A New Method of Assessing the Impact of Evidence-Based Medicine on Claim Outcomes.

OBJECTIVE: The objective of this study is to develop a method of quantifying compliance with Evidence-Based Medicine (EBM) guidelines as a means of assessing the relationship between the use of EBM guidelines and illness absence and costs in workers' compensation. METHODS: A total of 45,951 indemnity claims with two years of development filed between 2008 and 2013 were utilized to develop the methodology. RESULTS: The newly developed methodology adequately assessed the relationship between claim outcomes (duration and medical incurred) and adherence to EBM guidelines, controlling for medical complexity, distinct number of International Classification of Diseases (ICD)-9 codes, and other confounding factors. CONCLUSIONS: The compliance score described in this paper may be a useful tool for determining the impact of worker's compensation treatment guidelines on claim outcomes.

Effect of physician-dispensed medication on workers' compensation claim outcomes in the state of Illinois.

OBJECTIVE: To evaluate differences between physician-dispensed and non-physician-dispensed medication with regard to lost time, prescription volume, and pharmaceutical, medical, indemnity costs in the Illinois workers' compensation system. METHODS: We studied a sample of 6824 workers' compensation indemnity claims that were opened and closed between January 1, 2007, and December 31, 2012, by Accident Fund Holdings in the State of Illinois. RESULTS: The number of prescriptions per claim and pharmaceutical, medical, and indemnity costs, as well as time out from work, were significantly higher in claims where a pharmaceutical was dispensed by the physician within 90 days of injury than in claims where physician dispensing did not occur. These differences persisted controlling for age, sex, attorney involvement, and injury complexity. CONCLUSION: Physician dispensing is associated with higher costs and more lost time than pharmacy-dispensed medications in workers' compensation claims.

The effect of opioid use on workers' compensation claim cost in the State of Michigan.

OBJECTIVE: To investigate the association between opioid utilization and catastrophic claim (≥$100,000) cost. METHOD: A total of 12,226 workers' compensation indemnity claims that were opened and closed from January 1, 2006 to February 28, 2010 in the State of Michigan were selected for multivariate logistic regression analyses. RESULT: Controlling for sex, age, claim duration, number of distinct International Classification of Diseases-Ninth Revision codes per claim, and legal involvement, the presence of short-acting opioids on a claim were 1.76 (95% confidence interval: 1.23 to 2.51) and long-acting opioids 3.94 (95% confidence interval: 2.35 to 6.89) more likely to have a final cost $100,000 or more than a claim without any prescription. CONCLUSION: The use of opioid medications, particularly long-acting opioid medications, is an independent risk factor for the development of catastrophic claims.

Daily peritoneal administration of sodium pyrophosphate in a dialysis solution prevents the development of vascular calcification in a mouse model of uraemia.

BACKGROUND: The high rate of cardiovascular mortality in patients with end-stage renal disease (ESRD) is a significant barrier to improved life expectancy. Unique in this population is the marked development and aggressive worsening of vascular calcification (VC). Pyrophosphate (PPi), an endogenous molecule, appears to naturally inhibit soft tissue calcification, but may be depressed in chronic kidney disease (CKD) and ESRD. Although once thought to be a promising therapeutic, PPi's very short half-life in circulation curtailed earlier studies. We tested the possibility that a slow, continuous entry of PPi into the circulation and prevention of VC might be achieved by daily peritoneal dialysis (PD). METHODS: Pharmacokinetic studies were first carried out in rats with renal impairment resulting from a 5/6 nephrectomy. Efficacy studies were then performed in the apolipoprotein E gene knockout mouse model overlaid with CKD. PPi was delivered by means of a permanent peritoneal catheter in a solution simulating PD, but without the timed removal of spent dialysate. von Kossa's staining followed by semiquantitative morphological image processing, with separation of inside (intimal) and outside (presumed medial) lesions, was used to determine aortic root calcification. RESULTS: In comparison to an intravenous bolus, delivery of PPi in a PD solution resulted in a slower, extended delivery over >4 h. Next, the efficacy studies showed that a 6-day/week PD-simulated administration of PPi resulted in a dose-dependent inhibition of aortic calcification in both intimal and medial lesions. A dose-response effect on total aortic calcification was also documented, with a full inhibition seen at the highest dose. A limited peritoneal catheter-related inflammation was observed, as expected, and included the placebo-treated control groups. This inflammatory response could have masked a lower level PPi-specific adverse effect, but none was observed. CONCLUSIONS: Our findings suggest potential for PPi, administered during PD, to prevent the development of VC and to potentially extend the life of ESRD patients.

Transforming patient and family access to medical information: utilisation patterns of a patient-accessible electronic health record.

OBJECTIVE: The purpose of this study was to evaluate the utilisation of a web-based multimedia patient-accessible electronic health record, for patients with congenital cardiac disease. PATIENTS AND METHODS: This was a prospective analysis of patients undergoing congenital cardiac surgery at a single institution from 1 September, 2006 to 1 February, 2009. After meetings with hospital administration, physicians, nurses, and patients, we configured a subset of the cardiac program's web-based clinical electronic health record for patient and family access. The Electronic Health Record continuously measured frequency and time of logins, logins during and between hospitalisations, and page views by type (imaging versus textual data). RESULTS: Of the first 270 patients offered access to the system, 252 became users (93% adoption rate). System uptime was 99.9%, and no security breaches were reported. Users accessed the system more often while the patients were in hospital (67% of total logins) than after discharge (33% of total logins). The maximum number of logins by a family was 440, and the minimum was 1. The average number of logins per family was 25. Imaging data were viewed significantly more frequently than textual data (p 0.001). A total of 12 patients died during the study period and 11 members of their families continued to access their Electronic Health Records after the date of death. CONCLUSIONS: A web-based Patient Accessible Electronic Health Record was designed for patients with congenital cardiac disease. The adoption rate was high, and utilisation patterns suggest that the Electronic Health Record could become a useful tool for health information exchange.

Patterns of lactate values after congenital heart surgery and timing of cardiopulmonary support.

BACKGROUND: We sought to determine if postoperative serial lactate determinations follow predictable patterns that could be useful in directing management, especially the initiation of postoperative mechanical cardiopulmonary support (CPS). METHODS: Eight patients undergoing CPS in a 2-year period and 147 patients not requiring postoperative CPS in 6 months of that period were stratified into 6 categories based on short-term risk for mortality (1 being the lowest risk). Lactate values for the first 48 hours postoperatively were retrospectively analyzed. RESULTS: Survivors not requiring CPS in category 6 (n = 16) followed a distinct pattern different from those of categories 1 through 4 (n = 128). Review of postoperative CPS survivors (n = 4) indicated that CPS was initiated electively without cardiac arrest in all 4, and lactate values showed a downward trend within 12 hours of initiation in all cases (mean lactate, 10.12 +/- 1.88 mmol/L; range, 1.4 to 16 mmol/L; mean initiation time, 16.5 hours postoperatively). Three fourths of the CPS nonsurvivors suffered cardiac arrest before CPS and showed rising lactate values despite support (mean lactate, 11.95 +/- 1.37 mmol/L; range, 1.6 to 18.6 mmol/L; mean initiation time, 21.25 hours postoperatively). Indications for initiation of CPS in patients with elevated lactate values were reviewed. Two thirds of patients who died without CPS had preterminal cardiac arrest. CONCLUSIONS: We have defined the normal pattern of postoperative lactate values in our institution. These data suggest that an abnormal lactate pattern may be useful in determining the timing of CPS initiation in hemodynamically stable patients with high or rising lactate values, before cardiac arrest or end organ damage.

Internet rounds: a congenital heart surgeon's Web log.

As the complexity of congenital heart care increases, and expectations for improved outcomes grow, the limitations of current medical information management systems are exposed. Despite advances in information management technology, achieving a state of information resonance within a congenital heart team, where comprehensive patient data and real time program performance can be intuitively accessed on demand, remains an elusive goal. The World Wide Web constitutes a potential platform for a medical information management system capable of overcoming the limitations of traditional medical information exchange. We designed and implemented an Internet based information management system to collect, store and exchange comprehensive patient information, and measure clinical performance in real time. Use of this system has been associated with improved clinical outcomes for a congenital heart team.

The fenestrated Kawashima operation for single ventricle with interrupted inferior vena cava.

An 8-month-old boy with double outlet right ventricle with hypoplastic left ventricle, heterotaxy, left atrial isomerism, bilateral superior vena cavae without bridging vein, and interruption of the inferior vena cava with azygous continuation to the left superior cava underwent a bilateral bidirectional cavopulmonary anastomosis. A calibrated 3-mm connection between the right pulmonary artery and the common atrium was constructed with the proximal right superior vena cava to allow right to left shunting, analogous to a fenestration in a Fontan operation. We hypothesize that in small young patients undergoing the Kawashima operation a fenestration may improve postoperative hemodynamics.

Agarose-dextran gels as synthetic analogs of glomerular basement membrane: water permeability.

Novel agarose-dextran hydrogels were synthesized and their suitability as experimental models of glomerular basement membrane was examined by measuring their Darcy (hydraulic) permeabilities (kappa). Immobilization of large dextran molecules in agarose was achieved by electron beam irradiation. Composite gels were made with agarose volume fractions (phi(a)) of 0.04 or 0.08 and dextran volume fractions (phi(d)) ranging from 0 to 0.02 (fiber volume/gel volume), using either of two dextran molecular weights (500 or 2000). At either agarose concentration and for either size of dextran, kappa decreased markedly as the amount of dextran was increased. Statistically significant deviations from the value of kappa for pure agarose were obtained for remarkably small volume fractions of dextran: phi(d) > or = 0.0003 for phi(a) = 0.04 and phi(d) > or = 0.001 for phi(a) = 0.08. The Darcy permeabilities were much more sensitive to phi(d) than to phi(a), and were as much as 26 times smaller than those of pure agarose. Although phi(d) was an important variable, dextran molecular weight was not. The effects of dextran addition on kappa were described fairly well using simple structural idealizations. At high agarose concentrations, the dextran chains behaved as fine fibers interspersed among coarse agarose fibrils, whereas, at low concentrations, the dextran molecules began to resemble spherical obstacles embedded in agarose gels. The ability to achieve physiologically relevant Darcy permeabilities with these materials (as low as 1.6 nm2) makes them an attractive experimental model for glomerular basement membrane and possibly other extracellular matrices.