Impact of a High-Risk,Ambulatory COVID-19 Remote Patient Monitoring Program on Utilization,Cost, and Mortality

ObjectiveTo evaluate care utilization, cost, and mortality among high-risk patients enrolled in a coronavirus disease 2019 (COVID-19) remote patient monitoring (RPM) program.MethodsThis retrospective analysis included patients diagnosed with COVID-19 at risk for severe disease who enrolled in the RPM program between March 2020 and October 2021. The program included in-home technology for symptom and physiologic data monitoring with centralized care management. Propensity score matching established matched cohorts of RPM-engaged (defined as ≥1 RPM technology interactions) and non-engaged patients using a logistic regression model of 59 baseline characteristics. Billing codes and the electronic death certificate system were used for data abstraction from the electronic health record and reporting of care utilization and mortality endpoints.ResultsAmong 5796 RPM-enrolled patients, 80.0% engaged with the technology. Following matching, 1128 pairs of RPM-engaged and non-engaged patients comprised the analysis cohorts. Mean patient age was 63.3 years, 50.9% of patients were female, and 81.9% were non-Hispanic White. Patients who were RPM-engaged experienced significantly lower rates of 30-day, all-cause hospitalization (13.7% vs 18.0%, P=.01), prolonged hospitalization (3.5% vs 6.7%, P=.001), intensive care unit admission (2.3% vs 4.2%, P=.01), and mortality (0.5% vs 1.7%; odds ratio, 0.31; 95% CI, 0.12 to 0.78; P=.01), as well as cost of care ($2306.33 USD vs $3565.97 USD, P=0.04), than those enrolled in RPM but non-engaged.ConclusionHigh-risk COVID-19 patients enrolled and engaged in an RPM program experienced lower rates of hospitalization, intensive care unit admission, mortality, and cost than those enrolled and non-engaged. These findings translate to improved hospital bed access and patient outcomes.     

Differences in Health Care Utilization in the Year Before Suicide Death: A Population-Based Case-Control Study

ObjectiveTo compare health care usage between suicide decedents and living controls in the year before suicide in a large representative US population.Patients and MethodsCases (n=1221) and controls (n=3663) belonged to an integrated health care system from January 1, 2009, through December 31, 2014. Cases and controls were matched for age and sex in a 1:3 ratio, with diagnostic and/or billing codes used to enumerate and classify health care visits in the year before the index suicide. Matched analysis via conditional logistic regression related odds of suicide to visit type. A generalized estimating equation model was used to compare timing and frequency of visits between cases and controls.ResultsIn the year before death, cases had an increased odds of both inpatient hospitalizations and emergency department nonmental health visits (odds ratio [OR], 1.55; 95% CI, 1.27-1.88; P<.001 and OR, 1.42; 95% CI, 1.26-1.60; P<.001) but not outpatient nonmental health visits (OR, 1.00; 95% CI, 0.99-1.01; P=.63). Decedents increased health care utilization closer to suicide death and had significantly more health care visits than did controls 3 months before suicide (6 vs 2; P=.01) but not 9 to 12 months before suicide (4 vs 2; P=.07). At all time points, cases used more mental health care services than did controls.ConclusionCompared with controls, suicide decedents had emergency department visits and more inpatient hospitalizations, both mental health and nonmental health related. As death approached, cases' frequency of health care usage increased. The only category in which cases and controls did not differ was in the frequency of outpatient nonmental health visits.     

Association of Elevated Triglycerides With Increased Cardiovascular Risk and Direct Costs in Statin-Treated Patients

ObjectiveTo retrospectively investigate the real-world impact of elevated triglyceride (TG) levels on cardiovascular (CV) outcomes, medical resource utilization, and medical costs using observational administrative claims data from the Optum Research Database.MethodsPatients with one or more claims for statin therapy between January 1, 2010, and December 31, 2010, and 6 months or more of baseline data prior to the index date were eligible for inclusion in the study. Patients aged 45 years or older with diabetes and/or atherosclerotic CV disease were included and analyzed in an elevated TG cohort (≥150 mg/dL) vs a comparator cohort with TG levels less than 150 mg/dL and high-density lipoprotein cholesterol (HDL-C) levels greater than 40 mg/dL.ResultsIn the elevated TG vs propensity-matched comparator cohorts (both N=23,181 patients), the mean age was 62.2 vs 62.6 years, mean follow-up was 41.4 vs 42.5 months, 49.7% (11,518) vs 49.5% (11,467) were female, 83.7% (19,392) vs 84.0% (19,478) had diabetes, and 29.8% (6915) vs 29.3% (6800) had atherosclerotic CV disease. In the elevated TG (N=27,471 patients) vs comparator (N=32,506 patients) cohorts, multivariate analysis revealed significantly greater risk of composite major CV events (hazard ratio [HR], 1.26; 95% CI, 1.19-1.34; P<.001), nonfatal myocardial infarction (HR, 1.32; 95% CI, 1.20-1.45; P<.001), nonfatal stroke (HR, 1.14; 95% CI, 1.04-1.24; P=.004), and need for coronary revascularization (HR, 1.46; 95% CI, 1.33-1.61; P<.001) but not unstable angina (P=.53) or CV death (P=.23). Increased CV risk was maintained with the addition of non–HDL-C to the multivariate model and with high and low HDL-C subgroup analysis. Total direct health care costs (cost ratio, 1.12; 95% CI, 1.08-1.16; P<.001) and inpatient hospital stays (HR, 1.13; 95% CI, 1.10-1.17; P<.001) were significantly higher in the elevated TG cohort vs the comparator cohort.ConclusionStatin-treated patients with TG levels of 150 mg/dL or greater had worse CV and health economic outcomes than those with well-managed TG (<150 mg/dL) and HDL-C (>40 mg/dL) levels.     

Empiric aztreonam is associated with increased mortality compared to beta-lactams in septic shock

PurposeTo determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents.MethodsThis was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality.ResultsInitial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27–3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08–2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups.ConclusionsCompared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.     

Mortality Risk for Patients With Stage IV Cancer and Acute Illness Hospitalization

ContextCancer prognosis data often come from clinical trials which exclude patients with acute illness.ObjectivesFor patients with Stage IV cancer and acute illness hospitalization to 1) describe predictors of 60-day mortality and 2) compare documented decision-making for survivors and decedents.MethodsInvestigators studied a consecutive prospective cohort of patients with Stage IV cancer and acute illness hospitalization. Structured health record and obituary reviews provided data on 60-day mortality (outcome), demographics, health status, and treatment; logistic regression models identified mortality predictors.ResultsFour hundred ninety-two patients with Stage IV cancer and acute illness hospitalization had median age of 60.2 (51% female, 38% minority race/ethnicity); 156 (32%) died within 60 days, and median survival for decedents was 28 days. Nutritional insufficiency (odds rato [OR] 1.83), serum albumin (OR 2.15 per 1.0 g/dL), and hospital days (OR 1.04) were associated with mortality; age, gender, race, cancer, and acute illness type were not predictive.On admission, 79% of patients had orders indicating Full Code. During 60-day follow-up, 42% of patients discussed goals of care. Documented goals of care discussions were more common for decedents than survivors (70% vs. 28%, P < 0.001), as were orders for do not resuscitate/do not intubate (68% vs. 24%, P < 0.001), stopping cancer-directed therapy (29% vs. 10%, P < 0.001), specialty Palliative Care (79% vs. 44%, P < 0.001), and Hospice (68% vs. 14%, P < 0.001).ConclusionAcute illness hospitalization is a sentinel event in Stage IV cancer. Short-term mortality is high; nutritional decline increases risk. For patients with Stage IV cancer, acute illness hospitalization should trigger goals of care discussions.     

Let’s Empower and Prepare (LEAP): Evaluation of a Structured Transition Program for Young Adults With Type 1 Diabetes

OBJECTIVETo evaluate the efficacy of a structured transition program compared with usual care in improving routine follow-up, clinical, and psychosocial outcomes among young adults with type 1 diabetes.RESULTSLimitations in CG follow-up prevented direct comparisons of adult care visits; however, at the 12-month follow-up among IG participants discharged from pediatric care (n = 32), 78% had one or more adult visits. Among IG participants, the total number of clinic visits did not differ between those who transitioned and those who remained in pediatric care (3.0 ± 1.24 vs. 3.11 ± 0.94, P = 0.74). IG compared with CG participants had improved glycemic control (−0.40 ± 1.16% vs. 0.42 ± 1.51% [4.4 ± 12.7 mmol/mol vs. 4.6 ± 16.5 mmol/mol], P = 0.01), incidence of severe hypoglycemia (0.0% vs. 16%, P = 0.02), and global well-being (P = 0.02) at 12 months.CONCLUSIONSA structured transition program was successful in facilitating transition to adult care without a decrease in clinical follow-up. Compared with usual care, the transition program facilitated improvements in glycemic control, hypoglycemia, and psychosocial well-being.     

Patients living with disabilities: The need for high-quality primary care

ObjectiveTo compare the potential risk factors for lower-quality primary care, the potential markers of unmet needs in primary care, and the willingness to participate in future research among primary care patients with versus without physical disabilities.DesignA waiting room survey using a convenience sample.SettingA family health team (FHT) in Kitchener-Waterloo, Ont, with a designated Mobility Clinic.ParticipantsA total of 40 patients seen at the FHT Mobility Clinic and 80 patients from the general patient population of the same FHT.ResultsPatients from the Mobility Clinic were more than twice as likely to be receiving benefits or social assistance (75.0% vs 32.1%, P < .001), were twice as likely to report an annual household income of less than $40000 (58.6% vs 29.2%, P = .006), and were more likely to report their health status to be fair or poor (42.5% vs 16.2%, P = .002). Half of Mobility Clinic patients had visited the emergency department at least once in the preceding year, compared with 29.7% in the general patient population (P = .027). When asked if they would be willing to provide their health card number in the future so that it could be linked to health care data for research, 82.5% of Mobility Clinic patients agreed versus 55.0% of those in the general patient population (P = .004).ConclusionIn this study, patients with disabilities were at a social disadvantage compared with their peers without disabilities and were more likely to use the emergency department, suggesting that they had unmet health needs. Future research should continue to explore this patient population and to investigate if an interprofessional primary health care team approach focused on patients with disabilities can help to increase quality of care.     

Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS?

Objectives

Symptoms are compared among patients with coronary artery disease (CAD) admitted to the emergency department with or without acute coronary syndrome (ACS). Sex and age are also assessed.

Methods

A secondary analysis from the PROMOTION (Patient Response tO Myocardial Infarction fOllowing a Teaching Intervention Offered by Nurses) trial, an multicenter randomized controlled trial, was conducted.

Results

Of 3522 patients with CAD, at 2 years, 565 (16%) presented to the emergency department, 234 (41%) with non-ACS and 331 (59%) with ACS. Shortness of breath (33% vs 25%, P = .028) or dizziness (11% vs 3%, P = .001) were more common in non-ACS. Chest pain (65% vs 77%, P = .002) or arm pain (9% vs 21%, P = .001) were more common in ACS. In men without ACS, dizziness was more common (11% vs 2%; P = .001). Men with ACS were more likely to have chest pain (78% vs 64%; P = .003); both men and women with ACS more often had arm pain (men, 19% vs 10% [P = .019]; women, 26% vs 13% [P = .023]). In multivariate analysis, patients with shortness of breath (odds ratio [OR], 0.617 [confidence interval [CI], 0.410-0.929]; P = .021) or dizziness (OR, .0311 [CI, 0.136-0.708]; P = .005) were more likely to have non-ACS. Patients with prior percutaneous coronary intervention (OR, 1.592 [CI, 1.087-2.332]; P = .017), chest pain (OR, 1.579 [CI, 1.051-2.375]; P = .028), or arm pain (OR, 1.751 [CI, 1.013-3.025]; P <.042) were more likely to have ACS.

Conclusions

In patients with CAD, shortness of breath and dizziness are more common in non-ACS, whereas prior percutaneous coronary intervention and chest or arm pain are important factors to include during ACS triage.     

Nontraditional risk factors of coronary artery disease among Palestinians: A case-control study

BackgroundCoronary Artery Disease (CAD) is one of the most common causes of death in Palestine. This study aimed to assess the nontraditional risk factors among CAD patients underwent invasive coronary angiography in Gaza-Palestine.MethodsUnmatched one-to-one case-control study was conducted among 200 participants. Cases were recruited from newly discovered CAD patients after a confirmed diagnosis of CAD by interventional cardiologist post catheterization "coronary angiography" in Al-Shifa Cardiovascular Catheterization Center. Controls were enrolled from individuals with no history of CAD. An interview-based questionnaire was used to assess patient's characteristic data and medical history; anthropometric, and the Ankle Brachial Index(ABI) was measured and calculated. Furthermore, biochemical analysis of high sensitivity C-reactive protein (hs-CRP) level and Random blood glucose level (RBG) and Leukocyte count (WBCs)were investigated. All required ethical approvals were obtained. Data were managed and analyzed by STATA version 14. Correlation analysis by multivariate logistic regression was done.Resultshs-CRP, RBG, and WBCs remained significant predictors for CAD adjusted for age, education level, employment status, and monthly income. As, the odds of CAD increased by 3% for each unit increased in hs-CRP (Odd Ratio (OR)=1.03; 95% confidence interval (CI):1.01, 1.06; P = 0.020); and the odds of CAD was augmented by 30% for each unit increased in WBCs (OR= 1.30; 95% CI: 1.07, 1.67; P = 0.010); While the odds of CAD was 5 times more for each unit increased in RBG (OR=5.04; 95% CI: 1.17, 14.88; P = 0.003). Still, age remained a significant risk factor as the odds of CAD was 19% more for each increased year in age (OR=1.19; 95%CI: 1.13, 1.26; P<0.001).ConclusionNontraditional factors (hs-CRP, RBG, and WBCs) are significant predictors of CAD, and should be considered in adult patients coming with attacks of angina pain.     

Frequency and Characteristics of First-Time Palliative Care Referrals During the Last Day of Life

ContextPalliative care referrals (PCRs) improve symptom management, provide psychosocial and spiritual support, clarify goals of care, and facilitate discharge planning. However, very late PCR can result in increased clinician distress and prevent patients and families from benefiting from the full spectrum of interdisciplinary care.ObjectivesTo determine the frequency and predictors of PCR within 24 hours of death.MethodsConsecutive first-time inpatient PCR from September 1, 2013 to August 31, 2017 was identified to determine the frequency and predictors of referrals within 24 hours of death. We compared the clinical characteristics with a random sample of patients discharged alive or died more than 24 hours after first-time PCR as a control, stratified by year of consult in a 1:1 ratio.ResultsOf 7322 first-time PCRs, 154 (2%) died within 24 hours of referral. These patients were older (P = 0.003) and had higher scores for depression (P = 0.0009), drowsiness (P = 0.02), and shortness of breath (P = 0.008) compared with a random sample of 153 patients discharged alive or died more than 24 hours after first-time PCR. Patients who received a PCR within 24 hours of death were more likely than the control group to have Eastern Cooperative Oncology Group 4 (95% vs. 25%, P < 0.0001), delirium (89% vs. 17%, P < 0.0001), do-not-resuscitate code status (81% vs. 18%, P < 0.0001), and hematologic malignancies (39% vs. 16%, P < 0.0001). In the multivariate analysis, depression (odds ratio [OR] 1.4; P = 0.005), do-not-resuscitate code status (OR 9.1; P = 0.003), and Eastern Cooperative Oncology Group 4 (OR 9.8; P = 0.003) were independently associated with first-time PCR within 24 hours of death.ConclusionAlthough only a small proportion of first-time PCR occurred in the last 24 hours of life, the patients had a significant amount of distress, indicating a missed opportunity for timely palliative care intervention. These sentinel events call for specific guidelines to better support patients, families, and clinicians during this difficult time. Further research is needed to understand how to minimize very late PCR.     

Health Care Resource Utilization and Medical Costs of Spinal Cord Injury With Neuropathic Pain in a Commercially Insured Population in the United States

ObjectiveTo evaluate health care resource use, costs, and cost drivers among patients with neuropathic pain (NeP) after spinal cord injury (SCI) in a commercially insured population.DesignRetrospective longitudinal cohort study comparing SCI patients with and without NeP.SettingTruven Health MarketScan commercial claims database from 2005 through 2012.ParticipantsCommercially insured SCI patients with NeP (n=3524) propensity score matched to SCI patients without NeP (n=3524).InterventionsNot applicable.Main Outcomes MeasuresHealth care resource utilization and expenditures for the 12 months after NeP onset (index event; identified through International Classification of Diseases, 9th Revision, Clinical Modification diagnosis 338.0x or use of NeP-specific antiepileptic drugs or NeP-specific antidepressants) in patients with SCI compared with matched patients without NeP.ResultsUtilization over 12 months postindex among patients with SCI-associated NeP was higher than among SCI-only patients for inpatient admissions (27.4% vs 22.1%), emergency department visits (36.7% vs 26.4%), and office visits per patient (mean ± SD: 13.0±9.5 vs 9.5±8.3); all P values were <.001. All-cause expenditures showed adjusted incremental costs of $22,545 (95% confidence interval, $19,010–$26,168) per patient with SCI-associated NeP during the 12-month postindex period.ConclusionsPatients with evidence of NeP secondary to SCI have significantly higher health care utilization and total costs compared with SCI patients without evidence of NeP. Factors contributing to NeP in patients with SCI need to be clinically assessed to determine the optimal approach for treating these individuals.     

Identifying Distinct High Unmet-Need Phenotypes and Their Associated Bladder Cancer Patient Demographic,Clinical, Psychosocial,and Functional Characteristics: Results of Two Clustering Methods

ObjectivesWe explored phenotypes of high unmet need of patients with bladder cancer and their associated patient demographic, clinical, psychosocial, and functional characteristics.Data SourcesPatients (N=159) were recruited from the Bladder Cancer Advocacy Network and completed an online survey measuring unmet needs (BCNAS-32), quality of life (FACT-Bl), anxiety and depression (HADS), coping (BRIEF Cope), social support (SPS), and self-efficacy beliefs (GSE). Hierarchical agglomerative (HA) and partitioning clustering (PC) analyses were used to identify and confirm high unmet-need phenotypes and their associated patient characteristics. Results showed a two-cluster solution; a cluster of patients with high unmet needs (17% and 34%, respectively) and a cluster of patients with low-moderate unmet needs (83% and 66%, respectively). These two methods showed moderate agreement (κ=0.57) and no significant differences in patient demographic and clinical characteristics between the two groups. However, the high-need group identified by the HA clustering method had significantly higher psychological (81 vs 66, p < .05), health system (93 vs 74, p < .001), daily living (93 vs 74, P < .001), sexuality (97 vs 69, P < .001), logistics (84 vs 69, P < .001), and communication (90 vs 76, P < .001) needs. This group also had worse quality of life and emotional adjustment and lower personal and social resources (P < .001) compared with the group identified by the PC method.ConclusionA significant proportion of patients with bladder cancer continues to have high unique but inter-related phenotypes of needs based on the HA clustering method.Implications for Nursing PracticeIdentifying characteristics of the most vulnerable patients will help tailor support programs to assist these patients with their unmet needs.     

Care workers health in Swiss nursing homes and its association with psychosocial work environment: A cross-sectional study

BackgroundPrevious studies have demonstrated poor health of care workers in nursing homes. Yet, little is known about the prevalence of physical and mental health outcomes, and their associations with the psychosocial work environment in nursing homes.Objectives(1) To explore the prevalence of physical and mental health outcomes of care workers in Swiss nursing homes, (2) their association with psychosocial work environment.MethodsThis is a secondary data analysis of the cross-sectional Swiss Nursing Home Human Resources Project (SHURP). We used survey data on socio-demographic characteristics and work environment factors from care workers (N = 3471) working in Swiss nursing homes (N = 155), collected between May 2012 and April 2013. GEE logistic regression models were used to estimate the relationship between psychosocial work environment and physical and mental health outcomes, taking into account care workers’ age.ResultsBack pain (19.0%) and emotional exhaustion (24.2%) were the most frequent self-reported physical and mental health. Back pain was associated with increased workload (odds ratios (OR) 1.52, confidence interval (CI) 1.29–1.79), conflict with other health professionals and lack of recognition (OR 1.72, CI 1.40–2.11), and frequent verbal aggression by residents (OR 1.36, CI 1.06–1.74), and inversely associated with staffing adequacy (OR 0.69, CI 0.56–0.84); emotional exhaustion was associated with increased workload (OR 1.96, CI 1.65–2.34), lack of job preparation (OR 1.41, CI 1.14–1.73), and conflict with other health professionals and lack of recognition (OR 1.68, CI 1.37–2.06), and inversely associated with leadership (OR 0.70, CI 0.56–0.87).ConclusionsPhysical and mental health among care workers in Swiss nursing homes is of concern. Modifying psychosocial work environment factors offer promising strategies to improve health. Longitudinal studies are needed to conduct targeted assessments of care workers health status, taking into account their age, along with the exposure to all four domains of the proposed WHO model.     

Impact of Dementia on Patterns of Home Care After Inpatient Rehabilitation Discharge for Older Adults After Hip Fractures

ObjectiveTo describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia.DesignRetrospective cohort study of individually linked health administrative data.SettingCommunity-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada.ParticipantsA total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017.InterventionsNot applicable.Main Outcome MeasuresThe proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex.ResultsCompared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60).ConclusionsAmong older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.     

Health Care Utilization and Costs Associated With Pediatric Chronic Pain

The population prevalence of pediatric chronic pain is not well characterized, in part because of a lack of nationally representative data. Previous research suggests that pediatric chronic pain prolongs inpatient stay and increases costs, but the population-level association between pediatric chronic pain and health care utilization is unclear. We use the 2016 National Survey of Children's Health to describe the prevalence of pediatric chronic pain, and compare health care utilization among children ages 0 to 17 years according to the presence of chronic pain. Using a sample of 43,712 children, we estimate the population prevalence of chronic pain to be 6%. In multivariable analysis, chronic pain was not associated with increased odds of primary care or mental health care use, but was associated with greater odds of using other specialty care (odds ratio [OR]?=?2.01, 95% confidence interval [CI] = 1.62–2.47; P?<?.001), complementary and alternative medicine (OR?=?2.32, 95% CI = 1.79–3.03; P?<?.001), and emergency care (OR?=?1.62, 95% CI = 1.29–2.02; P?<?.001). In this population-based survey, children with chronic pain were more likely to use specialty care but not mental health care. The higher likelihood of emergency care use in this group raises the question of whether better management of pediatric chronic pain could reduce emergency department use.

Clinical and Economic Burden in Patients with Diagnosis of Peripheral Arterial Disease in a Claims Database in Japan

Purpose

The effect of peripheral arterial disease (PAD) among young and middle-aged adults can be significant, but no previous study has examined the prognosis and the associated health care cost of the disease in this population. We evaluated the clinical and economic burden of PAD in patients from a large claims database to clarify the effect of the disease on a relatively young working Japanese population.

Methods

Patients aged ≥45 and ≤64 years with first PAD diagnosis between 2005 and 2011 comprised the PAD cohort (n = 362); an age- and sex-matched non-PAD comparison cohort (n = 362) was also identified. Rates of cardiovascular events/interventions, health care utilization, and costs were compared.

Findings

The mean (SD) age of the cohort was 52.8 (5.6) years and 40.8% were women. Baseline Charlson comorbidity index was significantly higher in the PAD cohort than in the non-PAD cohort (1.90 [2.19] vs 1.16 [1.99]; P < 0.001). The PAD cohort had significantly higher first-year event rates than did the non-PAD cohort for myocardial infarction (2.2% vs 0.2%; P = 0.019) and ischemic stroke (4.1% vs 0.5%; P = 0.001). Health care utilization was significantly greater for the PAD cohort for all parameters assessed (number of hospitalization, inpatient days, and outpatient visits) in the first year (all, P < 0.001). Total annual costs for health care were significantly higher in the PAD cohort than in the non-PAD cohort in the first year (P < 0.001). Among patients with diabetes, patients with PAD (n = 98) had significantly greater first-year event rates (myocardial infarction, ischemic stroke, coronary artery bypass surgery, peripheral arterial revascularization, percutaneous coronary intervention, and limb amputation; all, P < 0.001), significantly greater number of clinic visits (P = 0.023), and total cost burden than did patients without PAD (n = 63).

Implications

Even in a relatively young working Japanese population, PAD is associated with substantial clinical and economic burden.     

Predictors for daily interruption of sedation therapy by nurses: A prospective,multicenter study

PurposeThe aim of the study was to identify the nurse and patient-related factors predicting daily interruption of sedation (DIS) performance by nurses in the intensive care unit (ICU).MethodsNurses, caring for a mechanically ventilated patient receiving 24 hours or more of a continuously infused sedative, were interviewed at the bedside to determine their willingness to perform DIS on this patient and to determine the influence of 20 nurse- and 47 patient-related factors on DIS completion.ResultsThe 57 (44%) of 130 of nurses willing to perform DIS had performed DIS at least once in the past (P < .0001) and were not targeting deep sedation (ie, Sedation Agitation Scale [SAS] ≤ 2 [P = .03]). The DIS performance was less likely with use of higher-dose continuous midazolam (P = .006), a fraction of inspired oxygen (Fio₂) greater than 50% (P = .03), or positive end-expiratory pressure greater than 5 mm Hg (P = .006) and in patients either deeply sedated (SAS ≤ 2) (P = .05) or agitated (SAS ≥ 5) in the past 24 hours (P = .003). Prior DIS experience (odds ratio [OR], 2.54; P = .004), hours of sedation-related continuing education (OR, 1.13; P = .02), and a target of deep sedation (OR, 0.49; P = .02) were independent nurse-related factors for DIS performance. Nurse's willingness to conduct DIS ranged from 45% to 80% based on the interaction between patient sex, current Fio₂, and agitation in past 24 hours.ConclusionsEducational strategies and institutional protocols focused on improving use of DIS need to consider the various nurse- and patient-related factors that affect DIS performance by nurses in the ICU.     

Clinical exome sequencing vs. usual care for hereditary colorectal cancer diagnosis: A pilot comparative effectiveness study

BackgroundClinical exome sequencing (CES) provides the advantage of assessing genetic variation across the human exome compared to a traditional stepwise diagnostic approach or multi-gene panels. Comparative effectiveness research methods offer an approach to better understand the patient-centered and economic outcomes of CES.PurposeTo evaluate CES compared to usual care (UC) in the diagnostic work-up of inherited colorectal cancer/polyposis (CRCP) in a randomized controlled trial (RCT).MethodsThe primary outcome was clinical sensitivity for the diagnosis of inherited CRCP; secondary outcomes included psychosocial outcomes, family communication, and healthcare resource utilization. Participants were surveyed 2 and 4 weeks after results return and at 3-month intervals up to 1 year.ResultsEvolving outcome measures and standard of care presented critical challenges. The majority of participants in the UC arm received multi-gene panels [94.73%]. Rates of genetic findings supporting the diagnosis of hereditary CRCP were 7.5% [7/93] vs. 5.4% [5/93] in the CES and UC arms, respectively (P = 0.28). Differences in privacy concerns after receiving CRCP results were identified (0.88 in UC vs 0.38 in CES, P = 0.05); however, healthcare resource utilization, family communication and psychosocial outcomes were similar between the two arms. More participants with positive results (17.7%) intended to change their life insurance 1 month after the first return visit compared to participants returned a variant of uncertain significance (9.1%) or negative result (4.8%) (P = 0.09).ConclusionOur results suggest that CES provides similar clinical benefits to multi-gene panels in the diagnosis of hereditary CRCP.     

Troponin elevation predicts critical care needs and in-hospital mortality after thrombolysis in white but not black stroke patients

IntroductionStroke patients undergoing intravenous thrombolysis (IVT) are at increased risk for critical care interventions and mortality. Cardiac troponin elevation is common in stroke patients; however, its prognostic significance is unclear. The present study evaluates troponin elevation as a predictor of critical care needs and mortality in post-IVT patients and describes racial differences in its predictive accuracy.MethodsLogistic regression and receiver operating characteristics (ROC) analysis were used to determine racial differences in the predictive accuracy of troponin elevation for critical care needs and mortality in post-IVT patients.ResultsTroponin elevation predicted critical care needs in white (odds ratio [OR] 29.40, 95% confidence interval [CI] 4.86-177.81) but not black patients (OR 0.50, 95% CI 0.14-1.78; P value for interaction < .001). Adding troponin elevation to a prediction model for critical care needs in whites improved the area under the curve from 0.670 to 0.844 (P = .006); however, addition of troponin elevation did not improve the model in blacks (area under the curve 0.843 vs 0.851, P = .54). Troponin elevation was associated with in-hospital mortality in whites (OR 21.94, 95% CI 3.51-137.11) but not blacks (OR 1.10, 95% CI 0.19-6.32, P value for interaction .022).ConclusionTroponin is a useful predictor of poor outcome in white but not black post-IVT stroke patients.