Major perioperative morbidity does not affect long-term survival in patients undergoing esophagectomy for cancer of the esophagus or gastroesophageal junction.

INTRODUCTION: The incidence of cancer of the esophagus/GE junction is dramatically increasing but continues to have a dismal prognosis. Esophagectomy provides the best opportunity for long-term cure but is hampered by increased rates of perioperative morbidity. We reviewed our large institutional experience to evaluate the impact of postoperative complications on the long-term survival of patients undergoing resection for curative intent. METHODS: We identified 237 patients who underwent esophagogastrectomy, with curative intent, for cancer between 1994 and 2008. Complications were graded using the previously published Clavien scale. Survival was calculated using Kaplan-Meier methodology and survival curves were compared using log-rank tests. Multivariate analysis was performed with continuous and categorical variables as predictors of survival, and examined with logistic regression and odds ratio confidence intervals. RESULTS: There were 12 (5 %) perioperative deaths. The average age of all patients was 62 years, and the majority (82 %) was male. Complication grade did not significantly affect long-term survival, although patients with grade IV (serious) complications did have a decreased survival (p = 0.15). Predictors of survival showed that the minimally invasive type esophagectomy (p = 0.0004) and pathologic stage (p = 0.0007) were determining factors. There was a significant difference in overall survival among patients who experienced pneumonia (p = 0.00016) and respiratory complications (p = 0.0004), but this was not significant on multivariate analysis. CONCLUSIONS: In this single-institution series, we found that major perioperative morbidity did not have a negative impact on long-term survival which is different than previous series. The impact of tumor characteristics at time of resection on long-term survival is of most importance.

External validation of the COVID-19 4C mortality score in an urban United States cohort.

BACKGROUND: Identifying patients at risk for mortality from COVID-19 is crucial to triage, clinical decision-making, and the allocation of scarce hospital resources. The 4C Mortality Score effectively predicts COVID-19 mortality, but it has not been validated in a United States (U.S.) population. The purpose of this study is to determine whether the 4C Mortality Score accurately predicts COVID-19 mortality in an urban U.S. adult inpatient population. METHODS: This retrospective cohort study included adult patients admitted to a single-center, tertiary care hospital (Philadelphia, PA) with a positive SARS-CoV-2 PCR from 3/01/2020 to 6/06/2020. Variables were extracted through a combination of automated export and manual chart review. The outcome of interest was mortality during hospital admission or within 30 days of discharge. RESULTS: This study included 426 patients; mean age was 64.4 years, 43.4% were female, and 54.5% self-identified as Black or African American. All-cause mortality was observed in 71 patients (16.7%). The area under the receiver operator characteristic curve of the 4C Mortality Score was 0.85 (95% confidence interval, 0.79-0.89). CONCLUSIONS: Clinicians may use the 4C Mortality Score in an urban, majority Black, U.S. inpatient population. The derivation and validation cohorts were treated in the pre-vaccine era so the 4C Score may over-predict mortality in current patient populations. With stubbornly high inpatient mortality rates, however, the 4C Score remains one of the best tools available to date to inform thoughtful triage and treatment allocation.

Using Health Plan Authorization Data to Predict Hospitalizations and Readmissions in a Combined Commercial and Medicaid Population.

Health plans develop predictive models to predict key clinical events (eg, admissions, readmissions, emergency department visits). The authors developed predictive models of admissions and readmissions for a quality improvement organization with many large government and private health plan clients. Its membership and authorization data were used to develop models predicting 2019 inpatient stays, and 2019 readmissions following 2019 admissions, based on patients' age and sex, diagnoses identified and procedures requested in 2018 authorizations, and 2018 admission authorizations. In addition to testing multivariate models, risk scores were calculated for admission and readmission for all patients in the model. The admissions model (C = 0.8491) is much more accurate than the readmissions model (C = 0.6237). Measures of risk score central tendency and skewness indicate that the vast majority of members had little risk of hospitalization in 2019; the mean (standard deviation) was 0.042 (0.074), and the median was 0.018. These risk scores can be used to identify members at risk of admission and to support proactive risk management (eg, design of health management programs). Different risk thresholds can be used to identify different subsets of members for follow-up, depending on overall strategy and available resources. This model development project was novel in employing authorization data rather than utilization data. Advantages of authorization data are their timeliness, and the fact that they are sometimes the only data available, but disadvantages of authorization data are that authorized services are not always actually performed, and diagnoses are often "rule out" rather than final diagnoses.

Clinical Transformation in Care for Patients With Sickle Cell Disease at an Urban Academic Medical Center.

This article demonstrates effects on utilization of a clinical transformation: changing locus of care from a dedicated sickle cell day unit to an approach that "fast-tracks" patients through the emergency department (ED) into an observation unit with 24/7 access. Retrospective quantitative analyses of claims and Epic electronic medical record data for patients with sickle cell disease treated at Thomas Jefferson University (inpatient and ED) assessed effects of the clinical transformation. Additionally, case studies were conducted to confirm and deepen the quantitative analyses. This study was approved by the Thomas Jefferson University Institutional Review Board. The quantitative analyses show significant decreases in ED and inpatient utilization following the transformation. These effects likely were facilitated by increased observation stays. This study demonstrated the impact on utilization of transformation in care (from dedicated day unit to an approach that fast-tracks patients into an observation unit). Additional case studies support the quantitative findings.

Evaluation of an Ongoing Diabetes Group Medical Visit in a Family Medicine Practice.

PURPOSE: Group medical visits (GMVs), which combine 1-on-1 clinical consultations and group self-management education, have emerged as a promising vehicle for supporting type 2 diabetes management in primary care. However, few evaluations exist of ongoing diabetes GMVs embedded in medical practices. METHODS: This study used a quasi-experimental design to evaluate diabetes GMV at a large family medicine practice. We examined program attendance and attrition, used propensity score matching to create a matched comparison group, and compared participants and the matched group on clinical, process of care, and utilization outcomes. RESULTS: GMV participants (n = 230) attended an average of 1 session. Participants did not differ significantly from the matched comparison group (n = 230) on clinical, process of care or utilization outcomes. CONCLUSIONS: The diabetes GMV was not associated with improvements in outcomes. Further studies should examine diabetes GMV implementation challenges to enhance their effectiveness in everyday practice.

Patient and Provider Characteristics Associated With Optimal Post-Fracture Osteoporosis Management.

Despite an estimated 2 million osteoporosis (OP)-related fractures annually, quality of care for post-fracture OP management remains low. This study aimed to identify patient and provider characteristics associated with achieving or not achieving optimal post-fracture OP management, as defined by the current HEDIS quality measure. The study included women 67 to 85 years of age, with ≥1 fracture, and continuous enrollment in a Humana insurance plan. The study identified a higher percentage of black women in the not achieved group (6.2% vs 5.4%; P < .0001) and Hispanic women in the achieved group (3.0% vs 1.3%; P < .0001). The not achieved group largely included patients residing in the South and urban and suburban areas. The majority of providers were primary care or OP-related specialty, and 66% did not achieve the 4-star OP rating. The study findings can guide development of predictive models to identify at-risk women to improve post-fracture OP management.

Interactive voice response reminder effects on preventive service utilization.

This study evaluated the effects of interactive voice response (IVR) system reminders to managed care organization (MCO) members to obtain mammograms, Papanicolaou (Pap) tests, and influenza immunizations. The MCO identified 3 member cohorts and sent IVR reminders to get preventive services. Analyses employed claims data to examine relationships between IVR reminders and preventive service use 5 to 9 months post-intervention among members without prior utilization. Multivariate logistic regressions controlling for age, gender (for influenza immunizations), and risk stratum confirmed hypothesized relationships between intervention and preventive services: mammograms, odds ratio (OR) = 1.263 (95% confidence interval [CI] = 1.104, 1.444); Pap tests, OR = 1.241 (1.107, 1.391); influenza immunizations, OR = 2.072 (1.665, 2.580). IVR reminders are associated with higher rates of mammograms, Pap tests, and influenza immunizations. Study limitations include unknown generalizability of results and possible self-selection. There is justification for more IVR interventions and research to enhance MCO members' preventive service utilization.

Comparative effectiveness of total population versus disease-specific neural network models in predicting medical costs.

The objective of this research was to compare the accuracy of two types of neural networks in identifying individuals at risk for high medical costs for three chronic conditions. Two neural network models-a population model and three disease-specific models-were compared regarding effectiveness predicting high costs. Subjects included 33,908 health plan members with diabetes, 19,264 with asthma, and 2,605 with cardiac conditions. For model development/ testing, only members with 24 months of continuous enrollment were included. Models were developed to predict probability of high costs in 2000 (top 15% of distribution) based on 1999 claims factors. After validation, models were applied to 2000 claims factors to predict probability of high 2001 costs. Each member received two scores-population model score applied to cohort and disease model score. Receiver Operating Characteristic (ROC) curves compared sensitivity, specificity, and total performance of population model and three disease models. Diabetes-specific model accuracy, C = 0.786 (95%CI = 0.779-0.794), was greater than that of population model applied to diabetic cohort, C = 0.767 (0.759-0.775). Asthma-specific model accuracy, C = 0.835 (0.825-0.844), was no different from that of population model applied to asthma cohort, C = 0.844 (0.835-0.853). Cardiac-specific model accuracy, C = 0.651 (0.620-0.683), was lower than that of population model applied to cardiac cohort, C = 0.726 (0.697-0.756). The population model predictive power, compared to the disease model predictive power, varied by disease; in general, the larger the cohort, the greater the advantage in predictive power of the disease model compared to the population model. Given these findings, disease management program staff should test multiple approaches before implementing predictive models.

Cost-benefit analysis of chlorhexidine gluconate dressing in the prevention of catheter-related bloodstream infections.

OBJECTIVES: To compare the costs with the benefits of using chlorhexidine gluconate dressings on central venous catheters and to determine the effectiveness of these dressings in reducing local infections and catheter-related bloodstream infections (CRBSIs), costs, and mortality. DESIGN: Cost-benefit analysis using randomized, controlled trial data on chlorhexidine dressing prevention of local infection and CRBSI, data on cost of chlorhexidine dressing versus standard treatment, data on averted cost of treating local infection and CRBSI, and data on mortality attributable to CRBSI. Decision analysis evaluated averted CRBSI treatment cost per patient resulting from chlorhexidine dressing use. Sensitivity analyses demonstrated net benefit of chlorhexidine dressing, varying baseline rate of CRBSI, incremental cost of treating CRBSI, and number of catheters, and evaluated mortality preventable through chlorhexidine dressing use, varying baseline rate of CRBSI, number of catheters, and mortality attributable to CRBSI. PATIENTS AND SETTING: Patients of all Philadelphia area hospitals and one Philadelphia academic medical center. RESULTS: Estimated potential annual U.S. net benefits from chlorhexidine dressing use ranged from $275 million to approximately $1.97 billion. Cost-benefit findings persisted in sensitivity analyses varying baseline rate of CRBSI, incremental cost of treating CRBSI, and overall number of catheters used. Preventable mortality analyses showed potential decreases of between 329 and 3,906 U.S. deaths annually as a result of nationwide use of chlorhexidine dressing. CONCLUSIONS: Chlorhexidine dressings would reduce costs, local infections and CRBSIs, and deaths. Use of chlorhexidine dressings should be considered to prevent infections among patients with catheters.

Use and effectiveness of pharmacy continuing-education materials.

The use and effectiveness of pharmacy continuing-education (CE) materials were studied. A 31-item survey was administered to pharmacists via an Internet portal. A recruitment letter, which included a description of the study and the Internet address to access the survey, was mailed to 2000 pharmacists. Only pharmacists who were currently practicing pharmacy in a community pharmacy or in a health care setting were included in the analysis. Pharmacists were asked to indicate the format of CE they generally used, formats used in the six months prior to the survey, and the format of their most recent CE. They were also asked to assess the effectiveness of CE programs and their ability to enhance pharmacists' knowledge and clinical practice behavior. Descriptive statistics were computed for all variables. Chi-square analyses were performed to compare subgroup responses. Of the 373 pharmacists completing the survey, 365 met the inclusion criteria. Of these respondents, 31% worked in a chain pharmacy, 25% in an inpatient pharmacy, and 23% in an independent pharmacy. Pharmacists most commonly obtained CE from printed materials (92%), lectures and seminars (75%), Internet-based materials (53%), and symposia (44%). Respondents found all types of CE programs effective in improving their knowledge, but less effective in enhancing their clinical practice behavior. Pharmacists perceived different types of CE programs as valuable resources for their educational needs. Printed materials, lectures, and seminars were the most commonly used CE formats. Pharmacists considered CE programs very effective in enhancing their knowledge and less valuable in improving their pharmacy practice activities.

Hospital organizational change and financial status: costs and outcomes of care in Philadelphia.

Two recent changes in Philadelphia-area hospital organizations are consolidation into systems and acquisition of 2 medical school hospitals by a for-profit chain. This study explored whether such consolidation and conversion affected costs and outcomes of care. The analysis included 1,617,581 discharges from 49 acute-care hospitals from 1997 to 1999. Analyses within and between medical school hospitals examined trends in discharges, case mix, length of stay, and mortality. The study addressed 2 questions: whether, as hospitals consolidate into medical school hospital-based systems, volume, severity, length of stay, and mortality increase in those hospitals; and whether for-profit conversion redistributes complex, high-cost admissions to nonprofit hospitals. The 2 medical school hospitals that became for-profit experienced decreases in volume and resource intensity, coupled at one with an increase in severity. However, these patterns were produced more by the system's financial instability than by consolidation or conversion.

A predictive model of hospitalization risk among disabled medicaid enrollees.

OBJECTIVES: To identify Medicaid patients, based on 1 year of administrative data, who were at high risk of admission to a hospital in the next year, and who were most likely to benefit from outreach and targeted interventions. STUDY DESIGN: Observational cohort study for predictive modeling. METHODS: Claims, enrollment, and eligibility data for 2007 from a state Medicaid program were used to provide the independent variables for a logistic regression model to predict inpatient stays in 2008 for fully covered, continuously enrolled, disabled members. The model was developed using a 50% random sample from the state and was validated against the other 50%. Further validation was carried out by applying the parameters from the model to data from a second state's disabled Medicaid population. RESULTS: The strongest predictors in the model developed from the first 50% sample were over age 65 years, inpatient stay(s) in 2007, and higher Charlson Comorbidity Index scores. The areas under the receiver operating characteristic curve for the model based on the 50% state sample and its application to the 2 other samples ranged from 0.79 to 0.81. Models developed independently for all 3 samples were as high as 0.86. The results show a consistent trend of more accurate prediction of hospitalization with increasing risk score. CONCLUSIONS: This is a fairly robust method for targeting Medicaid members with a high probability of future avoidable hospitalizations for possible case management or other interventions. Comparison with a second state's Medicaid program provides additional evidence for the usefulness of the model.

Are medical students being taught invasive skills using simulation?

INTRODUCTION: Basic invasive procedural skills are traditionally taught during clerkships. Using simulation to teach invasive skills provides students the opportunity to practice in a structured environment without risking patient safety. We surveyed incoming interns at Thomas Jefferson University Hospital to assess the prevalence of simulation training for invasive and semi-invasive procedural skills during medical school. METHODS: From 2008 to 2010, we surveyed 357 incoming interns at Thomas Jefferson University Hospital. The questionnaire asked incoming interns if they received formal instruction or procedural training with or without a simulation component for 34 procedures during medical school. Interns indicated their number of attempts and successes for each procedure in clinical care. RESULTS: All 357 incoming interns completed the survey. Experience in 28 procedures is reported in this article. For all but three basic procedures, more than 75% of interns received formal didactic instruction. Only 3 advanced procedures were formally taught to most interns. The prevalence of simulation training for the basic and advanced procedures was 46% and 23%, respectively. For the basic procedures, the average number of attempts and successes was 6.5 (range, 0-13.9) and 6.2 (range, 0-13.4), respectively. For the advanced procedures, the average number of attempts and successes was 1.5 (range, 0-4.8) and 1.3 (range, 0-4.7), respectively. CONCLUSIONS: Although most medical students receive formal instruction in basic procedures, fewer receive formal instruction in advanced procedures. The use of simulation to complement this training occurs less often. Simulation training should be increased in undergraduate medical education and integrated into graduate medical education.

Quality of care for 2 common pediatric conditions treated by convenient care providers.

Rates of adherence to 2 quality measures, modeled after Heathcare Effectiveness Data and Information Set (HEDIS) measures, were evaluated in a pediatric population in a convenient care (retail medicine) clinic setting. The measures were appropriate testing for children with pharyngitis and appropriate treatment for children with upper-respiratory infection (URI). The convenient care clinic (CCC) achieved a ranking above the HEDIS 90th percentile for the pharyngitis measure and approximately midway between the 50th and 90th percentiles for the URI measure for the 2007 reporting period. This represents the third major study reporting quality of care for pharyngitis in a CCC setting and the first study for URIs. Other aspects of quality--namely access, follow-up, and equity--are also reported on for the population in question.

Is gastrectomy safe in the elderly? A single institution review.

The population of the United States is aging. Studies within the last several years have demonstrated that major abdominal operations in elderly patients can be done safely, but with increased rates of complications. We set out to determine the rates of morbidity and mortality in elderly patients undergoing gastric resection at a tertiary care university hospital. A retrospective analysis was performed of 157 consecutive gastric resections between January 1998 and July 2007. Group A (n = 99) consisted of patients < 75-years-old at surgery, whereas group B (n = 58) included patients who were ≥ 75 years of age at time of surgery. These two groups had their clinical and demographic data analyzed. Postoperative length of hospital stay, perioperative major morbidity, and in-hospital mortality were analyzed using analysis of variance, χ(2), and multivariate analyses. The average age of patients in group A was 57 years, compared with 81 years in group B. We found no significant difference in the percentage of gastric resections for malignancy (group A, 49% vs group B, 62%) or emergency surgery (group A, 10% vs group B, 10%) between age groups. There was a significant increase in length of stay in the older patients (11.7 days vs 17.6 days; P = 0.032), as well as major complications (11.1% in group A vs 27.6% in group B; P = 0.008). The in-hospital mortality rates approached significance (group A, 4% vs group B, 12%; P = 0.057). Gastric resection in elderly patients carries with it longer hospital stays, higher risk of complications, and in-hospital mortality rates despite similarity in patient disease. This information is imperative to convey to the elderly patients in the preoperative period before gastric resection.

Prevalence of obesity, type II diabetes mellitus, hyperlipidemia, and hypertension in the United States: findings from the GE Centricity Electronic Medical Record database.

This study analyzed GE Centricity Electronic Medical Record (EMR) data to examine the effects of body mass index (BMI) and obesity, key risk factor components of metabolic syndrome, on the prevalence of 3 chronic diseases: type II diabetes mellitus, hyperlipidemia, and hypertension. These chronic diseases occur with high prevalence and impose high disease burdens. The rationale for using Centricity EMR data is 2-fold. First, EMRs may be a good source of BMI/obesity data, which are often underreported in surveys and administrative databases. Second, EMRs provide an ideal means to track variables over time and, thus, allow longitudinal analyses of relationships between risk factors and disease prevalence and progression. Analysis of Centricity EMR data showed associations of age, sex, race/ethnicity, and BMI with diagnosed prevalence of the 3 conditions. Results include uniform direct correlations between age and BMI and prevalence of each disease; uniformly greater disease prevalence for males than females; varying differences by race/ethnicity (ie, African Americans have the highest prevalence of diagnosed type II diabetes and hypertension, while whites have the highest prevalence of diagnosed hypertension); and adverse effects of comorbidities. The direct associations between BMI and disease prevalence are consistent for males and females and across all racial/ethnic groups. The results reported herein contribute to the growing literature about the adverse effects of obesity on chronic disease prevalence and about the potential value of EMR data to elucidate trends in disease prevalence and facilitate longitudinal analyses.

Comparison of GE Centricity Electronic Medical Record database and National Ambulatory Medical Care Survey findings on the prevalence of major conditions in the United States.

The study objective was to facilitate investigations by assessing the external validity and generalizability of the Centricity Electronic Medical Record (EMR) database and analytical results to the US population using the National Ambulatory Medical Care Survey (NAMCS) data and results as an appropriate validation resource. Demographic and diagnostic data from the NAMCS were compared to similar data from the Centricity EMR database, and the impact of the different methods of data collection was analyzed. Compared to NAMCS survey data on visits, Centricity EMR data shows higher proportions of visits by younger patients and by females. Other comparisons suggest more acute visits in Centricity and more chronic visits in NAMCS. The key finding from the Centricity EMR is more visits for the 13 chronic conditions highlighted in the NAMCS survey, with virtually all comparisons showing higher proportions in Centricity. Although data and results from Centricity and NAMCS are not perfectly comparable, once techniques are employed to deal with limitations, Centricity data appear more sensitive in capturing diagnoses, especially chronic diagnoses. Likely explanations include differences in data collection using the EMR versus the survey, particularly more comprehensive medical documentation requirements for the Centricity EMR and its inclusion of laboratory results and medication data collected over time, compared to the survey, which focused on the primary reason for that visit. It is likely that Centricity data reflect medical problems more accurately and provide a more accurate estimate of the distribution of diagnoses in ambulatory visits in the United States. Further research should address potential methodological approaches to maximize the validity and utility of EMR databases.