Hospital Readmission From Home Health Care Before and After Prospective Payment

PURPOSE: To describe and compare clients who were readmitted to the hospital during an episode of home health care, before and after the inception of the prospective payment system (PPS). DESIGN: A longitudinal mixed design was used to replicate a study conducted 9 years previously (pre-PPS) in the same home care agency in the central part of the United States. METHODS: Seventy-six closed-case medical records from a not-for-profit hospital-affiliated home care agency were retrospectively reviewed and compared to pre-PPS data. The same data collection tool, the Hospital Readmission Inventory, was used for both pre- and post-PPS studies. Nurse administrators at the data collection agency were interviewed concerning comparative results. FINDINGS: Currently readmitted clients were sicker than were those in the previous research report, they were readmitted sooner for a different diagnosis, and they had less continuity of services. CONCLUSIONS: The home health care industry has undergone a dramatic change in payment for services, from fee-for-service to PPS. Of particular concern is the adverse patient outcome of an unplanned hospital readmission. Prior studies have characterized such patients in home health care, but no comparative reports were found in a literature search since the inception of PPS. Findings from this study indicated that an increased emphasis on cost containment and higher-risk clients appear to have changed patterns of care delivery.     

'Event tree' analysis of out-of-hospital cardiac arrest data: confirming the importance of bystander CPR

OBJECTIVE: The British National Service Framework (NSF) for heart disease commended the 'Utstein style' for auditing out-of-hospital cardiac arrests. The NSF also set standards for pre-hospital treatment and response times. To increase the flexibility of Utstein, an 'event tree' technique is proposed as an audit tool. Event trees consist of nodes and branches on which numbers, percentages or probability values are entered. METHODS: Using the London Ambulance Service's (LAS) 1997 database on 3,759 out-of-hospital cardiac arrests, 2,772 arrests witnessed by lay bystanders or unwitnessed were analysed focusing on bystander cardiopulmonary resuscitation (BCPR) and response times. RESULTS: The Utstein template showed that witnessed arrests in ventricular fibrillation (VF) or ventricular tachycardia (VT) who had received BCPR achieved a return of spontaneous circulation (ROSC) in the field significantly more often than non-BCPR recipients-26 versus 16% (P=0.006). But the likelihood of being admitted to a hospital bed, and discharged alive, was only marginally better for BCPR recipients. To examine the influence of BCPR on the presenting rhythm an event tree showed that in 48% of witnessed BCPR cases the presenting rhythm was VF/VT, whereas, for witnessed non-BCPR cases, 27% were in VF/VT (P<0.0001). With unwitnessed arrests, 31% of BCPR cases were in VF/VT compared with 18% for non-BCPR cases (P<0.0001). Call to scene time was less than 8 min for 66% of all VF/VT arrests. CONCLUSION: The event trees, when combined with the Utstein template, demonstrated the importance of examining comprehensively datasets for both witnessed and unwitnessed cardiac arrests when monitoring performance standards. The analyses also emphasised the relevance of community programmes in Greater London for teaching basic life saving skills.     

Adverse Tumor Biology Associated with Mesenterico-Portal Vein Resection Influences Survival in Patients with Pancreatic Ductal Adenocarcinoma

Background

Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

Patients and Methods

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD?VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.

Results

Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD?VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD?VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD?VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.

Conclusions

PD with VR has similar morbidity but worse OS compared with a PD?VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.     

Using mobile technology to overcome language barriers in medicine

Australia has a large migrant population with variable fluency in English. Interpreting services help ensure that healthcare services are delivered appropriately to these populations. However, the use of professional interpreters in hospitals is expensive. There are also issues with service availability and convenience. Mobile devices containing software with translating abilities have promising potential to improve communication between patients and hospital staff as an adjunct to professional interpreters. It is highly convenient and inexpensive. There are concerns about the accuracy of the interpretation done with such software and more research needs to be carried out to support or allay these concerns. For now, clinically important and medicolegal related interpretation should be undertaken by professional interpreters whereas less crucial tasks may be performed with the help of interpreting software on mobile devices.     

Surgical delivery of drug releasing poly(lactic-co-glycolic acid)/poly(ethylene glycol) paste with in vivo effects against glioblastoma

Introduction

The median survival of patients with glioblastoma multiforme (astrocytoma grade 4) remains less than 18 months despite radical surgery, radiotherapy and systemic chemotherapy. Surgical implantation of chemotherapy eluting wafers into the resection cavity has been shown to improve length of survival but the current licensed therapy has several drawbacks. This paper investigates in vivo efficacy of a novel drug eluting paste in glioblastoma.

Methods

Poly(lactic-co-glycolic acid)/poly(ethylene glycol) (PLGA/PEG) self-sintering paste was loaded with the chemotherapeutic agent etoposide and delivered surgically into partially resected tumours in a flank murine glioblastoma xenograft model.

Results

Surgical delivery of the paste was successful and practical, with no toxicity or surgical morbidity to the animals. The paste was retained in the tumour cavity, and preliminary results suggest a useful antitumour and antiangiogenic effect, particularly at higher doses. Bioluminescent imaging was not affected significantly by the presence of the paste in the tumour.

Conclusions

Chemotherapy loaded PLGA/PEG paste seems to be a promising technology capable of delivering active drugs into partially resected tumours. The preliminary results of this study suggest efficacy with no toxicity and will lead to larger scale efficacy studies in orthotopic glioblastoma models.     

Use of preoperative antidepressants is not associated with postoperative hospital length of stay

Purpose

Antidepressant medications are commonly prescribed for the treatment of depression, anxiety, and chronic pain. Their use may lead to a number of side effects with important implications in the perioperative period. Our aim was to examine the effect of preoperative antidepressant administration on post-surgical hospital length of stay (LOS) in elective non-cardiac surgery patients.

Design

Historical cohort study.

Methods

Demographic and preoperative data were collected by chart review for all non-cardiac surgery patients who were assessed in the preoperative consult clinic from April 2008 through February 2009. Patients were grouped according to whether or not they were taking antidepressant medications. Median length of stay was compared between patients who took antidepressants preoperatively and those who did not.

Results

Data were collected for 3,692 patients. Two hundred eighty-nine (7.8%) patients were taking antidepressants preoperatively. Use of antidepressants was not associated with an increased hospital LOS. The median LOS was four days both for patients who took antidepressants preoperatively (95% confidence interval [CI] 4 to 4) and for those who did not (95% CI 3 to 5) (P = 0.13).

Conclusions

The preoperative use of antidepressant medications was not associated with increased postoperative hospital LOS following elective non-cardiac surgery.