Helping individuals with firearm injuries: A cluster randomized trial.

BACKGROUND: Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries. METHODS: We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization. RESULTS: Neither assignment to or engagement with the intervention, defined as having at least 1 contact point with the support specialist, was associated with risk of arrest at 2 years post-hospital discharge (relative risk for intervention assignment, 1.15; 95% confidence interval, 0.90-1.48; relative risk for intervention engagement, 1.07; 95% confidence interval, 0.74-2.19). There was similarly no association observed for subsequent injury. CONCLUSIONS: This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program. LEVEL OF EVIDENCE: Care management, level II.

Prediction of VRC01 neutralization sensitivity by HIV-1 gp160 sequence features.

The broadly neutralizing antibody (bnAb) VRC01 is being evaluated for its efficacy to prevent HIV-1 infection in the Antibody Mediated Prevention (AMP) trials. A secondary objective of AMP utilizes sieve analysis to investigate how VRC01 prevention efficacy (PE) varies with HIV-1 envelope (Env) amino acid (AA) sequence features. An exhaustive analysis that tests how PE depends on every AA feature with sufficient variation would have low statistical power. To design an adequately powered primary sieve analysis for AMP, we modeled VRC01 neutralization as a function of Env AA sequence features of 611 HIV-1 gp160 pseudoviruses from the CATNAP database, with objectives: (1) to develop models that best predict the neutralization readouts; and (2) to rank AA features by their predictive importance with classification and regression methods. The dataset was split in half, and machine learning algorithms were applied to each half, each analyzed separately using cross-validation and hold-out validation. We selected Super Learner, a nonparametric ensemble-based cross-validated learning method, for advancement to the primary sieve analysis. This method predicted the dichotomous resistance outcome of whether the IC50 neutralization titer of VRC01 for a given Env pseudovirus is right-censored (indicating resistance) with an average validated AUC of 0.868 across the two hold-out datasets. Quantitative log IC50 was predicted with an average validated R2 of 0.355. Features predicting neutralization sensitivity or resistance included 26 surface-accessible residues in the VRC01 and CD4 binding footprints, the length of gp120, the length of Env, the number of cysteines in gp120, the number of cysteines in Env, and 4 potential N-linked glycosylation sites; the top features will be advanced to the primary sieve analysis. This modeling framework may also inform the study of VRC01 in the treatment of HIV-infected persons.

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions.

BACKGROUND: Terminal intensive care unit (ICU) stays represent an important target to increase value of care. OBJECTIVE: To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value. DESIGN: Secondary analysis of an intervention study to improve quality of care for critically ill patients. SETTING/PATIENTS: 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. METHODS: Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models. MAIN RESULTS: Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics. CONCLUSIONS: Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models.

Economic Feasibility of Staffing the Intensive Care Unit with a Communication Facilitator.

RATIONALE: In the intensive care unit (ICU), complex decision making by clinicians and families requires good communication to ensure that care is consistent with the patients' values and goals. OBJECTIVES: To assess the economic feasibility of staffing ICUs with a communication facilitator. METHODS: Data were from a randomized trial of an "ICU communication facilitator" linked to hospital financial records; eligible patients (n = 135) were admitted to the ICU at a single hospital with predicted mortality ≥30% and a surrogate decision maker. Adjusted regression analyses assessed differences in ICU total and direct variable costs between intervention and control patients. A bootstrap-based simulation assessed the cost efficiency of a facilitator while varying the full-time equivalent of the facilitator and the ICU mortality risk. MEASUREMENTS AND MAIN RESULTS: Total ICU costs (mean 22.8k; 95% CI, -42.0k to -3.6k; P = 0.02) and average daily ICU costs (mean, -0.38k; 95% CI, -0.65k to -0.11k; P = 0.006)] were reduced significantly with the intervention. Despite more contacts, families of survivors spent less time per encounter with facilitators than did families of decedents (mean, 25 [SD, 11] min vs. 36 [SD, 14] min). Simulation demonstrated maximal weekly savings with a 1.0 full-time equivalent facilitator and a predicted ICU mortality of 15% (total weekly ICU cost savings, $58.4k [95% CI, $57.7k-59.2k]; weekly direct variable savings, $5.7k [95% CI, $5.5k-5.8k]) after incorporating facilitator costs. CONCLUSIONS: Adding a full-time trained communication facilitator in the ICU may improve the quality of care while simultaneously reducing short-term (direct variable) and long-term (total) health care costs. This intervention is likely to be more cost effective in a lower-mortality population.

Travel Burden to Breast MRI and Utilization: Are Risk and Sociodemographics Related?

PURPOSE: Mammography, unlike MRI, is relatively geographically accessible. Additional travel time is often required to access breast MRI. However, the amount of additional travel time and whether it varies on the basis of sociodemographic or breast cancer risk factors is unknown. METHODS: The investigators examined screening mammography and MRI between 2005 and 2012 in the Breast Cancer Surveillance Consortium by (1) travel time to the closest and actual mammography facility used and the difference between the two, (2) women's breast cancer risk factors, and (3) sociodemographic characteristics. Logistic regression was used to examine the odds of traveling farther than the closest facility in relation to women's characteristics. RESULTS: Among 821,683 screening mammographic examinations, 76.6% occurred at the closest facility, compared with 51.9% of screening MRI studies (n = 3,687). The median differential travel time among women not using the closest facility for mammography was 14 min (interquartile range, 8-25 min) versus 20 min (interquartile range, 11-40 min) for breast MRI. Differential travel time for both imaging modalities did not vary notably by breast cancer risk factors but was significantly longer for nonurban residents. For non-Hispanic black compared with non-Hispanic white women, the adjusted odds of traveling farther than the closest facility were 9% lower for mammography (odds ratio, 0.91; 95% confidence interval, 0.87-0.95) but more than two times higher for MRI (odds ratio, 2.64; 95% confidence interval, 1.36-5.13). CONCLUSIONS: Breast cancer risk factors were not related to excess travel time for screening MRI, but sociodemographic factors were, suggesting the possibility that geographic distribution of advanced imaging may exacerbated disparities for some vulnerable populations.

Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness.

OBJECTIVES: To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. DESIGN AND SETTING: Decision analysis using literature estimates and inpatient administrative data from Premier. PATIENTS: Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions' efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. CONCLUSIONS: In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.

Cross-national comparison of screening mammography accuracy measures in U.S., Norway, and Spain.

OBJECTIVE: To compare accuracy measures for mammographic screening in Norway, Spain, and the US. METHODS: Information from women aged 50-69 years who underwent mammographic screening 1996-2009 in the US (898,418 women), Norway (527,464), and Spain (517,317) was included. Screen-detected cancer, interval cancer, and the false-positive rates, sensitivity, specificity, positive predictive value (PPV) for recalls (PPV-1), PPV for biopsies (PPV-2), 1/PPV-1 and 1/PPV-2 were computed for each country. Analyses were stratified by age, screening history, time since last screening, calendar year, and mammography modality. RESULTS: The rate of screen-detected cancers was 4.5, 5.5, and 4.0 per 1000 screening exams in the US, Norway, and Spain respectively. The highest sensitivity and lowest specificity were reported in the US (83.1 % and 91.3 %, respectively), followed by Spain (79.0 % and 96.2 %) and Norway (75.5 % and 97.1 %). In Norway, Spain and the US, PPV-1 was 16.4 %, 9.8 %, and 4.9 %, and PPV-2 was 39.4 %, 38.9 %, and 25.9 %, respectively. The number of women needed to recall to detect one cancer was 20.3, 6.1, and 10.2 in the US, Norway, and Spain, respectively. CONCLUSIONS: Differences were found across countries, suggesting that opportunistic screening may translate into higher sensitivity at the cost of lower specificity and PPV. KEY POINTS: • Positive predictive value is higher in population-based screening programmes in Spain and Norway. • Opportunistic mammography screening in the US has lower positive predictive value. • Screening settings in the US translate into higher sensitivity and lower specificity. • The clinical burden may be higher for women screened opportunistically.

Variation in tracheal reintubations among patients undergoing cardiac surgery across Washington state hospitals.

OBJECTIVES: The objectives of this study were to examine the variation in reintubations across Washington state hospitals that perform cardiac surgery, and explore hospital and patient characteristics associated with variation in reintubation. DESIGN: Retrospective cohort study. SETTING: All nonfederal hospitals performing cardiac surgery in Washington state. PARTICIPANTS: A total of 15,103 patients undergoing coronary artery bypass grafting or valvular surgery between January 1, 2008 and September 30, 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient and hospital characteristics were compared between hospitals that had a reintubation frequency ≥5% or<5%. Multivariate logistic regression was used to compare the odds of reintubation across the hospitals. The authors tested for heterogeneity of odds of reintubation across hospitals by performing a likelihood ratio test on the hospital factor. After adjusting for patient-level characteristics and procedure type, significant heterogeneity in reintubations across hospitals was present (p = 0.005). This exploratory analyses suggested that hospitals with lower reintubations were more likely to have more acute care days and teaching intensive care units (ICU). CONCLUSIONS: After accounting for patient and procedure characteristics, significant heterogeneity in the relative odds of requiring reintubation was present across 16 nonfederal hospitals performing cardiac surgery in Washington state. The findings suggested that greater hospital volume and ICU teaching status were associated with fewer reintubations.

Advanced glycation/glycoxidation endproduct carboxymethyl-lysine and incidence of coronary heart disease and stroke in older adults.

BACKGROUND: Advanced glycation/glycoxidation endproducts (AGEs) accumulate in settings of increased oxidative stress--such as diabetes, chronic kidney disease and aging--where they promote vascular stiffness and atherogenesis, but the prospective association between AGEs and cardiovascular events in elders has not been previously examined. METHODS: To test the hypothesis that circulating levels of N(ɛ)-carboxymethyl-lysine (CML), a major AGE, increase the risk of incident coronary heart disease and stroke in older adults, we measured serum CML by immunoassay in 2111 individuals free of prevalent cardiovascular disease participating in a population-based study of U.S. adults ages 65 and older. RESULTS: During median follow-up of 9.1 years, 625 cardiovascular events occurred. CML was positively associated with incident cardiovascular events after adjustment for age, sex, race, systolic blood pressure, anti-hypertensive treatment, diabetes, smoking status, triglycerides, albumin, and self-reported health status (hazard ratio [HR] per SD [0.99 pmol/l] increase=1.11, 95% confidence interval [CI]=1.03-1.19). This association was not materially attenuated by additional adjustment for C-reactive protein, estimated glomerular filtration rate (eGFR), and urine albumin/creatinine ratio. Findings were similar for the component endpoints of coronary heart disease and stroke. CONCLUSIONS: In this large older cohort, CML was associated with an increased risk of cardiovascular events independent of a wide array of potential confounders and mediators. Although the moderate association limits CML's value for risk prediction, these community-based findings provide support for clinical trials to test AGE-lowering therapies for cardiovascular prevention in this population.

Transient renal enlargement in pediatric hematopoietic cell transplant recipients.

Age-dependent renal length tables are routinely used when interpreting pediatric ultrasound. Standard renal length tables may not be accurate for HCT patients due to treatment effects on kidney size. The purpose of this study was to determine whether renal size changes from expected lengths based on age after HCT in the absence of other markers of renal disease. Four hundred and fifty renal measurements were made on 101 patients who underwent HCT between 2006 and 2010. Renal length was measured at 1-90 days pre-HCT and at 0-30, 31-90, 91-180, and 181+ days post-HCT. Values were compared with normal renal length tables. Average post-HCT renal lengths were greater than established normative renal length data within every age group. Age-adjusted average renal lengths measured at 0-30 and 31-90 days post-transplantation were significantly larger than pre-HCT renal lengths, with relative increases of 6.9% (4.5, 9.4; p < 0.001) and 3.9% (1.4, 6.4; p = 0.003), respectively. Average renal length did not differ significantly after 90 days post-transplantation. HCT patients may have larger kidneys in the absence of renal disease. Awareness of the potential phenomenon of transient renal enlargement following HCT can prevent misdiagnosis and eliminate unnecessary diagnostic evaluations, interventions, anxiety, resource allocation, and financial costs.