Ambulatory care-sensitive emergency visits among patients with medical home access.

OBJECTIVES: To characterize patterns of emergency department (ED) utilization for ambulatory care-sensitive conditions (ACSCs) among patients with established care within a patient-centered medical home. STUDY DESIGN: Retrospective chart review using Michigan Medicine's (formerly University of Michigan Health System) electronic health record. METHODS: Ten general medicine (GM) physicians reviewed 256 ambulatory care-sensitive ED encounters that occurred between January 1, 2014, and December 31, 2014, among patients of a GM medical home. Physician reviewers abstracted from the medical record the day and time of ED presentation and the source of ED referral (eg, patient self-referral vs physician referral). Physicians assessed the appropriateness of the care location (eg, ED vs primary care). Interrater reliability was assessed using the kappa statistic, and the χ2 test was used to assess differences in the appropriateness of the care location according to ED referral source. RESULTS: Compared with all other days of the week, the fewest number of ED visits occurred on weekend days, and nearly half of patients (48%) presented to the ED after daytime hours, which were defined as 8 am to 3:59 pm. The majority (n = 185; 72%) of patients were self-referred to the ED. The ED was considered the appropriate care location in more than half (53%) of the reviewed cases. Among the 119 cases considered appropriate for GM management, the majority (86%) were self-referred to the ED. CONCLUSIONS: Patients with ACSCs often presented to the ED without contacting their medical home. Frequently, the ED is the most appropriate location given symptoms at presentation.

Heart failure: clinical problem and management issues.

Heart failure (HF) often presents as dyspnea either with exertion and/or recumbency. Patients also experience dependent swelling and fatigue. Measurement of the left ventricular ejection fraction (LVEF) identifies HF patients who may respond to pharmacologic therapy and/or electrophysiologic device implantation. Angiotension converting enzyme inhibitors, beta blockers, and aldosterone inhibitors can significantly lower the mortality and morbidity of HF in patients with an LVEF less than 35%. Cardiac defibrillators and biventricular pacemakers can also improve outcomes in selected patients with a decreased LVEF. The authors provide a guide for therapeutic decisions based on the inclusion criteria of the major clinical trials.

Could a single dose of pneumococcal conjugate vaccine in children be effective? Modeling the optimal age of vaccination.

Using incidence rates from CDC's Active Bacterial Core surveillance and immunogenicity data from the Navajo/Apache trial of pneumococcal conjugate vaccine (PCV), we used Markov modeling to predict the optimal age to give a single dose of PCV. Antibody concentration thresholds of 0.35 and 1.0 mcg/ml were considered protective. Our outcome was vaccine serotype-specific invasive pneumococcal disease (IPD) incidence at 24 months. The models predicted the optimal age to vaccinate is 5-7 months with vaccine-induced immunologic memory and 8-10 months without memory. IPD reduction ranged from 15 to 62%, depending on model parameters. A single PCV dose in infants could prevent substantial IPD.

Decision analysis of hormone replacement therapy after the Women's Health Initiative.

OBJECTIVES: The purpose of this study was to estimate the quality-adjusted life expectancy with and without hormone replacement therapy. STUDY DESIGN: We compared the quality-adjusted life expectancy with and without combination hormone replacement therapy in three cohorts of women with menopausal symptoms over a 20-year period using a Markov decision-analysis model. Women were either at high or low risk for breast cancer and coronary heart disease or at high risk for osteoporosis. RESULTS: Hormone replacement therapy decreases life expectancy slightly compared with no hormone replacement therapy if menopausal symptoms are not considered. However, if relief from menopausal symptoms is considered and the usefulness of life with symptoms is worth <0.996 compared with life without symptoms, then 5 years of hormone replacement therapy provides equivalent quality-adjusted life-years. CONCLUSION: Combination hormone replacement therapy decreases life expectancy if quality of life with menopausal symptoms is not considered. However, the benefit of hormone replacement therapy can exceed the risk for women with menopausal symptoms.