Will Performance Measurement Lead to Better Patient Outcomes?: What Are the Roles of the National Quality Forum and Medical Specialty Societies?

Performance measures (PMs) are specified metrics by which a health-care provider's care can be compared with national benchmarks. The use of PMs is a key component of efforts to improve the quality and value of health care. The National Quality Forum (NQF) is the federally recognized endorser of PMs. From 2006 to 2009, the Quality Improvement Committee (QIC) of the American College of Chest Physicians engaged in the review of proposed PMs as a member of the NQF. This article provides a review of the QIC's experience with PMs and NQF membership and the lessons learned, an overview of the enhancements made to the NQF endorsement process in 2010 and 2011, and a discussion of the next steps that would further strengthen the measure development and endorsement processes and increase the likelihood of measurement leading to better patient outcomes.     

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BackgroundPhysician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.ObjectiveTo examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.DesignPatient self-report surveys at treatment initiation linked to medical records.SettingVeterans Health Administration (VA) clinics nationally, 2018–2020.ParticipantsA total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White)Main MeasuresPatient self-reported preferences for medication and psychotherapy on 0–10 self-anchoring visual analog scales (0=“completely unwilling”; 10=“completely willing”). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.Key ResultsMore patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7–10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5–24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0–3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4–7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.ConclusionsMismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07136-2.KEY WORDS: major depression, treatment preferences, treatment adherence, Veterans     

Are myocardial eNOS and nNOS involved in the beta-adrenergic and muscarinic regulation of inotropy? A systematic investigation

OBJECTIVE: The role of constitutive nitric oxide (NO) production in the regulation of beta-adrenergic and muscarinic responses remains controversial. Conflicting data in left ventricular (LV) myocytes from eNOS knockout mice (eNOS-/-) have been ascribed to inconsistent experimental conditions (i.e., differences in the choice of controls, age of the mice, myocytes' stimulation frequency, and in the level of beta-adrenergic stimulation); however, the recent identification of a neuronal-like NO synthase (nNOS) in the LV myocardium has raised the possibility that this isoform may be involved in the modulation of beta-adrenergic and muscarinic responses. METHODS: To address these issues we recorded sarcomere shortening at 35 degrees C under basal conditions, in the presence of isoproterenol (ISO, 10-100 nmol/L) and of ISO plus carbamylcholine (CCh, 1 micromol/L) in LV myocytes isolated from eNOS-/- and nNOS-/- mice, their wild type littermates (eNOS+/+ and nNOS+/+) or C57BL/6J mice. eNOS-/- and control myocytes were studied at 1 and 3 Hz, in the presence of 10 and 100 nmol/L ISO, and responses were compared between young (3 months) and old (> or =12 months) mice. RESULTS: Contraction did not differ between young eNOS-/- and eNOS+/+ mice at all stages of the experimental protocol, either at 1 or 3 Hz or in response to 10 or 100 nmol/L ISO. However, myocytes from old eNOS-/- mice showed a reduced inotropic response to ISO compared with age-matched eNOS+/+ mice (P = 0.02). Similarly, there was a significant difference in the ISO response between eNOS+/+ and C57BL/6J myocytes (P < 0.01), suggesting that experimental variables such as age and the choice of control animals may have contributed to the inconsistency in the results reported in the literature. In contrast, nNOS-/- myocytes showed greater contraction and slower relaxation at all stages of the experimental protocol (P = 0.0003 and P = 0.01 vs. nNOS+/+ myocytes). CONCLUSIONS: Constitutive eNOS expression in murine LV myocytes is not essential for the muscarinic-mediated inhibition of beta-adrenergic signalling and does not appear to play a significant role in the regulation of basal and beta-adrenergic myocardial contraction. Our data suggest that nNOS is the myocardial constitutive isoform responsible for the NO-mediated autocrine regulation of myocardial inotropy and relaxation.     

Are There Pleiotropic Effects of Antihypertensive Medications or Is It All About the Blood Pressure in the Patient With Diabetes and Hypertension?

Many small studies with varied surrogate end points and numerous preclinical data have suggested the likelihood of there being specific benefits that exceed simple blood pressure control with drug classes such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers, which may be particularly relevant to the patient with diabetes and hypertension. Large clinical trials, however, have provided only token support for this idea. Likewise, meta-analyses that have incorporated varied clinical trials, albeit with somewhat heterogeneous data, have not been particularly forthcoming in their support of this concept. In the patient with diabetes and hypertension, tight blood pressure control, more so than using a specific drug class, is the most important aspect of therapy.     

Are Older People Dying of Depression? Findings from the Medical Research Council Trial of the Assessment and Management of Older People in the Community

OBJECTIVES: To examine the relationship between symptoms of depression and mortality in older people. DESIGN: Prospective longitudinal study. SETTING: Fifty-three general practices in the United Kingdom. PARTICIPANTS: Thirteen thousand ninety-seven people aged 75 and older participating in the Medical Research Council Trial of the Assessment and Management of Older People in the Community. MEASUREMENTS: Depression was measured using the 15-item Geriatric Depression Scale (GDS-15); the main outcome was all-cause mortality. RESULTS: Morbidity, disability, and lifestyle factors can explain most of the observed relationship between symptoms of depression and mortality (hazard ratio=1.75, 95% confidence interval (CI)=1.53-1.99), but after mutual adjustment for these factors, subjects who reported six or more symptoms of depression on the GDS-15 were still 27% more likely to have died by the end of the follow-up period than those below the threshold for depression (95% CI=1.11-1.45). CONCLUSION: The findings from this study suggest that depression confers a small risk for mortality in older people, not explained solely by poor health. The results support the encouragement of effective diagnosis, treatment, and support for individuals with depression as highlighted by the World Health Organization and the UK National Service Framework for older people.     

Combining Antiplatelet and Antithrombotic Therapy (Triple Therapy): What Are the Risks and Benefits?

Most patients with mechanical heart valves and many patients with atrial fibrillation will require long-term anticoagulation therapy. For patients with mechanical prosthetic valves, only warfarin is indicated. However, for patients with nonvalvular atrial fibrillation who are at increased risk for embolic stroke, one of the newer antithrombotic medications, such as rivaroxaban, dabigatran, and apixaban, also can be used. Patients with indications for antithrombotic therapy often will have coexisting vascular disease, such as coronary artery disease, requiring concomitant antiplatelet therapy with aspirin alone or more commonly with a dual antiplatelet regimen, aspirin and clopidogrel, or prasugrel or ticagrelor. The risks and benefits of this approach are still not well defined, and current guidelines have included recommendations based primarily on expert opinion.     

Are the effects of gamma-hydroxybutyrate (GHB) treatment partly physiological in alcohol dependence?

It has been hypothesized that the therapeutic effects of Gamma-hydroxybutyrate (GHB) in alcohol dependence could be related to ethanol-mimicking action of the drug and that GHB could reduce alcohol craving, intake and withdrawal by acting as a "substitute" of the alcohol in the central nervous system. Nevertheless, alcohol being the strongest trigger of craving and intake, it is difficult to ascribe reduction of craving and intake to ethanol-mimicking activity of GHB. I have recently proposed that alcohol/substance dependence could result from a GHB-deficiency-related dysphoric syndrome in which alcohol/substances would be sought to "substitute" for insufficient GHB effect. GHB is the sole identified naturally occurring gamma-aminobutyric acid B (GABA (B)) receptor agonist. Here, I propose that exogenous GHB might in fact "substitute" for deficient endogeneous GHB and represent true substitutive treatment for GHB-deficiency. And that baclofen and GHB could both compensate for deficient effect of the physiological GABA (B) receptor agonist(s).     

Tenofovir in the Treatment of Na?ve and Refractory Chronic Hepatitis B: A Single Center Experience in Saudi Arabia

Background/Aims:

Tenofovir disoproxil fumarate (TDF) is a nucleotide analog used in the treatment of chronic hepatitis B (CHB) infection. This study evaluated the efficacy of TDF in achieving undetectable HBV DNA after 48 weeks of treatment in a Saudi cohort of CHB patients.

Patients and Methods:

This retrospective study included patients treated at a tertiary care center in Saudi Arabia from January 2009 to December 2012. Of the 68 eligible patients, 51 were treatment naïve and 17 were treatment-refractory. Twenty-three patients tested positive for HBeAg. The remaining 45 patients were HBeAg-negative.

Results:

The mean HBV DNA viral load decreased from 95 million IU/mL at baseline to 263 IU/mL after 48 weeks of treatment (P < 0.001). Overall, 62% of patients achieved a complete virological response (CVR) and 37% a partial virological response (PVR). Respective CVR and PVR rates according to subgroup were: HBeAg-positive (21.7% and 78.3%) and HBeAg-negative (84.4% and 15.6%). At 48 weeks, HBV DNA was undetectable in 66.7% of treatment-naïve and 53% of treatment-refractory patients (P = 0.3). Seroconversion occurred in 13 (57%) of HBeAg-positive patients. Two (3%) of the HBeAg-negative patients lost HBsAg at follow up. Mean alanine aminotransferase decreased significantly from 134 U/L before treatment to 37 U/L at 48 weeks (P < 0.001). Significant adverse events were not encountered during the study period.

Conclusion:

Forty-eight weeks of treatment with TDF reduced HBV DNA to undetectable levels in more than half of our patients regardless of whether they were treatment-naïve or refractory. HBeAg-negative (vs positive) patients experienced a better response rate.     

Are high density lipoprotein (HDL) and triglyceride levels relevant in stroke prevention?

Although statins reduce the risk of non-haemorrhagic strokes and transient ischaemic attacks (TIA), little is known about the efficacy of fibrates. This situation has been partly remedied by the recent publication of two-fibrate based trials--The Veterans Affairs High Density Lipoprotein Cholesterol Intervention Trial (VAHIT) and the Bezafibrate Infarction Prevention Trial (BIP). In BIP, bezafibrate did not significantly reduce the risk of a cerebrovascular event (CVE). Bezafibrate increased the high density lipoprotein cholesterol (HDL) level by 18% to 40 mg/dl (1.03 mmol/l) and decreased triglyceride (TG) levels by 21% to 115 mg/dl (1.29 mmol/l). In contrast, in VAHIT, gemfibrozil significantly reduced the risk of investigators designated stroke (P=0.04) and TIA (P<0.001). Gemfibrozil increased HDL by 6% to 33 mg/dl (0.85 mmol/l) and decreased TG by 31% to 110 mg/dl (1.25 mmol/l). However, the baseline low density lipoprotein cholesterol (LDL) levels were higher in BIP than in VAHIT (148 versus 111 mg/dl; 3.82 versus 2.87 mmol/l). LDL levels were not markedly altered by treatment in either trial. Fibrates can improve several CVE predictors, like fibrinogen, lipoprotein (a), insulin sensitivity and platelet activity. Furthermore, lowered HDL and/or raised TG levels are associated with an increased risk of a CVE; fibrates are an appropriate treatment for this lipid profile. In conclusion, the evidence suggests that not only total cholesterol and LDL, but also HDL and TG levels predict the risk of a CVE. Statins, fibrates or a combination of these drugs can modify these variables.     

Efficacy and Safety of Lumen-Apposing Metal Stents in Management of Pancreatic Fluid Collections: Are They Better Than Plastic Stents? A Systematic Review and Meta-Analysis

Background and Aims

Endoscopic ultrasound (EUS)-guided transmural drainage has been increasingly utilized as a first-line therapeutic modality for drainage of pancreatic fluid collections (PFC). Recently, lumen-apposing metal stents (LAMS) have been utilized for management of PFCs. We conducted a systematic review and meta-analysis to evaluate the cumulative efficacy and safety of LAMS in the management of PFC (primary outcome). We also compared the efficacy and safety of LAMS with multiple plastic stents (MPS) in the management of PFC (secondary outcome).

Methods

We searched Medline, Embase and Cochrane databases from inception to November 5, 2016, to identify studies (with ≥ 10 patients) reporting technical success, clinical success, and adverse events (AE) of EUS-guided transmural drainage of PFC using LAMS. Weighted pooled rates (WPR) were calculated for technical success, clinical success and AE. Risk ratios (RR) were calculated and pooled to compare LAMS with MPS in terms of technical success, clinical success, and AE. Pooled mean difference (MD) was calculated to compare the number of endoscopic sessions required by each type of stent to achieve clinical success. All analyses were done using random effects model.

Results

Eleven studies with 688 patients were included in this meta-analysis. WPR for technical success of LAMS in PFC management was 98% (96, 99%), (I ² = 15%). WPR for clinical success was 93% (89, 96%) with moderate heterogeneity (I ² = 50%). There was no difference in clinical success for pseudocysts (PP) versus walled-off pancreatic necrosis (WON) (P = 0.51). WPR for AE was 13% (9, 20%), (I ² = 64%). AE were 10% more in WON as compared to PP (P = 0.009). Most common AE requiring intervention was stent migration (4.2%), followed by infection (3.8%), bleeding (2.4%), and stent occlusion (1.9%). Six studies with 504 patients compared the performance of LAMS with MPS. Pooled RR for technical success was 1.71 (0.38, 7.37). Pooled RR for clinical success was 0.37 (0.20, 0.67) in favor of LAMS. Pooled RR for AE was 0.39 (0.18, 0.84), (I ² = 50%). Pooled MD for number of endoscopic sessions was ? 0.84 (? 1.69, 0.01).

Conclusions

LAMS seem to have excellent efficacy and safety in the management of PFCs. They may be preferred over plastic stents as they are associated with better clinical success and lesser adverse events.

     

Are chorionic gonadotropin (HCG) and its alpha and beta subunits useful markers in non-trophoblastic tumors?

HCG and its subunits alpha and beta are produced by trophoblastic cancers constituting an index of early detection and monitoring for these tumors. Unlike HCG-alpha, we can obtain specific HCG and HCG-beta assays with LH-neutralized antiserum. Many normal non-trophoblastic tissues exhibit a HCG-like immunoreactivity. All choriocarcinomatous testicular tumors produce HCG and HCG-beta. Half of all testicular teratomas produce HCG and its subunits while a third of all seminomas exhibit an HCG-like immunoreactivity, whether choriocarcinomatous component is present or not. Serum HCG levels are elevated in seminomas (5 to 22%) as well as teratomas '55 to 89%). Less than 15% of breast, digestive and lung cancers have increased serum levels of HCG and/or its 2 subunits. HCG is most often produced by undifferentiated lung cancers, hepatoblastomas and adrenal carcinomas. There is usually a parallel relation between these serum levels and the clinical evolution of the disease under chemotherapy. In breast cancer, these levels do not constitue a "prognosis index". HCG production by non-trophoblastic tumors can induce clinical symptoms such as precocious puberty and gynecomastia.     

Are you busy for the next 5 years? Recruitment in the Childhood Asthma Prevention Study (CAPS)

OBJECTIVE: The process of recruitment into randomized controlled trials is not often reported. In the present paper, the methods used for recruitment into the Childhood Asthma Prevention Study are reported and the reasons why eligible subjects chose not to participate or withdrew from the trial are examined. METHODOLOGY: Recruitment was conducted at the antenatal clinics of six hospitals in Sydney (NSW, Australia). Pregnant women with a family history of asthma who consented to participate were randomized into one of four groups and were asked to follow a set of interventions. The study will continue until the infants are 5 years old. RESULTS: Of 7171 women screened, 2095 (29.2%) were eligible, of whom only 616 (29.4% of eligible women) were recruited. The main reasons for not taking part in the study were a lack of interest, ineligibility (on further questioning), inability to be contacted and 'too busy'. During the first 21/2 years of the trial, 10% of participants withdrew. The most common reasons for withdrawal from the study were loss of contact, family moving interstate or overseas and medical reasons. In families that withdrew from the trial or who were eligible but did not participate, the parents were significantly younger, mothers were less educated and fathers were less likely to be in full-time employment. CONCLUSIONS: By collecting demographic data on people who withdrew from the study and chose not to participate, we gained a better understanding of why our recruitment rate was low. The preferential recruitment of some sectors of the community has important implications for the ways in which future studies will be planned.     

Treatment of Hepatocellular Carcinoma——Recent Advances and Prospects in the 21~(st)Century

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Safety and efficacy of ARNI (valsartan/sacubitril) vs ACEI (enalapril) in acute heart failure – A prospective observational study

ObjectiveTo compare the safety and efficacy of valsartan/sacubitril (angiotensin receptor neprilysin inhibitor [ARNI]) against enalapril (angiotensin-converting enzyme inhibitor [ACEI]) in patients with acute heart failure at 6-month follow-up.MethodsIn this prospective, single centre, and observational study conducted between September 2017 and February 2020 in India, patients with acute decompensated heart failure with reduced ejection fraction (<40%) were included. Patients were divided in two groups: valsartan/sacubitril (ARNI) group and enalapril (ACEI). Patients were followed up for at least 6 months after administration of first dose and were evaluated for safety, efficacy, and tolerability of target drug. Student's independent t-test was employed for comparing continuous variables. Chi-square test or Fisher's exact test, whichever appropriate, was applied for comparing categorical variables.ResultsA total of 200 patients were included in the present study, 100 each in ARNI and ACEI group. The mean age of the population was 61.2 ± 8.4 years and 62.6 ± 8.6 years in ARNI group and ACEI group, respectively. The mean maximum tolerated dose by population in ARNI group was 203.6 mg and 8.9 mg in ACEI group. Readmission for heart failure were seen significantly higher in ACEI group than ARNI group (p value = 0.001). Parameters like ejection fraction, left ventricular end diastolic and systolic dimensions, 6 min walk test and Kansas City Cardiomyopathy Questionnaires (KCCQ) showed p values < 0.05 between the groups.ConclusionThe ARNI study group showed better safety and efficacy outcomes at the end of 6 months follow-up compared to ACEI group.     

Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable?

We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6‐month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty‐five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X‐ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in‐hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.     

Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable?

We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.