Financial and Work-flow Benefits of Reducing Avoidable Hospitalizations of Nursing Home Residents.

OBJECTIVES: 1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes. DESIGN: A CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012-2020). SETTING AND PARTICIPANTS: Setting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region. METHODS: Financial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis. RESULTS: There was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015-2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014-2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes. CONCLUSIONS: Reducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization. IMPLICATIONS: Focusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Results of the Missouri Quality Initiative in Sustaining Changes in Nursing Home Care: Six-Year Trends of Reducing Hospitalizations of Nursing Home Residents.

OBJECTIVES: The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents. DESIGN: A CMS funded demonstration project analyzed over 6-years using a single group design. SETTING AND PARTICIPANTS: The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019. MEASURES: Resident data were analyzed using descriptive methods of aggregate facilities' hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described. INTERVENTION: Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents. RESULTS: Total transfers for 2014-2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified. CONCLUSIONS/IMPLICATIONS: The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN's daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations' support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Longitudinal Impact of APRNs on Nursing Home Quality Measures in the Missouri Quality Initiative.

OBJECTIVES: To measure the impact of advanced practice nurses (APRNs) on quality measures (QM) scores of nursing homes (NHs) in the CMS funded Missouri Quality Initiative (MOQI) that was designed to reduce avoidable hospitalizations of NH residents, improve quality of care, and reduce overall healthcare spending. DESIGN: A four group comparative analysis of longitudinal data from September 2013 thru December 2019. SETTING: NHs in the interventions of both Phases 1 (2012-2016) and 2 (2016-2020) of MOQI (n=16) in the St. Louis area; matched comparations in the same counties as MOQI NHs (n=27); selected Phase 2 payment intervention NHs in Missouri (n=24); NHs in the remainder of the state (n=406). PARTICIPANTS: NHs in Missouri Intervention: Phase 1 of The Missouri Quality Initiative (MOQI), a Centers for Medicare and Medicaid (CMS) Innovations Center funded research initiative, was a multifaceted intervention in NHs in the Midwest, which embedded full-time APRNs in participating NHs to reduce hospitalizations and improve care of NH residents. Phase 2 extended the MOQI intervention in the original intervention NHs and added a CMS designed Payment Intervention; Phase 2 added a second group of NHs to receive the Payment. Intervention Only. MEASUREMENTS: Eight QMs selected by CMS for the Initiative were falls, pressure ulcers, urinary tract infections, indwelling catheters, restraint use, activities of daily living, weight loss, and antipsychotic medication use. For each of the monthly QMs (2013 thru 2019) an unobserved components model (UCM) was fitted for comparison of groups. RESULTS: The analysis of QMs reveals that that the MOQI Intervention + Payment group (group with the embedded APRNs) out-performed all comparison groups: matched comparison with neither intervention, Payment Intervention only, and remainder of the state. CONCLUSION: These results confirm the QM analyses of Phase 1, that MOQI NHs with full-time APRNs are effective to improve quality of care.

The Role of Serotonin Transporter in Human Lung Development and in Neonatal Lung Disorders.

Introduction. Failure of the vascular pulmonary remodeling at birth often manifests as pulmonary hypertension (PHT) and is associated with a variety of neonatal lung disorders including a uniformly fatal developmental disorder known as alveolar capillary dysplasia with misalignment of pulmonary veins (ACD/MPV). Serum serotonin regulation has been linked to pulmonary vascular function and disease, and serotonin transporter (SERT) is thought to be one of the key regulators in these processes. We sought to find evidence of a role that SERT plays in the neonatal respiratory adaptation process and in the pathomechanism of ACD/MPV. Methods. We used histology and immunohistochemistry to determine the timetable of SERT protein expression in normal human fetal and postnatal lungs and in cases of newborn and childhood PHT of varied etiology. In addition, we tested for a SERT gene promoter defect in ACD/MPV patients. Results. We found that SERT protein expression begins at 30 weeks of gestation, increases to term, and stays high postnatally. ACD/MPV patients had diminished SERT expression without SERT promoter alteration. Conclusion. We concluded that SERT/serotonin pathway is crucial in the process of pulmonary vascular remodeling/adaptation at birth and plays a key role in the pathobiology of ACD/MPV.

Relationship between cellular ATP, potassium, sodium and magnesium concentrations in mammalian and avian erythrocytes.

Intracellular K+/Na+ ratios of erythrocytes of various mammalian species are known to differ markedly. We have measured ATP, K+, Na+, Mg2+, H2O contents of erythrocytes of twelve mammalian and three avian species. Our results indicate that the intracellular ATP concentration in erythrocytes of different species is in close positive correlation with the K+/Na+ ratios (linear correlation coefficient, r = 0.852). Furthermore, ATP levels in erythrocytes of individual sheep with different potassium concentrations correspond with their K+/Na+ ratios (r = 0.747). Intracellular magnesium concentrations also correlate with ATP concentrations in erythrocytes of different species (r = 0.629) and in different sheep (r = 0.549).

Preparing Nursing Homes for the Future of Health Information Exchange.

OBJECTIVE: Our purpose was to describe how we prepared 16 nursing homes (NHs) for health information exchange (HIE) implementation. BACKGROUND: NH HIE connecting internal and external stakeholders are in their infancy. U.S. initiatives are demonstrating HIE use to increase access and securely exchange personal health information to improve patient outcomes. METHOD: To achieve our objectives we conducted readiness assessments, performed 32 hours of clinical observation and developed 6 use cases, and conducted semi-structured interviews with 230 participants during 68 site visits to validate use cases and explore HIE. RESULTS: All 16 NHs had technology available to support resident care. Resident care technologies were integrated much more with internal than external stakeholders. A wide range of technologies were accessible only during administrative office hours. Six non-emergent use cases most commonly communicated by NH staff were: 1) scheduling appointments, 2) Laboratory specimen drawing, 3) pharmacy orders and reconciliation, 4) social work discharge planning, 5) admissions and pre-admissions, and 6) pharmacy-medication reconciliation. Emerging themes from semi-structured interviews about use cases included: availability of information technology in clinical settings, accessibility of HIE at the point of care, and policies/procedures for sending/receiving secure personal health information. CONCLUSION: We learned that every facility needed additional technological and human resources to build an HIE network. Also, use cases help clinical staff apply theoretical problems of HIE implementation and helps them think through the implications of using HIE to communicate about clinical care.

Cerebral mucormycosis: proton MR spectroscopy and MR imaging.

Proton magnetic resonance spectroscopy (MRS) was integrated with magnetic resonance imaging (MRI) in the evaluation of a case of cerebral mucormycosis. MRS showed markedly elevated lactate, depleted N-acetyl aspartate and metabolite resonances attributable to succinate and acetate. The spectroscopy profile is essentially similar to that of bacterial abscess but without the commonly seen resonances of the amino acids valine, leucine and isoleucine. Our extensive literature review did not yield any reports of MRS findings on cerebral mucormycosis. MRS prospectively limited the differential diagnoses given the otherwise nonspecific and complex MR imaging findings in our immunosuppressed patient.

Human and dog erythrocytes: relationship between cellular ATP levels, ATP consumption and potassium concentrations.

The intracellular K+/Na+ ratio of various mammalian cell types are known to differ remarkably. Particularly noteworthy is the fact that erythrocytes of different mammalian species contain entirely different potassium and sodium concentrations. The human erythrocyte is an example of the supposedly "normal" high potassium cell, while the dog erythrocyte contains ten times more sodium than potassium ions (Table I). Furthermore, this difference is sustained despite the plasma sodium and potassium concentrations being almost identical in both species (high Na+ and low K+). In spite of these inorganic ion differences, both human and dog erythrocytes contain 33% dry material (mostly Hb) and 67% water. Conventional cell theory would couple cellular volume regulation with Na+ and K+ dependent ATPase activity which is believed to control intracellular Na+/K+ concentrations. Since the high Na+ and low K+ contents of dog erythrocytes are believed to be due to the lack of the postulated Na/K-ATPase enzyme, they must presumably have an alternative mechanism of volume regulation, otherwise current ideas of membrane ATPase activity coupled volume regulation need serious reconsideration. The object of our investigation was to explore the relationship between ATPase activity, ATP levels and the Na+/K+ concentrations in human and dog erythrocytes. Our results indicate that the intracellular ATP level in erythrocytes correspond with their K+, Na+ content. They are discussed in relation to conventional membrane transport theory and also to Ling's "association-induction hypothesis", the latter proving to be a more useful basis on which to interpret results.

Cation distribution in mammalian red blood cells: interspecies and intraspecies relationships between cellular ATP, potassium, sodium and magnesium concentrations.

The intracellular K+/Na+ ratio of erythrocytes of different mammalian species are known to differ markedly. These differences are sustained despite plasma potassium and sodium concentrations being almost identical, i.e. high [Na+] and low [K+], in all mammalian species. Conventional cell theory couples intracellular K+ and Na+ concentrations with Na+/K(+)-dependent ATPase activity. Ling's Association-Induction (AI) hypothesis couples intracellular K+ and Na+ concentrations with the concentration of ATP, by way of an inductive adsorption of both monovalent cations on the available terminal and lateral carboxyl groups of proteins. Based on the working hypothesis, different relationships are expected between the erythrocyte K+ and Na+ concentrations and ATP levels. Our results indicate that the intracellular ATP level in erythrocytes of different species corresponds with intracellular K+ and Na+ levels, K+/Na+ ratios and total K+ + Na+ levels. Similar relationships were revealed between the erythrocyte ATP and monovalent cation contents of different individual sheep.

The ontogeny of human pulmonary angiotensin-converting enzyme and its aberrant expression may contribute to the pathobiology of bronchopulmonary dysplasia (BPD).

INTRODUCTION: The mammalian lung possesses the highest level of angiotensin converting enzyme (ACE) amongst all the organs. ACE is known to generate angiotensin (AT)-II from AT-I and to regulate serum bradykinin level, thereby controlling blood pressure. Recent data, however, indicate a role for ACE derived AT-II in angiogenesis, pulmonary hypertension, and neonatal lung disease. The ontogeny of ACE in humans has not been investigated. We studied pulmonary ACE expression during human lung development and in human bronchopulmonary dysplasia (BPD). MATERIAL AND METHODS: Human fetal autopsy lung tissue representing all three trimesters (12, 13, 16, 18, 24, 34, 39, and 40 weeks of gestational age (WGA)), as well as from 1 to 10 years of age with no significant lung pathology were used. In addition lung sections of patients with BPD (n = 5) were selected. The slides were immunostained using an anti-ACE monoclonal antibody. The temporal and spatial pattern of ACE expression was contrasted to that of the pan-endothelial marker CD31. Staining intensity was graded. RESULTS: Mildly diffuse and strong microvascular endothelial immunreactivity for ACE was seen in the human fetus as early as 12 WGA. ACE expression peaked at mid gestation and remained high throughout gestation and postnatally. In BPD lungs ACE endothelial staining was largely absent, and when focal staining was observed the intensity was weak. CONCLUSION: We established that ACE expression is present in the human fetal lung as early as 12 WGA, remains active pre- and postnatally, and ACE expression was downregulated in BPD lungs. We speculate that ACE may be involved in the process of lung development.

Neither normal nor diseased placentas contain lymphatic vessels.

BACKGROUND: Scant data on placental lymphatic vessels have pointed to the absence of lymphatic circulation. A recent study on mesenchymal dysplasia (MD), however, has identified pathologic lymphangiogenesis using the D2-40 lymphatic marker. These conflicting data have prompted us to investigate whether lymphatic vessels are present in normal developing placentas and in placental disorders characterized by cistern formation. DESIGN: Seventeen human placentas without significant pathological abnormality ranging from 12 to 39 weeks of gestational age were studied. Cisternal placental disorders were represented by mesenchymal dysplasia (n = 1), partial hydatitiform mole (n = 2), spontaneous abortion (n = 3) and complete hydatiform mole (n = 2). To identify lymphatic vessels, we used lymphatic endothelial markers Prox-1 and D2-40. The pan-endothelial marker CD31 was used to highlight overall placental vasculature and to determine if the lining cells of cisterns were of endothelial origin. Lymphatic marker positivity was assessed in maternal (decidual) as well as in fetal (chorionic villous) vasculature. RESULTS: No staining with Prox-1 or D2-40 was identified in fetal vessels in developing or term placentas, or in selected cisternal placental disorders, although both markers highlighted a number of thin-walled decidual vessels. Cistern lining cells were negative for Prox-1, D2-40 and CD31. D2-40 consistently marked stromal cells in chorionic villi and highlighted perivascular/pericellular extracellular matrix. CONCLUSION: We established that no lymphatic vasculature is present in the chorionic villi during development, at term or in selected edematous placental disorders. The cisternal lining cells are not endothelial cells; most likely they are of stromal cell origin. Lymphangiogenesis is a part of decidual vascular remodeling during gestation.

Primary mesenteric angiosarcoma in a child with associated lymphangiectasia: a case report.

Angiosarcomas are rare tumors in children, usually occurring in soft tissue and liver. By contrast, angiosarcoma in adults usually occurs in the extremities in conjunction with lymphedema. Mesenteric angiosarcoma has only rarely been reported. When angiosarcomas arise in this location, they usually represent a 2nd malignancy following Hodgkin's lymphoma. We report a child who presented to the emergency room with an acute abdomen and underwent emergency surgery for a mesenteric angiosarcoma with associated lymphangiectasia of the bowel and mesentery. A brief review of the literature and the nomenclature of these unusual tumors are discussed.

Homozygous mutation of MYBPC3 associated with severe infantile hypertrophic cardiomyopathy at high frequency among the Amish.

BACKGROUND: Familial hypertrophic cardiomyopathy (HCM) is a leading cause of sudden cardiac death among young and apparently healthy people. Autosomal dominant mutations within genes encoding sarcomeric proteins have been identified. An autosomal recessive form of HCM has been discovered in a group of Amish children that is associated with poor prognosis and death within the first year of life. Affected patients experienced progressive cardiac failure despite maximal medical treatment. Postmortem histology showed myofibre disarray and myocyte loss consistent with refractory clinical deterioration in affected infants. OBJECTIVE: To conduct a genome-wide screen for linkage and try to identify an autozygous region which cosegregates with the infant cardiac phenotype METHODS AND RESULTS: An autozygous region of chromosome 11 which cosegregates with the infant cardiac phenotype was identified. This region contained the MYBPC3 gene, which has previously been associated with autosomal dominant adult-onset HCM. Sequence analysis of the MYBPC3 gene identified a splice site mutation in intron 30 which was homozygous in all affected infants. All surviving patients with the homozygous MYBPC3 gene mutations (3330+2T>G) underwent an orthotopic heart transplantation. CONCLUSIONS: Homozygous mutations in the MYBPC3 gene have been identified as the cause of severe infantile HCM among the Amish population.

Resolving ethical conflicts in a managed health care environment.

The managed health care environment is replete with situations that create ethical conflicts for the professional social worker. This article examines two such conflicts--competing fiduciary relationships and justice versus injustice--as they relate to social work practice and the 1996 revised NASW Code of Ethics. Mechanisms to reduce these ethical conflicts are presented. The obligation for social workers to participate in social action as a method of reducing injustices found in managed care environments is examined through the principle of distributive justice, egalitarianism, and the NASW Code of Ethics.

Preserving end-of-life autonomy: the Patient Self-Determination Act and the Uniform Health Care Decisions Act.

As medical technology continues to advance and health care choices become more complicated, the preservation of end-of-life autonomy is an increasingly important issue faced by various client populations. This article examines two legislative efforts aimed at preserving end-of-life autonomy: The Patient Self-Determination Act and the Uniform Health Care Decisions Act. The enactment of both acts will provide a more comprehensive approach to advance directive planning. The article advocates for passage of the Uniform Health Care Decisions Act in all 50 states. Implications for social work practice are discussed from a research, community action, and clinical perspective.

Cortical responses from adults and infants to complex visual stimuli.

Event-related potentials (ERPs) time-locked to the onset of visual stimuli were extracted from the EEG of normal adult (N = 16) and infant (N = 23) subjects. Subjects were not required to make any response. Stimuli delivered to the adults were 150 msec exposures of 2 sets of colored slides projected in 4 blocks, 2 in focus and 2 out of focus. Infants received 2-sec exposures of slides showing people, colored drawings or scenes from Disneyland, as well as 2-sec illuminations of the experimenter as she played a game or of a TV screen the baby was watching. The adult ERPs showed 6 waves (N1 through P4) in the 140--600-msec range; this included a positive wave at around 350 msec that was large when the stimuli were focused and smaller when they were not. The waves in the 150--200-msec range, by contrast, steadily dropped in amplitude as the experiment progressed. The infant ERPs differed greatly from the adult ones in morphology, usually showing a positive (latency about 200 msec)--negative(5--600msec)--positive(1000msec) sequence. This ERP appeared in all the stimulus conditions; its presence or absence, furthermore, was correlated with whether or not the baby seemed interested in the stimuli. Four infants failed to produce these ERPs; an independent measure of attention to the stimuli, heart rate deceleration, was demonstrated in two of them. An electrode placed beneath the eye to monitor eye movements yielded ERPs closely resembling those derived from the scalp in most subjects; reasons are given for assigning this response to activity in the brain, probably at the frontal pole. This study appears to be one of the first to search for cognitive 'late waves' in a no-task situation. The results suggest that further work with such task-free paradigms may yield additional useful techniques for studying the ERP.

Brain stem evoked response audiometry in newborn hearing screening.

Brain stem evoked response audiometry (BERA) has been used as an auditory screening procedure in three groups of newborn infants. Group 1 consisted of 220 normal-term infants who were tested within 72 hours of birth; no hearing abnormalities were uncovered (386 ears), and their threshold responses (for clicks) lay between a 10- and 20-dB hearing level (re: adult). Group 2 consisted of 75 newborns who were treated in an intensive care unit for one to 14 weeks; four were found to have severe sensorineural hearing loss (seven ears) at the time of discharge. Group 3 consisted of a group of 325 infants, 1 year or older, who had previously been discharged from the same intensive care unit; of these infants, an additional four showed severe sensorineural hearing loss. All abnormalities that were identified by BERA were subsequently confirmed by conventional audiometric measures. The estimate of an incidence of severe hearing loss in one of 50 infants who required intensive care in the neonatal period calls for careful testing of this population.

Brain stem auditory-evoked responses in premature infants.

Brain stem auditory-evoked responses were recorded in 24 infants ranging in age from six-weeks premature to term. At a given age, the latency of the response increased with decreasing stimulus intensity. Further, as age increased, there was a systematic decrease in latency of the response at each sound intensity level. The response was shown not to be fatigue or sleep stage. It may, therefore, be of use for evaluating auditory function in high-risk newborn infants.

Actin-filament motion in the in vitro motility assay has a periodic component.

The interaction between actin and myosin can be studied in the in vitro motility assay, where fluorescently labelled actin filaments are observed to move over a lawn of myosin heads. To examine details of this movement, we measured systematically the velocities of the front end, rear end, and centroid of the actin filament as the filament translated over the assay surface. We found that these velocities exhibited an unexpectedly periodic component, alternating regularly between high and low values, superimposed on the steady velocity component. The period of the oscillatory component was approximately 380 ms. When translation was stopped by an increase in osmolarity, the filaments wiggled with a periodicity similar to the translating filament, implying that wiggling and translation may be related. Rigor filaments showed no periodicity. From the frequency content of the auto- and cross-correlation functions derived from the velocities of the front end, rear end, and centroid of the actin filament, we infer a deterministic, possibly wave-like process travelling along the actin filament. Potential molecular mechanisms underlying this phenomenon are considered.