The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study.

BACKGROUND: Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs). OBJECTIVE: To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD. EXPOSURE: OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD. KEY RESULTS: The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD. CONCLUSIONS: This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study.

BACKGROUND: Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission. AIM: The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs. SETTING: Two academic hospitals and six SNFs in Baltimore, MD. PARTICIPANTS: Hospitalists and medical directors or directors of nursing from the partner SNF. PROGRAM DESCRIPTION: During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021. PROGRAM EVALUATION: During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions. DISCUSSION: Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.

Transforming Health Care from Volume to Value: Moving the Needle Through Population Health.

United States health systems face unique challenges in transitioning from volume-based to value-based care, particularly for academic institutions. Providing complex specialty and tertiary care dependent on servicing large geographic areas, and concomitantly meeting education and research academic missions may limit the time and resources available for focusing on the care coordination needs of complex local populations. Despite these challenges, academic medicine is well situated to capitalize on the promise of value-based care and to lead broad improvements in both teaching and nonteaching hospitals. If properly executed, value-based care and complex specialty care can be complementary and synergistic. We postulate that the transition from volume to value in population health requires all health care organizations to advance and formalize infrastructure in 3 core areas: organizational capabilities; provider engagement; and engagement of the patient, family, and community. Although these apply to all organizations, for academic health systems, this transition must also be interwoven with the other domains of the tripartite mission.

The Use of Rituximab in the Management of Refractory Dermatomyositis.

There is growing adoption of rituximab in the treatment of dermatomyositis patients whose disease is refractory to steroids. However, the effects have not been extensively studied. This is a retrospective study of 25 patients with dermatomyositis who were treated with rituximab. Data from January 2000 to July 2014 was obtained from a clinical data repository, which yielded results from two tertiary centers in the United States. We analyzed information on muscle weakness, skin disease, enzyme levels, and immunosuppressive medication use before and after treatment with rituximab. The follow-up time was six months. Among the patients with skin disease before treatment with rituximab, 72.2% had a clinical improvement in their skin disease at the follow-up visit (P less than0.01). Among the patients with proximal muscle weakness before treatment with rituximab, 81.8% had clinical improvement in their symptoms at the follow-up visit (P less than0.01). The average prednisone dose before rituximab therapy was 18.9 mg, and this dropped to 11.0 mg at follow up (P less than 0.05). The average number of immunosuppressive medications taken by patients dropped from 2.04 to 1.74 (P less than0.05). These changes were less in magnitude and significance among the subset of patient that had an additional connective tissue autoimmune condition.

J Drugs Dermatol. 2017;16(2):162-166.

Granulomatous skin involvement in a patient with an unusual NOD2 mutation.

Blau syndrome is a rare disorder that is classically characterised by granulomatous arthritis, skin eruptions and uveitis, which occur in the absence of lung involvement. Blau syndrome has been linked to encoding mutations in the NOD-2 gene and is inherited in an autosomal dominant form. The most commonly observed mutations are missense substitutions affecting the arginine residue at position 334. The rare E600A mutation has been described as causing uveitis without skin involvement. Our patient is a 54-year-old man with an unusual heterozygous c.1799A>C(E600A) mutation, who was seen for bilateral lower extremity swelling and pain. On physical examination, he was found to have lower leg oedema with decreased hair growth on the affected area. Biopsy showed non-caseating micro-granulomas consistent with a diagnosis of Blau syndrome. The patient had excellent response to colchicine, but this was stopped because he developed elevated transaminases. Thus, we present an unusual genetic form of a rare condition and we demonstrate skin involvement in a subtype where cutaneous involvement has not hitherto been reported. In addition, the type and presentation of the skin involvement is different from that normally found in classic Blau syndrome. Finally, we report his response to colchicine, although it was ultimately not tolerated by this patient.

Cognition and take-up of subsidized drug benefits by Medicare beneficiaries.

IMPORTANCE: Take-up of the Medicare Part D low-income subsidy (LIS) by eligible beneficiaries has been low despite the attractive drug coverage it offers at no cost to beneficiaries and outreach efforts by the Social Security Administration. OBJECTIVE: To examine the role of beneficiaries' cognitive abilities in explaining this puzzle. DESIGN AND SETTING: Analysis of survey data from the nationally representative Health and Retirement Study. PARTICIPANTS: Elderly Medicare beneficiaries who were likely eligible for the LIS, excluding Medicaid and Supplemental Security Income recipients who automatically receive the subsidy without applying. MAIN OUTCOMES AND MEASURES: Using survey assessments of overall cognition and numeracy from 2006 to 2010, we examined how cognitive abilities were associated with self-reported Part D enrollment, awareness of the LIS, and application for the LIS. We also compared out-of-pocket drug spending and premium costs between LIS-eligible beneficiaries who did and did not report receipt of the LIS. Analyses were adjusted for sociodemographic characteristics, household income and assets, health status, and presence of chronic conditions. RESULTS: Compared with LIS-eligible beneficiaries in the top quartile of overall cognition, those in the bottom quartile were significantly less likely to report Part D enrollment (adjusted rate, 63.5% vs 52.0%; P = .002), LIS awareness (58.3% vs 33.3%; P = .001), and LIS application (25.5% vs 12.7%; P < .001). Lower numeracy was also associated with lower rates of Part D enrollment (P = .03) and LIS application (P = .002). Reported receipt of the LIS was associated with significantly lower annual out-of-pocket drug spending (adjusted mean difference, -$256; P = .02) and premium costs (-$273; P = .02). CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries likely eligible for the Part D LIS, poorer cognition and numeracy were associated with lower reported take-up. Current educational and outreach efforts encouraging LIS applications may not be sufficient for beneficiaries with limited abilities to process and respond to information. Additional policies may be needed to extend the financial protection conferred by the LIS to all eligible seniors.

Economic evaluations in shoulder pathologies: a systematic review of the literature.

BACKGROUND: Economic evaluations provide decision makers with a tool for reducing health care costs because they assess both the costs and consequences of health care interventions. This study reviewed the quality of published economic evaluations for shoulder pathologies. MATERIALS AND METHOD: A MEDLINE search was conducted to identify articles published from 1980 to 2010 that contained "cost" or "economic" combined with terms for several shoulder disorders and treatments. We selected studies that fit the definition of 1 of the 4 routinely performed economic evaluations: cost-minimization, cost-effectiveness, cost-utility, and cost-benefit analyses. Study quality was determined by measuring adherence to 6 established health economic principles, as described in the literature. RESULTS: The search retrieved 942 studies. Of these, 32 were determined to be economic evaluations, and 53% of the economic evaluations were published from 2005 to 2010. Only 8 of the 32 studies (25%) adhered to all 6 health economic principles. Publication in a nonsurgical journal (P < .05) or in more recent years (P < .01) was significantly associated with higher quality. CONCLUSION: Future health care resource allocation will likely be based on the economic feasibility of treatments. Although the number and quality of economic evaluations of shoulder disorders have risen in recent years, the current state of the literature is poor. Given that availability of such data may factor in private and public reimbursement decisions, there is a clear demand for more rigorous economic evaluations.