Which Readmissions May Be Preventable? Lessons Learned From a Posthospitalization Care Transitions Program for High-risk Elders.

BACKGROUND: Care transitions programs have been shown to reduce hospital readmissions. OBJECTIVES: The main objective of this study was to evaluate effects of the Mayo Clinic Care Transitions (MCCTs) Program on potentially preventable and nonpreventable 30-day unplanned readmissions among high-risk elders. RESEARCH DESIGN: This was a retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care. SUBJECTS: The subjects were primary care patients, who were 60 years or older, at high-risk for readmission, and hospitalized for any cause between January 1, 2011 and June 30, 2013. MEASURES: Hospital readmission within 30 days. The 3M algorithm was used to identify potentially preventable readmissions. Readmissions for ambulatory care sensitive conditions, a subset of preventable readmissions identified by the 3M algorithm, were also assessed. RESULTS: The study cohort included 365 pairs of MCCT enrollees and propensity score-matched controls. Patients were similar in age (mean 83 y) and other baseline demographic and clinical characteristics, including reason for index hospitalization. MCCT enrollees had a significantly lower all-cause readmission rate [12.4% (95% confidence interval: CI, 8.9-15.7) vs. 20.1% (15.8-24.1); P=0.004] resulting from a decrease in potentially preventable readmissions [8.4% (95% CI, 5.5-11.3) vs. 14.3% (95% CI, 10.5-17.9); P=0.01]. Few potentially preventable readmissions were for ambulatory care sensitive conditions (6.7% vs. 12.0%). The rates of nonpotentially preventable readmissions were similar [4.3% (95% CI, 2.2-6.5) vs. 6.7% (95% CI, 4.0-9.4); P=0.16]. Potentially preventable readmissions were reduced by 44% (hazard ratio, 0.56; 95% CI, 0.36-0.88; P=0.01) with no change in other readmissions. CONCLUSIONS: The MCCT significantly reduces preventable readmissions, suggesting that access to multidisciplinary care can reduce readmissions and improve outcomes for high-risk elders.

Blood metal concentrations and cardiac structure and function in total joint arthroplasty patients.

BACKGROUND: There is concern regarding potential long-term cardiotoxicity with systemic distribution of metals in total joint arthroplasty (TJA) patients. AIM: To determine the association of commonly used implant metals with echocardiographic measures in TJA patients. METHODS: The study comprised 110 TJA patients who had a recent history of high chromium, cobalt or titanium concentrations. Patients underwent two-dimensional, three-dimensional, Doppler and speckle-strain transthoracic echocardiography and a blood draw to measure metal concentrations. Age and sex-adjusted linear and logistic regression models were used to examine the association of metal concentrations (exposure) with echocardiographic measures (outcome). RESULTS: Higher cobalt concentrations were associated with increased left ventricular end-diastolic volume (estimate 5.09; 95%CI: 0.02-10.17) as well as left atrial and right ventricular dilation, particularly in men but no changes in cardiac function. Higher titanium concentrations were associated with a reduction in left ventricle global longitudinal strain (estimate 0.38; 95%CI: 0.70 to 0.06) and cardiac index (estimate 0.08; 95%CI, -0.15 to -0.01). CONCLUSION: Elevated cobalt and titanium concentrations may be associated with structural and functional cardiac changes in some patients. Longitudinal studies are warranted to better understand the systemic effects of metals in TJA patients.

The Tangle of Autonomy, Beneficence, Liberty, and Consent in the CESS Debate.

This commentary on the task force report addresses the complex issues involved in autonomy, beneficence, liberty, and consent, which are often in competition in this and many other treatment issues for individuals with intellectual and developmental disabilities, especially those with limited vocal/verbal repertoires. The issues at hand are multifaceted, and behavior analysts should be aware there is much we do not know enough about. As good scientists, it is important to maintain an attitude of philosophic doubt and endeavor to deepen understanding.

Report of the ABAI Task Force on Contingent Electric Skin Shock.

As a task force appointed by the Executive Council of the Association for Behavior Analysis International (ABAI), we investigated the clinical use of contingent electric skin shock (CESS) in behavior analytic treatments for severe problem behavior. We studied how CESS is used in contemporary behavior analysis, reinforcement-based alternatives to CESS, and current ethical and professional guidelines for applied behavior analysts. We recommended that ABAI uphold clients' right to receive CESS when it is restricted to extreme cases and used under rigorous professional and legal oversight. Our recommendation was rejected by a vote of the full members of ABAI, who instead endorsed an alternative recommendation, developed by members of the Executive Council, that opposed the use of CESS under any condition. Here we present for the record our report and initial recommendations, the formal statement that was rejected by the members of ABAI, and the statement that was endorsed.

Cross-sectional association between systemic metal concentrations and immune markers in patients with total joint arthroplasty.

Total joint arthroplasty (TJA) implants are composed of metal components. Although they are regarded safe, the long-term immunological effects of chronic exposure to the specific implant materials are unknown. We recruited 115 hip and/or knee TJA patients (mean age 68 years) who provided a blood draw for measurement of chromium, cobalt, titanium concentrations, inflammatory markers and systemic distribution of immune cells. We examined differences between the immune markers and the systemic concentrations of chromium, cobalt and titanium. CD66-b neutrophils, early natural killer cells (NK), and eosinophils were present in higher percentages in patients with chromium and cobalt concentrations greater than the median. The opposite pattern was observed with titanium where the percentages of CD66-b neutrophils, early NK, and eosinophils were higher in patients with undetectable titanium. Cobalt concentrations were positively correlated with a higher percentage of gamma delta T cells. Both chromium and cobalt concentrations were positively correlated with higher percentages of plasmablasts. Titanium concentrations were positively correlated with higher CD4 effector memory T cells, regulatory T cell count and Th1 CD4 helper cells. In this exploratory study, we observed altered distribution of immune cells in TJA patients with elevated systemic metal concentrations. Although these correlations were not strong, these exploratory findings warrant further investigation into the role of increased metals circulating in blood and its role in immune modulation.

Correlation of Blood Metal Concentrations with Cognitive Scores and Neuroimaging Findings in Patients with Total Joint Arthroplasty.

Total joint arthroplasty (TJA) implants are composed of metals, ceramics, and/or polyethylene. Studies suggest that the debris released from metal implants may possess neurotoxic properties with reports of neuropsychiatric symptoms and memory deficits, which could be relevant to Alzheimer's disease and related dementias. This exploratory study examined the cross-sectional correlation of blood metal concentrations with cognitive performance and neuroimaging findings in a convenience sample of 113 TJA patients with history of elevated blood metal concentrations of either titanium, cobalt and/or chromium. Associations with neuroimaging measures were observed but not with cognitive scores. Larger studies with longitudinal follow-up are warranted.

Teaching the History of Applied Behavior Analysis.

Incorporating historical readings and discussion into applied behavior-analytic coursework may be an important strategy for developing well-rounded behavior analysts. However, little guidance is available to instructors interested in teaching the history of applied behavior analysis. This article describes how the history of behavior analysis can be incorporated into a course on applied behavior analysis to achieve this goal. The history of punishment/aversives in behavior analysis will be provided as an example of how the history of behavior analysis can be embedded into applied coursework. The historical interaction between the culture at large (i.e., the culture beyond behavior analysis) and behavior-analytic literature and events related to punishment will be described because both affect the field and have led to the current state of practice. History related to early ethical standards, early experimental analysis of behavior literature, the backlash against early applied behavior analysis, and the field of behavior analysis' response to the backlash is discussed.

Leading the Charge: A Look Inside the Behavior Analysis in Practice Emergency Series of Publications on Systemic Racism and Police Brutality.

This article introduces the "Behavior Analysis in Practice Emergency Series of Publications on Systemic Racism and Police Brutality." After the murder of George Floyd, the behavior analytic community was charged to respond in the spirit of Dr. Martin Luther King's challenge to social scientists. The charge of Dr. King was to explain real life phenomena negatively affecting the Black community. This series covered a wide range of topics with the intent of creating solutions that may be used to address remnants of the overarching impact of systemic racism and anti-Blackness. In this editorial, we provide an overview of the major themes of the accepted articles, some personal accounts of the editorial team, context for the special issue, discuss the contributions of the included articles, and a discussion of the areas in need of further work.

Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities.

Obtaining assent from potential research participants is an important component of research for reasons related to ethics compliance, self-determination, and choice. However, unique issues arise when working with populations who cannot assent through traditional means, such as individuals with Autism Spectrum Disorder (ASD) and related developmental disabilities (DD). The purpose of this paper is to review and discuss assent practices within behavior-analytic research to identify strategies that can be used to obtain assent from potential participants with ASD and DDs. We began with a descriptive literature review of behavior-analytic articles that included the term "assent" to identify what practices behavior analysts have used to obtain assent from participants. In short, very few articles that clearly addressed assent procedures were identified. Thus, we propose a model for gaining assent when working with individuals with ASD and DDs.

Toward the Development of a Functional Analysis Risk Assessment Decision Tool.

Risk-benefit analyses are essential in the decision-making process when selecting the most effective and least restrictive assessment and treatment options for our clients. Clinical expertise, informed by the client's preferences and the research literature, is needed in order to weigh the potential detrimental effects of a procedure against its expected benefits. Unfortunately, safety recommendations pertaining to functional analyses (FAs) are scattered or not consistently reported in the literature, which could lead some practitioners to misjudge the risks of FA. We surveyed behavior analysts to determine their perceived need for a risk assessment tool to evaluate risks prior to conducting an FA. In a sample of 664 Board Certified Behavior Analysts (BCBAs) and doctoral-level Board Certified Behavior Analysts (BCBA-Ds), 96.2% reported that a tool that evaluated the risks of proceeding with an FA would be useful for the professional practice of applied behavior analysis. We then developed an interactive tool to assess risk, which provides suggestions to mitigate the risks of an FA and validity recommendations. Subsequently, an expert panel of 10 BCBA-Ds reviewed the tool. Experts suggested that it was best suited as an instructional resource for those learning about the FA process and as a supporting resource for early practitioners' clinical decision making.

Correction to: Toward the Development of a Functional Analysis Risk Assessment Decision Tool.

[This corrects the article DOI: 10.1007/s40617-020-00433-y.].

Considerations of Baseline Classroom Conditions in Conducting Functional Behavior Assessments in School Settings.

Research has shown that environmental classroom variables affect academic performance and student behavior, and appropriate behavior is often related to the presence of effective teaching practices and classroom management (Moore Partin, Robertson, Maggin, Oliver, & Wehby Preventing School Failure, 54, 172-178, 2010). For behavior analysts consulting in elementary education, some referrals for assessment and treatment of individual student behavior can be resolved by helping teachers establish effective class-wide practices. For this reason, some researchers suggest that behavior analysts should assess baseline classroom conditions as part of a functional behavior assessment (FBA; Anderson & St. Peter Behavior Analysis in Practice, 6(2), 62, 2013; Sutherland & Wehby Journal of Emotional and Behavioral Disorders, 11, 239-248, 2001). Through a literature review on effective classroom practices, we identified four specific classroom variables that have large effects on both learning outcomes and student behavior; we suggest consultants consider these four variables in baseline classroom assessments: (a) rates of active student responding (ASR), (b) appropriateness of the curriculum, (c) feedback and reinforcement, and (d) effective instructions and transitions. In this article, we will discuss each of these variables, describe how they can affect classroom behavior, and provide recommended targets from the research literature. We also provide a data-collection form for practitioners to use in their assessments of baseline classroom ecology, and for situations when these practices are not in place, we suggest potential resources for antecedent- and consequence-based interventions to decrease challenging classroom behavior.

Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment.

BACKGROUND: Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success. OBJECTIVE: To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions. DESIGN: Retrospective cohort. PATIENTS: A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013. SETTING: Midwest primary care practice in an integrated health system. INTERVENTION: Enrollment in a CTP during acute hospitalization. MEASUREMENTS: The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare. RESULTS: The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission. CONCLUSIONS: No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

Using Microsoft Excel® to Build a Customized Partial-Interval Data Collection System.

Using data to inform treatment decisions is a hallmark of behavior analysis. However, collecting the type of data that behavior analysts often require can be a labor-intensive and time-consuming task. Electronic data collection systems have been identified as a tool to alleviate some of the issues related to data collection, but many obstacles still exist. Current limitations of electronic data collection systems include cost, adaptability, ease of use, and compliance with privacy and security guidelines. The purpose of this article is to offer practitioners an alternative to buying an electronic data collection system by providing a task analysis on how to build customized electronic data collection systems using Microsoft Excel®. This task analysis is written for individuals with limited or no experience working with Excel® but may also be of utility to individuals fluent in Excel®. This task analysis is organized into three sections: (a) creating a basic electronic data collection table with dropdown menus and autofill features, (b) creating a timestamp for all data entered, and (c) creating automatically graphing displays of data.

A Review of SAFMEDS: Evidence for Procedures, Outcomes and Directions for Future Research.

SAFMEDS is an assessment and instructional strategy pioneered in the late 1970s by Ogden Lindsley. SAFMEDS was developed as an extension and improvement of flashcards. The aims of this article are to provide an overview of the literature related to SAFMEDS and to identify further research needs. The results of this review suggest that a great deal of research is still needed to clarify the SAFMEDS procedures and the benefits of SAFMEDS over traditional instruction. These conclusions are in line with broader criticisms of fluency-based instruction.

Symptoms Reported by Frail Elderly Adults Independently Predict 30-Day Hospital Readmission or Emergency Department Care.

OBJECTIVES: To assess the degree to which self-reported symptoms predict unplanned readmission or emergency department (ED) care within 30 days of high-risk, elderly adults enrolled in a posthospitalization care transition program (CTP). DESIGN: Retrospective cohort study. SETTING: Posthospitalization CTP at Mayo Clinic, Rochester, Minnesota, from January 1, 2013, through March 3, 2015. PARTICIPANTS: Frail, elderly adults (N = 230; mean age 83.5 ± 8.3, 46.5% male). MEASUREMENTS: Charlson Comorbidity Index (CCI) and self-reported symptoms, measured using the Edmonton Symptom Assessment System (ESAS), were ascertained upon CTP enrollment. RESULTS: Mean CCI was 3.9 ± 2.3. Of 51 participants returning to the hospital within 30 days of discharge, 13 had ED visits, and 38 were readmitted. Age, sex, and CCI were not significantly different between returning and nonreturning participants, but returning participants were significantly more likely to report shortness of breath (P = .004), anxiety (P = .02), depression (P = .02), and drowsiness (P = .01). Overall ESAS score was also a significant predictor of hospital return (P = .01). CONCLUSION: Four self-reported symptoms and overall ESAS score, but not CCI, ascertained after hospital discharge were strong predictors of hospital return within 30 days. Including symptoms in risk stratification of high-risk elderly adults may help target interventions and reduce readmissions.

Assessing the repeatability of resurgence in humans: Implications for the use of within-subject designs.

Resurgence refers to the recurrence of a previously reinforced response following the worsening of reinforcement conditions (e.g., extinction) for an alternative response. Because of the implications for treatment relapse, researchers have become particularly interested in mitigating resurgence of human behavior. Some studies have employed reversal designs and varied parameters across replications (e.g., ABCADC) to compare effects of second-phase variables. Although resurgence is generally repeatable within and between subjects, the extent to which similar levels of resurgence occur across replications is less clear. To assess the repeatability of resurgence, we conducted a secondary analysis of 62 human-operant data sets using ABCABC reversal designs from two laboratories in the United States. We found significant reductions in the magnitude of resurgence during the second exposure to extinction relative to the first exposure when all other phase variables were held constant. These results suggest that researchers should exercise caution when using within-subject, across-phase replications to compare resurgence between variable manipulations with human participants.

Feeding Tubes and Health Care Service Utilization in Amyotrophic Lateral Sclerosis: Benefits and Limits to a Retrospective, Multicenter Study Using Big Data.

Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurologic disorder with predictable challenges regarding disease progression and end-of-life care. These include need for respiratory and nutritional support. Little is known about how such choices impact end-of-life health service utilization for these patients. Using OptumLabs Data Warehouse, a large administrative claims database with more than 150 million privately insured, geographically diverse enrollees, we sought to explore outcomes associated with the use of enteral nutrition (EN). Patients were of age ≥18 years, with first ALS diagnosis during calendar years 2006-2012, and 6 months of continuous health plan coverage before first diagnosis. EN use was identified using procedure codes. Data were summarized descriptively. Among 1974 patients with ALS, mean age was 60.0 ± 12.5 years, 41.8% were women, and 9.7% demonstrated use of EN. Median time from ALS diagnosis to evidence of EN was 211 days (interquartile range [IQR]: 70-426). Those receiving EN had greater aggregate comorbidity (47% with Charlson-Deyo Comorbidity Index ≥ 3 vs only 27% in non-EN subset). In total, 38.1% of patients had at least 1 hospitalization, with median time to hospitalization of 162 days. Unfortunately, the EN group ended coverage a median of 155 days after EN started (IQR: 63.5-388), thereby limiting ability to capture outcomes. Although many ALS patients were identified, EN use was lower than expected, due to being earlier in disease trajectory and lost to follow-up with transition from private insurance. As such, databases exclusively including privately insured patients may be suboptimal for detecting late complications of protracted illnesses.