Clinical Validation of R-T Estimation for CoaguChek XS INR Results.

BACKGROUND: Despite the emergence of several new oral anticoagulants, warfarin remains a widely used form of anticoagulation that continues to have a role in the treatment of cardiac and thrombotic conditions. OBJECTIVE: The goal of this study was to evaluate whether the R-T estimation, an equation developed in a previous study, was a valid clinical tool in managing patients' warfarin therapy in an anticoagulation clinic in lieu of obtaining a venipuncture international normalized ratio (INR) secondary to a high CoaguChek XS (CXS) INR. METHODS: This study used a randomized double-blind method to compare the clinical decisions made using venipuncture or CXS machine and recorded the INR, percentage dose change, time to clinical decision from check-in, and scheduled follow-up. RESULTS: In the analysis of the difference in percentage dose change, a 1.0% (95% CI = -0.78 to 2.68; P = 0.27) difference was observed overall, and a 1.2% (95% CI = -0.59 to 2.95; P = 0.18) difference was observed in the 4 to 5.9 subgroup. Clinical decisions were reached 17 minutes faster (95% CI = 11-24; P < 0.001) overall and 17 minutes faster (95% CI = 10-24; P < 0.001) in the 4 to 5.9 subgroup. Scheduled follow-up was 0.38 weeks sooner (95% CI = 0.01-0.67; P = 0.014) overall and 0.36 weeks sooner (95% CI = 0-0.66; P = 0.041) in the 4 to 5.9 subgroup. CONCLUSIONS: The results of this study support the use of the R-T estimation for correction of INR values obtained using the CXS meter when the INR is in the range of 4 to 5.9. This correction will allow clinics using this device to more efficiently manage patients taking warfarin.

Patterns and factors associated with intensive use of ED services: implications for allocating resources.

AIM: This study aims to better understand the patterns and factors associated with the use of emergency department (ED) services on high-volume and intensive (defined by high volume and high-patient severity) days to improve resource allocation and reduce ED overcrowding. METHODS: This study created a new index of "intensive use" based on the volume and severity of illness and a 3-part categorization (normal volume, high volume, intensive use) to measure stress in the ED environment. This retrospective, cross-sectional study collected data from hospital clinical and financial records of all patients seen in 2001 at an urban academic hospital ED. RESULTS: Multiple logistic regression models identified factors associated with high volume and intensive use. Factors associated with intensive days included being in a motor vehicle crash; having a gun or stab wound; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. Factors associated with high-volume days included falling from 0 to 10 ft; being in a motor vehicle crash; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. CONCLUSION: These findings offer inputs for reallocating resources and altering staffing models to more efficiently provide high-quality ED services and prevent overcrowding.

Dissociation of nanosilicates induces downstream endochondral differentiation gene expression program.

Bioactive materials harness the body's innate regenerative potential by directing endogenous progenitor cells to facilitate tissue repair. Dissolution products of inorganic biomaterials provide unique biomolecular signaling for tissue-specific differentiation. Inorganic ions (minerals) are vital to biological processes and play crucial roles in regulating gene expression patterns and directing cellular fate. However, mechanisms by which ionic dissolution products affect cellular differentiation are not well characterized. We demonstrate the role of the inorganic biomaterial synthetic two-dimensional nanosilicates and its ionic dissolution products on human mesenchymal stem cell differentiation. We use whole-transcriptome sequencing (RNA-sequencing) to characterize the contribution of nanosilicates and its ionic dissolution products on endochondral differentiation. Our study highlights the modulatory role of ions in stem cell transcriptome dynamics by regulating lineage-specific gene expression patterns. This work paves the way for leveraging biochemical characteristics of inorganic biomaterials to direct cellular processes and promote in situ tissue regeneration.

Implementation of a Clinical Pharmacist Service in the Hospice Setting: Financial and Clinical Impacts.

Hospice is a unique environment among all clinical fields of practice. Although every other specialty aims to work toward a curative goal or prevention of mortality, hospice completely redirects focus solely on pain and symptom management and sustaining the highest quality of life possible. Addition of a clinical pharmacist to the interdisciplinary group (IDG) is not common, but Haven: Advanced Illness Care added a clinical pharmacist to the team in 2017. Substantial financial impacts were made in the first year, and clinical impacts were well regarded by physicians and nurses. A cost savings of $427,705 was observed, and the clinical pharmacist provided a great deal of expertise to the IDG. Adding a clinical pharmacist to the IDG of other hospice organizations may prove to be a worthy investment.

Identifying high-risk patients for triage and resource allocation in the ED.

Five-point triage assessment scales currently used in many emergency departments (EDs) across the country have been shown to be accurate and reliable. We have found the system to be highly predictive of outcome (hospital admission, intensive care unit/operating room admission, or death) at either extreme of the scale but much less predictive in the middle triage group. This is problematic because the middle triage acuity group is the largest, in our experience comprising almost half of all patients. Patients triaged to the 2 highest acuity categories (A and B) have admission/ED death rates of 76% and 43%, respectively. In contrast, the 2 lowest acuity categories (D and E) have admission/ED death rates of 1% or less. The middle category (C), however, has an overall admission/ED death rate of 10%, too high to be comfortable with prolonged delays in the ED evaluation of these patients. We studied this group to determine if easily obtainable clinical factors could identify higher-risk patients in this heterogeneous category. Data were obtained from a retrospective, cross-sectional study of all patients seen in 2001 at an urban academic hospital ED. The main outcome measure for multivariate logistic regression models was hospital admission among patients triaged as acuity C. Acuity C patients who were 65 years or older, presenting with weakness or dizziness, shortness of breath, abdominal pain, or a final diagnosis related group diagnosis of psychosis, were more likely to be admitted than patients originally triaged in category B. These findings suggest that a few easily obtainable clinical factors may significantly improve the accuracy of triage and resource allocation among patients assigned with a middle-acuity score.

Correction of Point-of-Care INR Results in Warfarin Patients.

BACKGROUND: The measurement of international normalization ratio (INR) may be done by venous blood draw and use of a standard lab, or by fingerstick, using a point of care (POC) device such as the CoaguChek XS® (Roche Diagnostics), and the CoaguChek XS® has been validated to meet the International Organization for Standardization (ISO) performance requirements. OVERVIEW: The goal of this study was to determine a correction factor for Coaguchek XS INR levels to a predicted venipuncture (VP) INR level. METHODS: At the end of an anticoagulation clinic visit when a patient had an INR greater than or equal to 4, two INR results existed, that from the Coaguchek XS® meter and a venipuncture INR from the lab. The data were then discreetly recorded as a quality control for our clinic. The data were analyzed for possible significant trends between the two types of INR results. RESULTS: The equation that was determined to be the best fit to the data was 0.621 × POC + 0.639 = estimated VP. The overall root mean square error (MSE) for the calculated correction was a 0.44 INR. The root mean square errors were 0.41 and 0.58 for the 4 to 5.9 and 6 to 7.9 POC INR groups, respectively. CONCLUSION: The calculation that was derived in this study is not a surrogate for venipuncture INR in this clinic. However, the estimation of the INR may be useful clinically in guiding decision making in the future. (INR, Point of Care, Anticoagulation, Hematology).

Association between insurance status and admission rate for patients evaluated in the emergency department.

OBJECTIVES: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. METHODS: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for under insured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. RESULTS: Compared with the other insured group, under insured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed under insured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Under insured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. CONCLUSIONS: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference.

Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy.

UNLABELLED: In efforts to decrease emergency department (ED) crowding and health care costs, frequent users of ED services have been targeted for interventions to decrease their utilization. Previous studies have had different definitions for "frequent users" and have considered all frequent users as a homogeneous group. To the authors' knowledge, no study has examined visit characteristics and resource utilization of different levels of frequent use. OBJECTIVES: 1) to determine the rates of ED utilization by five user groups defined by number of annual visits, 2) to examine variations in visit characteristics by frequency of ED use, and 3) to compare levels of resource utilization among frequent user groups. METHODS: This was a retrospective, cross-sectional study of clinical and financial records for all ED visits to an urban, academic hospital in 2001. Multinomial logistic and linear regression models were used for analyses. Estimates were corrected for multiple comparisons (with Bonferroni corrections), where applicable, and adjusted for clustering within individuals (with Huber-White estimators). Outcome measures were triage acuity, diagnosis-related group (DRG) severity, disposition status, primary complaint, medical diagnosis, hospital inpatient length of stay, payment method, costs, and demographics. RESULTS: Patients with three to 20 visits were more likely to be admitted to the hospital than patients visiting once or twice. Patients visiting more than 20 times were less likely to require hospital admission and more likely to present with "nonurgent" conditions, have lower severity scores, and elope or leave the ED without medical attention than patients visiting the ED once. The group had fewer inpatient days and lower average costs than patients visiting once. Patients with six to 20 visits had traditional Medicaid coverage more often than those with one or two visits. Virtually no patients visiting more than 20 times had Medicare or Medicaid managed care, a health maintenance organization, or a preferred provider organization. CONCLUSIONS: Frequent ED users are a heterogeneous group. Many patients previously thought to overutilize the ED for socioeconomic or insignificant medical problems are as sick as less-frequent ED users. There is a small subgroup with more than 20 visits who are less ill or injured but also incurred lower-than-average costs per visit.

Clinical and economic factors associated with ambulance use to the emergency department.

BACKGROUND: Concern about ambulance diversion and emergency department (ED) overcrowding has increased scrutiny of ambulance use. Knowledge is limited, however, about clinical and economic factors associated with ambulance use compared to other arrival methods. OBJECTIVES: To compare clinical and economic factors associated with different arrival methods at a large, urban, academic hospital ED. METHODS: This was a retrospective, cross-sectional study of all patients seen during 2001 (N = 80,209) at an urban academic hospital ED. Data were obtained from hospital clinical and financial records. Outcomes included acuity and severity level, primary complaint, medical diagnosis, disposition, payment, length of stay, costs, and mode of arrival (bus, car, air-medical transport, walk-in, or ambulance). Multivariate logistic regression identified independent factors associated with ambulance use. RESULTS: In multivariate analysis, factors associated with ambulance use included: triage acuity A (resuscitation) (adjusted odds ratio [OR], 51.3; 95% confidence interval [CI] = 33.1 to 79.6) or B (emergent) (OR, 9.2; 95% CI = 6.1 to 13.7), Diagnosis Related Group severity level 4 (most severe) (OR, 1.4; 95% CI = 1.2 to 1.8), died (OR, 3.8; 95% CI = 1.5 to 9.0), hospital intensive care unit/operating room admission (OR, 1.9; 95% CI = 1.6 to 2.1), motor vehicle crash (OR, 7.1; 95% CI = 6.4 to 7.9), gunshot/stab wound (OR, 2.1; 95% CI = 1.5 to 2.8), fell 0-10 ft (OR, 2.0; 95% CI = 1.8 to 2.3). Medicaid Traditional (OR, 2.0; 95% CI = 1.4 to 2.4), Medicare Traditional (OR, 1.8; 95% CI = 1.7 to 2.1), arrived weekday midnight-8 am (OR, 2.0; 95% CI = 1.8 to 2.1), and age > or =65 years (OR, 1.3; 95% CI = 1.2 to 1.5). CONCLUSIONS: Ambulance use was related to severity of injury or illness, age, arrival time, and payer status. Patients arriving by ambulance were more likely to be acutely sick and severely injured and had longer ED length of stay and higher average costs, but they were less likely to have private managed care or to leave the ED against medical advice, compared to patients arriving by independent means.