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Thrombocytopenia Associated with Linezolid Therapy in Solid Organ Transplant Recipients: A Retrospective Cohort Study

Jeffrey Tessier, MD - Sat, 07/25/2015 - 05:00

Surg Infect (Larchmt). 2015 Aug;16(4):361-7. doi: 10.1089/sur.2013.190. Epub 2015 May 28.

ABSTRACT

BACKGROUND: Linezolid is associated infrequently with bone marrow suppression in immunocompetent patients, but hematologic complications from linezolid in transplant recipients are understudied. This study evaluated the hematologic safety of linezolid in solid organ transplant recipients.

METHODS: We performed a retrospective study of inpatients at our institution treated with linezolid from June 1, 2009 until June 6, 2012. The solid organ transplant cohort (TP) was compared with the non-transplant cohort (NTP) using parameters related to linezolid safety. Outcomes included incidences of leukopenia or thrombocytopenia at the end of linezolid treatment (EOT), lengths of stay, and blood product requirements.

RESULTS: The TP cohort included 110 patients; the NTP cohort included 583 patients. Baseline parameters were similar between the TP and NTP cohorts. Non-transplant patients were more likely to have methicillin-resistant Staphylococcus aureus (MRSA), whereas TP patients received more doses of linezolid (17.0 vs. 11.3, p<0.001) and were more likely to receive other drugs associated with thrombocytopenia (91.7% vs. 11.3%, p<0.0001). Transplant patients with normal platelet counts at baseline were more likely to have EOT thrombocytopenia (29.3% vs. 10.7%, p=0.005), and multivariable regression analysis confirmed only a beginning platelet count less than 150,000 platelets per micoliter to be significantly different between groups: 43% TP versus 26.9% NTP (p=0.0009) making it the only independent predictor of EOT thrombocytopenia. Finally, TP patients were more likely to require platelet transfusions compared with the NTP cohort.

CONCLUSIONS: Transplant patients who received linezolid had a higher incidence of EOT thrombocytopenia and platelet transfusions, compared with NTP. Transplant patients who are thrombocytopenic at baseline are at the greatest risk. These findings may relate to more frequent use of drugs associated with marrow suppression or greater linezolid exposure in the TP cohort. Clinicians caring for transplant patients should take into account this higher risk of thrombocytopenia and need for platelets when considering use of linezolid in this population.

PMID:26207396 | DOI:10.1089/sur.2013.190

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study

Richard Robinson, MD - Tue, 07/14/2015 - 05:00

Emerg Med Int. 2015;2015:401757. doi: 10.1155/2015/401757. Epub 2015 Jun 8.

ABSTRACT

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

PMID:26167302 | PMC:PMC4475699 | DOI:10.1155/2015/401757

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study

James d'Etienne, MD - Tue, 07/14/2015 - 05:00

Emerg Med Int. 2015;2015:401757. doi: 10.1155/2015/401757. Epub 2015 Jun 8.

ABSTRACT

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

PMID:26167302 | PMC:PMC4475699 | DOI:10.1155/2015/401757

Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study

Hao Wang, MD - Tue, 07/14/2015 - 05:00

Emerg Med Int. 2015;2015:401757. doi: 10.1155/2015/401757. Epub 2015 Jun 8.

ABSTRACT

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

PMID:26167302 | PMC:PMC4475699 | DOI:10.1155/2015/401757

Innervation of the Anterior Capsule of the Human Knee: Implications for Radiofrequency Ablation

Robert Menzies, MD - Sat, 06/13/2015 - 05:00

Reg Anesth Pain Med. 2015 Jul-Aug;40(4):363-8. doi: 10.1097/AAP.0000000000000269.

ABSTRACT

BACKGROUND AND OBJECTIVES: Chronic knee pain is common in all age groups. Some patients who fail conservative therapy benefit from radiofrequency neurotomy. Knowledge of the anatomy is critical to ensure a successful outcome. The purpose of this study was to reanalyze the innervation to the anterior knee capsule from the perspective of the interventional pain practitioner.

METHODS: The study included a comprehensive literature review followed by dissection of 8 human knees to identify the primary capsular innervation of the anterior knee joint. Photographs and measurements were obtained for each relevant nerve branch. Stainless-steel wires were placed along the course of each primary innervation, and radiographs were obtained.

RESULTS: Literature review revealed a lack of consensus on the number and origin of nerve branches innervating the anterior knee capsule. All dissections revealed the following 6 nerves: superolateral branch from the vastus lateralis, superomedial branch from the vastus medialis, middle branch from the vastus intermedius, inferolateral (recurrent) branch from the common peroneal nerve, inferomedial branch from the saphenous nerve, and a lateral articular nerve branch from the common peroneal nerve. Nerve branches showed variable proximal trajectories but constant distal points of contact with femur and tibia. The inferolateral peroneal nerve branch was found to be too close to the common peroneal nerve, making it inappropriate for radiofrequency neurotomy.

CONCLUSIONS: The innervation of the anterior capsule of the knee joint seems to follow a constant pattern making at least 3 of these nerves accessible to percutaneous ablation. To optimize clinical outcome, well-aligned radiographs are critical to guide lesion placement.

PMID:26066383 | DOI:10.1097/AAP.0000000000000269

The role of charity care and primary care physician assignment on ED use in homeless patients

Richard Robinson, MD - Sun, 05/24/2015 - 05:00

Am J Emerg Med. 2015 Aug;33(8):1006-11. doi: 10.1016/j.ajem.2015.04.026. Epub 2015 Apr 20.

ABSTRACT

OBJECTIVE: Homeless patients are a vulnerable population with a higher incidence of using the emergency department (ED) for noncrisis care. Multiple charity programs target their outreach toward improving the health of homeless patients, but few data are available on the effectiveness of reducing ED recidivism. The aim of this study is to determine whether inappropriate ED use for nonemergency care may be reduced by providing charity insurance and assigning homeless patients to a primary care physician (PCP) in an outpatient clinic setting.

METHODS: A retrospective medical records review of homeless patients presenting to the ED and receiving treatment between July 2013 and June 2014 was completed. Appropriate vs inappropriate use of the ED was determined using the New York University ED Algorithm. The association between patients with charity care coverage, PCP assignment status, and appropriate vs inappropriate ED use was analyzed and compared.

RESULTS: Following New York University ED Algorithm standards, 76% of all ED visits were deemed inappropriate with approximately 77% of homeless patients receiving charity care and 74% of patients with no insurance seeking noncrisis health care in the ED (P=.112). About 50% of inappropriate ED visits and 43.84% of appropriate ED visits occurred in patients with a PCP assignment (P=.019).

CONCLUSIONS: Both charity care homeless patients and those without insurance coverage tend to use the ED for noncrisis care resulting in high rates of inappropriate ED use. Simply providing charity care and/or PCP assignment does not seem to sufficiently reduce inappropriate ED use in homeless patients.

PMID:26001738 | DOI:10.1016/j.ajem.2015.04.026

The role of charity care and primary care physician assignment on ED use in homeless patients

Hao Wang, MD - Sun, 05/24/2015 - 05:00

Am J Emerg Med. 2015 Aug;33(8):1006-11. doi: 10.1016/j.ajem.2015.04.026. Epub 2015 Apr 20.

ABSTRACT

OBJECTIVE: Homeless patients are a vulnerable population with a higher incidence of using the emergency department (ED) for noncrisis care. Multiple charity programs target their outreach toward improving the health of homeless patients, but few data are available on the effectiveness of reducing ED recidivism. The aim of this study is to determine whether inappropriate ED use for nonemergency care may be reduced by providing charity insurance and assigning homeless patients to a primary care physician (PCP) in an outpatient clinic setting.

METHODS: A retrospective medical records review of homeless patients presenting to the ED and receiving treatment between July 2013 and June 2014 was completed. Appropriate vs inappropriate use of the ED was determined using the New York University ED Algorithm. The association between patients with charity care coverage, PCP assignment status, and appropriate vs inappropriate ED use was analyzed and compared.

RESULTS: Following New York University ED Algorithm standards, 76% of all ED visits were deemed inappropriate with approximately 77% of homeless patients receiving charity care and 74% of patients with no insurance seeking noncrisis health care in the ED (P=.112). About 50% of inappropriate ED visits and 43.84% of appropriate ED visits occurred in patients with a PCP assignment (P=.019).

CONCLUSIONS: Both charity care homeless patients and those without insurance coverage tend to use the ED for noncrisis care resulting in high rates of inappropriate ED use. Simply providing charity care and/or PCP assignment does not seem to sufficiently reduce inappropriate ED use in homeless patients.

PMID:26001738 | DOI:10.1016/j.ajem.2015.04.026

Shortening femoral osteotomy with stemmed resurfacing total knee arthroplasty for severe flexion contracture in Juvenile Rheumatoid Arthritis

Hugo Sanchez, MD - Fri, 05/15/2015 - 05:00

J Orthop. 2014 Jul 14;12(2):118-21. doi: 10.1016/j.jor.2014.05.002. eCollection 2015 Jun.

ABSTRACT

Juvenile Rheumatoid Arthritis (JRA) is a progressive disease characterized by pain, swelling, and loss of motion in the joints of adolescents. Total knee arthroplasty (TKA) can be indicated, during the adolescent years, in patients with advanced JRA to alleviate pain and improve function. Because of the relative infrequency of TKA in patients with JRA, evaluation of the type of TKA performed and the results merit review. This case report present two distinct operations performed to obtain full extension. 1. Distal femoral resection with conversion to hinged arthroplasty. 2. Femoral shortening osteotomy with resurfacing TKA.

PMID:25972704 | PMC:PMC4421091 | DOI:10.1016/j.jor.2014.05.002

Comparison of Hallux Interphalangeal Joint Arthrodesis Fixation Techniques: A Retrospective Multicenter Study

Travis Motley, DPM - Tue, 05/12/2015 - 05:00

J Foot Ankle Surg. 2016 Jan-Feb;55(1):22-7. doi: 10.1053/j.jfas.2015.04.007. Epub 2015 May 8.

ABSTRACT

Few studies have investigated the complications that occur after hallux interphalangeal joint arthrodesis. The present study evaluated complications in 152 patients aged 18 to 80 years from 2005 to 2012 from 4 different academic institutions after hallux interphalangeal joint arthrodesis. Overall, 65.8% of the patients had ≥1 complication. Infections occurred in 16.5%, dehiscence in 12.5%, and reoperations in 27.0%. The clinical nonunion rate was ≥17.8%, and the radiographic nonunion rate was ≥13.8%. After logistic regression analysis, only the study site and peripheral neuropathy were associated with having ≥1 complication (p < .01 and p < .05, respectively). Single screw fixation compared with other fixation did not have a statistically significant influence on the postoperative complications. However, when fixation was expanded to 4 categories, single screw fixation had lower infection and reoperation rates than either crossed Kirschner wires or other fixation category but not compared with crossed screws on multivariate logistic regression analysis. Although additional studies are warranted, the findings from the present study might aid in both the prognosis of complications and the support of the use of a single screw over crossed Kirchner wire fixation in hallux interphalangeal joint arthrodesis.

PMID:25960055 | DOI:10.1053/j.jfas.2015.04.007

Orthopedic emergencies: a practical emergency department classification (US-VAGON) in pelvic fractures

Hao Wang, MD - Tue, 04/21/2015 - 05:00

Emerg Med Clin North Am. 2015 May;33(2):451-73. doi: 10.1016/j.emc.2015.01.001.

ABSTRACT

Trauma is one of the leading causes of death before the age of 40 years and approximately 5% of patients with trauma who require hospital admission have pelvic fractures. This article updates the emergency department classification of pelvic fractures first described in 2000. This information is of practical value to emergency physicians in identifying the potential vascular, genitourinary, gastrointestinal, orthopedic, and neurologic complications and further assists them in the initial evaluation and treatment of patients with pelvic fractures.

PMID:25892731 | DOI:10.1016/j.emc.2015.01.001

Use of the SONET score to evaluate Urgent Care Center overcrowding: a prospective pilot study

Richard Robinson, MD - Thu, 04/16/2015 - 05:00

BMJ Open. 2015 Apr 14;5(4):e006860. doi: 10.1136/bmjopen-2014-006860.

ABSTRACT

OBJECTIVES: To derive a tool to determine Urgent Care Center (UCC) crowding and investigate the association between different levels of UCC overcrowding and negative patient care outcomes.

DESIGN: Prospective pilot study.

SETTING: Single centre study in the USA.

PARTICIPANTS: 3565 patients who registered at UCC during the 21-day study period were included. Patients who had no overcrowding statuses estimated due to incomplete collection of operational variables at the time of registration were excluded in this study. 3139 patients were enrolled in the final data analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES: A crowding estimation tool (SONET: Severely overcrowded, Overcrowded and Not overcrowded Estimation Tool) was derived using the linear regression analysis. The average length of stay (LOS) in UCC patients and the number of left without being seen (LWBS) patients were calculated and compared under the three different levels of UCC crowding.

RESULTS: Four independent operational variables could affect the UCC overcrowding score including the total number of patients, the number of results pending for patients, the number of patients in the waiting room and the longest time a patient was stationed in the waiting room. In addition, UCC overcrowding was associated with longer average LOS (not overcrowded: 133±76 min, overcrowded: 169±79 min, and severely overcrowded: 196±87 min, p<0.001) and an increased number of LWBS patients (not overcrowded: 0.28±0.69 patients, overcrowded: 0.64±0.98, and severely overcrowded: 1.00±0.97).

CONCLUSIONS: The overcrowding estimation tool (SONET) derived in this study might be used to determine different levels of crowding in a high volume UCC setting. It also showed that UCC overcrowding might be associated with negative patient care outcomes.

PMID:25872940 | PMC:PMC4401867 | DOI:10.1136/bmjopen-2014-006860

Use of the SONET score to evaluate Urgent Care Center overcrowding: a prospective pilot study

Hao Wang, MD - Thu, 04/16/2015 - 05:00

BMJ Open. 2015 Apr 14;5(4):e006860. doi: 10.1136/bmjopen-2014-006860.

ABSTRACT

OBJECTIVES: To derive a tool to determine Urgent Care Center (UCC) crowding and investigate the association between different levels of UCC overcrowding and negative patient care outcomes.

DESIGN: Prospective pilot study.

SETTING: Single centre study in the USA.

PARTICIPANTS: 3565 patients who registered at UCC during the 21-day study period were included. Patients who had no overcrowding statuses estimated due to incomplete collection of operational variables at the time of registration were excluded in this study. 3139 patients were enrolled in the final data analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES: A crowding estimation tool (SONET: Severely overcrowded, Overcrowded and Not overcrowded Estimation Tool) was derived using the linear regression analysis. The average length of stay (LOS) in UCC patients and the number of left without being seen (LWBS) patients were calculated and compared under the three different levels of UCC crowding.

RESULTS: Four independent operational variables could affect the UCC overcrowding score including the total number of patients, the number of results pending for patients, the number of patients in the waiting room and the longest time a patient was stationed in the waiting room. In addition, UCC overcrowding was associated with longer average LOS (not overcrowded: 133±76 min, overcrowded: 169±79 min, and severely overcrowded: 196±87 min, p<0.001) and an increased number of LWBS patients (not overcrowded: 0.28±0.69 patients, overcrowded: 0.64±0.98, and severely overcrowded: 1.00±0.97).

CONCLUSIONS: The overcrowding estimation tool (SONET) derived in this study might be used to determine different levels of crowding in a high volume UCC setting. It also showed that UCC overcrowding might be associated with negative patient care outcomes.

PMID:25872940 | PMC:PMC4401867 | DOI:10.1136/bmjopen-2014-006860

The correlation of family physician work with submitted codes and fees

Richard Young, MD - Tue, 12/16/2014 - 05:00

Am J Manag Care. 2014;20(11):876-82.

ABSTRACT

OBJECTIVES: The income disparity between primary care and other physicians has been attributed in part to the evaluation and management (E/M) rules written by CMS. The purpose of this study was to examine the relationship between family physicians' work and their actual coding practices and fees collected under these widely used rules.

STUDY DESIGN: This was a direct observational time-motion study.

METHODS: A diverse group of 15 family physicians were shadowed over consecutive patient visits at their ambulatory practices, usually for a half-day of clinic. Data about each visit were recorded, including time parameters; number of issues covered; number of labs, images, and chronic prescriptions ordered; the physician fee code from the Current Procedural Terminology (CPT) system that was submitted; the actual payer for each patient; and the actual fee collected. The primary outcome was the correlation between the time spent for each patient's care and coding/financial measures.

RESULTS: The average total time a physician spent per patient including documentation time was 20.0 minutes. The average fee collected was $101.40, including patient co-pays. The correlation between the actual fee collected and the physician's time spent working on each patient's behalf was poor (R2 = 0.137, P < .001). There was a wide variation in times and fees for each CPT code category.

CONCLUSIONS: The existing E/M rules and CPT coding system have created office visit fees that correlate poorly with family physician work. These findings provide another justification for disruptive primary care payment reform.

PMID:25495108

Efficacy of skin preparation in eradicating organisms before total knee arthroplasty

Hugo Sanchez, MD - Wed, 12/10/2014 - 05:00

Am J Orthop (Belle Mead NJ). 2014 Dec;43(12):E309-12.

ABSTRACT

The solution of 2% chlorhexidine gluconate and 70% isopropyl alcohol (Chloraprep) is commonly used for antiseptic skin preparation before surgery. We conducted a study to evaluate the efficacy of this solution in eradicating organisms during skin preparation for total knee arthroplasty (TKA), to isolate the organism type, and to evaluate possible contributing factors leading to infection. Ninety-nine patients who were undergoing TKA were swabbed for cultures in the popliteal fossa before and after solution application. Swabs were collected, cultured, and read. Culture isolates grew in 20 (20%) of the 99 patients before solution application and in 5 (5%) of the 99 after application. Mean presolution body mass index (BMI) was 38 for patients with bacterial isolates and 34 for patients without isolates (P<.03). Mean postsolution BMI was 40 for patients with bacterial isolates and 35 for patients without isolates. BMI was a statistically significant factor in predicting presence of isolates after solution application. In addition, presence of bacteria in presolution cultures was predictive of isolation in postsolution cultures. Diabetic patients were 3.6 times more likely than nondiabetic patients to have a bacterial isolate. Other factors did not predict organism isolation. No patient developed a postoperative infection.

PMID:25490018

Impact of lifelong exercise "dose" on left ventricular compliance and distensibility

Paul Bhella - Sat, 09/20/2014 - 05:00

J Am Coll Cardiol. 2014 Sep 23;64(12):1257-66. doi: 10.1016/j.jacc.2014.03.062.

ABSTRACT

BACKGROUND: Sedentary aging has deleterious effects on the cardiovascular system, including decreased left ventricular compliance and distensibility (LVCD). Conversely, Masters level athletes, who train intensively throughout adulthood, retain youthful LVCD.

OBJECTIVES: The purpose of this study was to test the hypothesis that preservation of LVCD may be possible with moderate lifelong exercise training.

METHODS: Healthy seniors (n = 102) were recruited from predefined populations, screened for lifelong patterns of exercise training, and stratified into 4 groups: "sedentary" (<2 sessions/week); "casual" (2 to 3 sessions/week); "committed" (4 to 5 sessions/week); and "competitive" Masters level athletes (6 to 7 sessions/week). Right heart catheterization and echocardiography were performed while preload was manipulated using lower body negative pressure and rapid saline infusion to define LV pressure-volume relationships and Frank-Starling curves.

RESULTS: Peak oxygen uptake and LV mass increased with escalating doses of lifelong exercise, with little change in systolic function. At baseline, LV distensibility was greater in committed (21%) and competitive (36%) exercisers than in sedentary subjects. Group LV stiffness constants (sedentary: 0.062 ± 0.039; casual: 0.079 ± 0.052; committed: 0.055 ± 0.033; and competitive: 0.035 ± 0.033) revealed: 1) increased stiffness in sedentary subjects compared to competitive athletes, whereas lifelong casual exercise had no effect; and 2) greater compliance in committed exercisers than in sedentary or casual exercisers.

CONCLUSIONS: Low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes. As LV stiffening has been implicated in the pathophysiology of many cardiovascular conditions affecting the elderly, this "dose" of exercise training may have important implications for prevention of cardiovascular disease.

PMID:25236519 | PMC:PMC4272199 | DOI:10.1016/j.jacc.2014.03.062

The inaccuracy of determining overcrowding status by using the national ED overcrowding study tool

Richard Robinson, MD - Tue, 09/02/2014 - 05:00

Am J Emerg Med. 2014 Oct;32(10):1230-6. doi: 10.1016/j.ajem.2014.07.032. Epub 2014 Aug 2.

ABSTRACT

BACKGROUND: Emergency department (ED) crowding has become more common, and perceptions of crowding vary among different health care providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings.

OBJECTIVE: The objectives of this study are to determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high-volume ED and assess the reliability and consistency of different providers' perceptions of ED crowding.

MATERIAL AND METHODS: This was a 2-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay and number of patients who left without being seen were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The interrater and intrarater agreements of ED crowding were tested.

RESULTS: In phase 1, the subject ED was determined to be overcrowded more than 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average length of stay and the number of left without being seen patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between health care providers was reached (κ = 0.5402, P < .0001). Test-retest reliability among providers was high (r = 0.8833, P = .0007). The strength of agreement between study groups and the NEDOCS was weak (κ = 0.3695, P < .001).

CONCLUSION: Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high-volume ED setting.

PMID:25176566 | DOI:10.1016/j.ajem.2014.07.032

The inaccuracy of determining overcrowding status by using the national ED overcrowding study tool

Hao Wang, MD - Tue, 09/02/2014 - 05:00

Am J Emerg Med. 2014 Oct;32(10):1230-6. doi: 10.1016/j.ajem.2014.07.032. Epub 2014 Aug 2.

ABSTRACT

BACKGROUND: Emergency department (ED) crowding has become more common, and perceptions of crowding vary among different health care providers. The National Emergency Department Overcrowding Study (NEDOCS) tool is the most commonly used tool to estimate ED crowding but still uncertain of its reliability in different ED settings.

OBJECTIVE: The objectives of this study are to determine the accuracy of using the NEDOCS tool to evaluate overcrowding in an extremely high-volume ED and assess the reliability and consistency of different providers' perceptions of ED crowding.

MATERIAL AND METHODS: This was a 2-phase study. In phase 1, ED crowding was determined by the NEDOCS tool. The ED length of stay and number of patients who left without being seen were analyzed. In phase 2, a survey of simulated ED census scenarios was completed by different providers. The interrater and intrarater agreements of ED crowding were tested.

RESULTS: In phase 1, the subject ED was determined to be overcrowded more than 75% of the time in which nearly 50% was rated as severely overcrowded by the NEDOCS tool. No statistically significant difference was found in terms of the average length of stay and the number of left without being seen patients under different crowding categories. In phase 2, 88 surveys were completed. A moderate level of agreement between health care providers was reached (κ = 0.5402, P < .0001). Test-retest reliability among providers was high (r = 0.8833, P = .0007). The strength of agreement between study groups and the NEDOCS was weak (κ = 0.3695, P < .001).

CONCLUSION: Using the NEDOCS tool to determine ED crowding might be inaccurate in an extremely high-volume ED setting.

PMID:25176566 | DOI:10.1016/j.ajem.2014.07.032

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

Richard Robinson, MD - Fri, 08/08/2014 - 05:00

BMC Cardiovasc Disord. 2014 Aug 7;14:97. doi: 10.1186/1471-2261-14-97.

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 | PMC:PMC4128541 | DOI:10.1186/1471-2261-14-97

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

Hao Wang, MD - Fri, 08/08/2014 - 05:00

BMC Cardiovasc Disord. 2014 Aug 7;14:97. doi: 10.1186/1471-2261-14-97.

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 | PMC:PMC4128541 | DOI:10.1186/1471-2261-14-97

Family physicians' opinions on the primary care documentation, coding, and billing system: a qualitative study from the residency research network of Texas

Richard Young, MD - Wed, 06/11/2014 - 05:00

Fam Med. 2014 May;46(5):378-84.

ABSTRACT

BACKGROUND AND OBJECTIVES: The study's aim was to deepen our understanding of family physicians' perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services.

METHODS: This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved.

RESULTS: The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals.

CONCLUSIONS: Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.

PMID:24915481

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