Changes in global mortality from aortic aneurysm.

OBJECTIVE: Globally, there has been a marked increase in aortic aneurysm-related deaths between 1990 and 2019. We sought to understand the underlying etiologies for this mortality trend by examining secular changes in both demographics and the prevalence of risk factors, and how these changes may vary across sociodemographic index (SDI) regions. METHODS: We queried the Global Burden of Disease Study (GBD) for aortic aneurysm deaths from 1990 to 2019 overall and by age group. We identified the percentage of aortic aneurysm deaths attributable to each risk factor identified by GBD modeling (smoking, hypertension, lead exposure, and high sodium diet) and their respective changes over time. We then analyzed aneurysm mortality by SDI region. RESULTS: The number of aortic aneurysm-related deaths have increased from 94,968 in 1990 to 172,427 in 2019, signifying an 81.6% increase, which greatly exceeds the 18.2% increase in all-cause mortality observed over the same time interval. Examination of age-specific mortality demonstrated that the number of aortic aneurysm deaths markedly correlated with advancing age. However, when considering rate of death rather than mortality count, overall age-standardized death rates decreased 18% from 2.72 per 100,000 in 1990 to 2.21 per 100,000 in 2019. Analysis of the specific risk factors associated with aneurysm death revealed that the percentage of deaths attributable to smoking decreased from 45.6% in 1990 to 34.6% in 2019, and deaths attributable to hypertension decreased from 38.7% to 34.7%. Globally, hypertension surpassed smoking as the leading risk factor. The reported rate of death was consistently greater as SDI increased, and this effect was most pronounced among low-middle and middle SDI regions (173.2% and 170.4%, respectively). CONCLUSIONS: Despite an overall increase in the number of aneurysm deaths, there was a decrease in the age-standardized death rate, demonstrating that the observed increased number of aortic aneurysm deaths between 1990 and 2019 was primarily driven by an overall increase in the age of the global population. Fortunately, it appears that the increase in overall aneurysm-related deaths has been modulated by improved risk factor modification, in particular smoking. Given the rise in aneurysm-related deaths, global expansion of vascular specialty capabilities is warranted and will serve to amplify improvements in population-based aneurysm health achieved with risk factor control.

Analysis of Variation in Organizational Definitions of Primary Care Panels: A Systematic Review.

Importance: Primary care panel size plays an increasing role in measuring primary care provider (ie, physicians and advanced practice providers, which include nurse practitioners and physician assistants) workload, setting practice capacity, and determining pay and can influence quality of care, access, and burnout. However, reported panel sizes vary widely. Objective: To identify how panels are defined, the degree of variation in these definitions, the consequences of different definitions of panel size, and research on strengths of different approaches. Evidence Review: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, MEDLINE, Web of Science, Embase, and Dissertations and Theses Global databases were searched from inception to April 28, 2021, for subject headings and text words to capture concepts of primary care panel size. Article review and data abstraction were performed independently by 2 reviewers. Main outcomes reported included rules for adding or removing patients from panels, rules for measuring primary care provider resources, consequences of different rules on reported panel size, and research on advantages and disadvantages of different rules. Findings: The literature search yielded 1687 articles, with 294 potentially relevant articles and 74 containing relevant data. Specific practices were identified from 29 health care systems and 5 empanelment implementation guides. Patients were most commonly empaneled after 1 primary care visit (24 of 34 [70.6%]), but some were empaneled only after several visits (5 [14.8%]), enrollment in a health plan (4 [11.8%]) or any visit to the health care system (1 [3.0%]). Patients were removed when no visit had occurred in a specified look-back period, which varied from 12 to 42 months. Regarding primary care provider resources, half of organizations assigned advanced practice providers independent panels and half had them share panels with a physician, increasing the physician's panel by 50% to 100%. Analyses demonstrated that changes in individual rules for adding patients, removing patients, or estimating primary care provider resources could increase reported panel size from 20% to 100%, without change in actual primary care provider workload. No research was found investigating advantages of different definitions. Conclusions and Relevance: Much variation exists in how panels are defined, and this variation can have substantial consequences on reported panel size. Research is needed on how to define primary care panels to best identify active patients, which could contribute to a widely accepted standard approach to panel definition.

Results of a Regional Effort to Improve Warfarin Management.

BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

Experience of the Veterans Health Administration in Massachusetts after state health care reform.

Starting in 2006, Massachusetts enacted a series of health insurance reforms that successfully led to 96.6% of its population being covered by 2011. As the rest of the nation undertakes similar reforms, it is unknown how the Veterans Health Administration (VHA), one of many important Federal health care programs, will be affected. Our state-level study approach assessed the effects of health reform on utilization of VHA services in Massachusetts from 2005 to 2011. Models were adjusted for state-level demographic and economic characteristics, including health insurance rates, unemployment rates, median household income, poverty rates, and percent of population 65 years and older. No statistically significant associative change was observed in Massachusetts relative to other states over this time period. The findings raise important questions about the continuing role of VHA in American health care as health insurance coverage is one of many factors that influence decisions on where to seek health care.

The effect of physician panel size on health care outcomes.

An inadequate supply of primary care providers is leading to a crisis in access. Pressures are being placed on primary care practices to increase panel sizes. The impact of these pressures on clinical processes, patient satisfaction and waiting times is largely unknown, although evidence from recent literature shows that longer waiting time results in higher mortality rates and other adverse outcomes. FY2004, Department of Veterans Affairs primary care patient data are used. GLIMMIX and other generalized linear model models illustrate how expanded panel sizes are correlated with clinical process indicators, patient satisfaction and waiting times, controlling for practice, provider and patient characteristics. We generally find that larger panel sizes are related to statistically significant increases in waiting time. However, larger panel sizes appear to have generally small effects on patient process indicators and satisfaction. Panels with more support staff have lower waiting times and small, improved outcomes. We find panels with older and clinically riskier patients have, on average, slightly lower waiting times and increased likelihoods of positive outcomes than panels with younger, healthier veterans. Female veterans appear to have reduced likelihoods of positive outcomes. Higher priority and female veterans also have lower satisfaction. Further study is needed to analyse the impact of potential panel size endogeneity in this system.

Relationship of scheduling interval to missed and cancelled clinic appointments.

BACKGROUND: The interval between when a clinical appointment is created and when it occurs may affect the rate of missed and cancelled appointments, affecting access and loss to follow-up, key component of quality. METHODS: We examined this relationship in various clinic types across Veterans Health Administration clinics nationwide. RESULTS: As the interval increased, the missed appointment rate increased from 12.0% at day 1 to 20.3% at day 13, then remained constant. Cancellation rates increased steadily from 19% during month 1 to 50% by month 12. CONCLUSIONS: Scheduling interval has a modest effect on missed appointment rates but a large effect on cancellation rates.

Factors associated with improved completion of computerized clinical reminders across a large healthcare system.

OBJECTIVE: To analyze the relationship of completion rates for a standardized set of computerized clinical reminders across a large healthcare system to practice and provider characteristics. METHODS: The relationship between completion rate for 13 standardized reminders at 49 primary care practices in the VA New England Healthcare System for a 30-day period and practice characteristics, provider demographics and, via survey, provider attitudes was analyzed. RESULTS: There was no difference in clinical reminder completion rate between staff physicians versus nurse practitioners/physician assistants (87.6% versus 88.1%) but both were better than residents (76.6%, p<0.0001). With residents excluded, there were no differences between hospital and community-based clinics or between teaching and non-teaching sites. Clinical reminder completion rate was lower for sites that did not fully utilize support staff in completion process versus sites that did (82.4% versus 88.1%, p<0.0001). Analysis of survey results showed no correlation of completion rate with provider demographics or attitudes towards reminders. However there was significant correlation with frequency of receiving individual feedback on reminder completion (r=0.288, p=0.004). CONCLUSION: Completion of computerized clinical reminders was not affected by a variety of provider characteristics, including professional training, demographics and provider attitude, although was lower among residents than staff providers. However incorporation of support staff into clinic processes and individualized feedback to providers were strongly associated with improved completion. These findings demonstrate the importance of considering practice and provider factors and not just technical elements when implementing informatics tools.

Adherence to computerized clinical reminders in a large healthcare delivery network.

OBJECTIVE: To evaluate clinicians' adherence with clinical reminders (CRs) across multiple ambulatory practice settings in an integrated health care network. MATERIALS AND METHODS: Adherence rate to 15 CRs, integrated into a computerized patient record system, was evaluated for 451 clinicians in 49 clinics from eight Veterans Affairs (VA) medical centers. RESULTS: Overall, mean rate of adherence to CRs for all clinics was 86.2%, with a range of 66.59% to 97.08% (P<.001). The hepatitis C risk assessment reminder was found to have the highest overall adherence rate (95.9%) and the tobacco use cessation had the lowest adherence rate (62.9%). Mean adherence rate for all reminders was 80.34% (P<.001). Mean adherence rate for individual clinicians was 82.6%, with a range of 29% to 100%. CONCLUSION: While overall adherence to CRs was high, there is significant variation by clinic, individual clinician and individual CR. Understanding this variation is critical in directing future efforts to improve the contribution of computerized CRs to quality and cost-effectiveness of care, and to decrease undesirable variation in clinical practice. Further research is needed to systematically evaluate clinician, reminder and systems related factors that influence adherence to CRs.

Management of alcohol withdrawal delirium. An evidence-based practice guideline.

BACKGROUND: Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal. Evidence suggests that appropriate care improves mortality, but systematic reviews are unavailable. METHODS: Articles with original data on management of alcohol withdrawal delirium underwent structured review and meta-analysis. RESULTS: Meta-analysis of 9 prospective controlled trials demonstrated that sedative-hypnotic agents are more effective than neuroleptic agents in reducing duration of delirium and mortality, with a relative risk of death when using neuroleptic agents of 6.6. Statistically significant differences among various benzodiazepines and barbiturates were not found. No deaths were reported in 217 patients from trials using benzodiazepines or barbiturates. CONCLUSIONS: Control of agitation should be achieved using parenteral rapid-acting sedative-hypnotic agents that are cross-tolerant with alcohol. Adequate doses should be used to maintain light somnolence for the duration of delirium. Coupled with comprehensive supportive medical care, this approach is highly effective in preventing morbidity and mortality.

Independent clinical correlates of severe alcohol withdrawal.

This retrospective cohort study sought to identify clinical variables that independently correlate with severe alcohol withdrawal and to quantify risk in a clinically useful manner. The records of 284 inpatients admitted to an acute detoxification unit at a Veterans Affairs teaching hospital were reviewed. Clinical data were recorded on standardized forms at the time of admission and abstracted by a physician reviewer. Alcohol withdrawal severity was prospectively measured with the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Seventy-one patients (25% of cohort) had severe withdrawal. We identified six independent correlates of severe withdrawal: use of a morning eye-opener (adjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2-25.9), an initial CIWA-Ar score > or =10 (OR, 5.1; 95% CI, 2.4-10.6), a serum aspartate aminotransferase > or =80 U/L (OR, 4.2; 95% CI, 2.0-8.8), past benzodiazepine use (OR, 3.6; 95% CI, 1.3-9.9), self-reported history of "delirium tremens" (OR, 2.9; 95% CI, 1.3-6.2), and prior participation in two or more alcohol treatment programs (OR, 2.6; 95% CI, 1.3-5.6). Significantly higher risk was observed in subjects with three or more independent correlates. In conclusion, several readily available clinical variables correlate with the occurrence of severe alcohol withdrawal. Ascertainment of these variables early in the course of alcohol withdrawal has the potential to improve triage and treatment decisions.