripheral vascular disease (OR 10.75, 95% CI 1.52-75.73, p = 0.017) increased the risk of unplanned readmission within 30 days of hospital discharge. However, patients with high LACE scores (≥10) had a significantly higher rate of ED revisits (15.04% vs 0%) within 30 days from the index discharge than those with low LACE scores (p = 0.030).
CONCLUSION: The LACE index may not accurately predict unplanned readmissions within 30 days from hospital discharge in CHF patients. The LACE high risk index may have utility as a screening tool to predict high risk ED revisits after hospital discharge.

PMID: 25099997 [PubMed - indexed for MEDLINE]

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