Assessment of potential factors associated with the sensitivity and specificity of Sofia Influenza A+B Fluorescent Immunoassay in an ambulatory care setting.

BACKGROUND: Seasonal influenza leads to an increase in outpatient clinic visits. Timely, accurate, and affordable testing could facilitate improved treatment outcomes. Rapid influenza diagnostic tests (RIDTs) provide results in as little as 15 minutes and are relatively inexpensive, but have reduced sensitivity when compared to RT-PCR. The contributions of multiple factors related to test performance are not well defined for ambulatory care settings. We assessed clinical and laboratory factors that may affect the sensitivity and specificity of Sofia Influenza A+B Fluorescence Immunoassay. STUDY DESIGN: We performed a post-hoc assessment of surveillance data amassed over seven years from five primary care clinics. We analyzed 4,475 paired RIDT and RT-PCR results from specimens collected from patients presenting with respiratory symptoms and examined eleven potential factors with additional sub-categories that could affect RIDT sensitivity. RESULTS: In an unadjusted analysis, greater sensitivity was associated with the presence of an influenza-like illness (ILI), no other virus detected, no seasonal influenza vaccination, younger age, lower cycle threshold value, fewer days since illness onset, nasal discharge, stuffy nose, and fever. After adjustment, presence of an ILI, younger age, fewer days from onset, no co-detection, and presence of a nasal discharge maintained significance. CONCLUSION: Clinical and laboratory factors may affect RIDT sensitivity. Identifying potential factors during point-of-care testing could aid clinicians in appropriately interpreting negative influenza RIDT results.

An assessment of parental knowledge, attitudes, and beliefs regarding influenza vaccination.

INTRODUCTION: Seasonal influenza imposes a significant clinical and economic burden. Despite the availability of an annual vaccine to prevent influenza infection and reduce disease severity, influenza vaccination rates remain suboptimal. Research suggests personal experience, perceived effectiveness, and concerns regarding vaccine safety and side effects are the most influential factors in predicting a parent's decision to vaccinate. However, current literature is primarily focused on the vaccine decision-making of healthcare workers and those at high risk for influenza complications. METHODS: To assess parental attitudes and beliefs regarding the influenza vaccine, a brief mixed-methods survey was developed and optimized for an electronic platform. The Health Belief Model informed survey design and data analysis. Questions were classified into five core concepts: knowledge, barriers, benefits, experience, and severity. Participants were solicited from a population of parents whose children had participated in a school-based influenza surveillance study (n = 244, 73% response rate). We tested associations between responses and children's influenza vaccination status the prior season. Categorical questions were tested using Pearson's chi-squared tests and numerical or ordered questions using Mann-Whitney tests. P-values were corrected using the Bonferroni method. RESULTS: Doubting effectiveness, concerns about side effects, inconvenience, and believing the vaccine is unnecessary were barriers negatively associated with parents' decision to vaccinate their children during the 2017-18 flu season (p < 0.001). Knowledge that the vaccine is effective in lowering risk, duration, and severity of influenza; receiving the influenza vaccine as an adult; and recognizing the importance of vaccination to prevent influenza transmission in high-risk populations were positively associated with parents' decision to vaccinate (p < 0.001). CONCLUSION: Understanding barriers and motivators behind parents' decision to vaccinate provides valuable insight that has the potential to shape vaccine messaging, recommendations, and policy. The motivation to vaccinate to prevent influenza transmission in high-risk populations is a novel finding that warrants further investigation.

A transition care coordinator model reduces hospital readmissions and costs.

BACKGROUND: The optimal structure and intensity of interventions to reduce hospital readmission remains uncertain, due in part to lack of head-to-head comparison. To address this gap, we evaluated two forms of an evidence-based, multi-component transitional care intervention. METHODS: A quasi-experimental evaluation design compared outcomes of Transition Care Coordinator (TCC) Care to Usual Care, while controlling for sociodemographic characteristics, comorbidities, readmission risk, and administrative factors. The study was conducted between January 1, 2013 and April 30, 2015 as a quality improvement initiative. Eligible adults (N = 7038) hospitalized with pneumonia, congestive heart failure, or chronic obstructive pulmonary disease were identified for program evaluation via an electronic health record algorithm. Nurse TCCs provided either a full intervention (delivered in-hospital and by post-discharge phone call) or a partial intervention (phone call only). RESULTS: A total of 762 hospitalizations with TCC Care (460 full intervention and 302 partial intervention) and 6276 with Usual Care was examined. In multivariable models, hospitalizations with TCC Care had significantly lower odds of readmission at 30 days (OR = 0.512, 95% CI 0.392 to 0.668) and 90 days (OR = 0.591, 95% CI 0.483 to 0.723). Adjusted costs were significantly lower at 30 days (difference = $3969, 95% CI $5099 to $2691) and 90 days (difference = $5684, 95% CI $7602 to $3627). The effect was similar whether patients received the full or partial intervention. CONCLUSION: An evidence-based multi-component intervention delivered by nurse TCCs reduced 30- and 90-day readmissions and associated health care costs. Lower intensity interventions delivered by telephone after discharge may have similar effectiveness to in-hospital programs.

Cost-effectiveness analysis of magnetic resonance imaging-conditional pacemaker implantation: Insights from a multicenter study and implications in the current era.

BACKGROUND: Magnetic resonance imaging (MRI)-conditional pacemakers (M-PPMs) grant patients greater accessibility to MRI scans. The cost-effectiveness of implanting M-PPM is unknown. OBJECTIVE: The purpose of this study was to determine the cost-effectiveness of M-PPM implantation. METHODS: Cost-effectiveness analysis was performed on patients receiving a M-PPM across 4 institutions. The incremental cost-effectiveness ratio (ICER) was calculated by dividing the sum of the total incremental cost of implanting a M-PPM vs a conventional pacemaker and the cost of MRI scans by the utility of MRI scans in terms of quality-adjusted life-years (QALY) gained. QALY and lifespan of M-PPM (7-11 years) data were obtained from the literature. The benchmark of <$100,000 per QALY was used as the threshold for cost-effectiveness. Computer modeling/simulations were used to calculate the percentage of patients required to achieve this benchmark, to extrapolate the cumulative projected percentage of patients utilizing MRI scans over the lifespan of a M-PPM via the Weibull parametric survival model, and to conduct univariate and multivariate, probabilistic sensitivity analyses. RESULTS: The ICER during the follow-up period (21 ± 17 months) was $451,569. The cost-effectiveness ICER benchmark is reached 7.0 years postimplantation, when a projected 38% of recipients would receive MRI scans. The projected percentage of patients receiving MRI scans at 11 years was 58%, yielding an ICER of $74,221 per QALY. Henceforth, assuming increased MRI usage in regular PPM based on Centers for Medicare & Medicaid Services memo CAG00399R4 and decreased cost of M-PPM, M-PPM implantation is still cost-effective, with a lifetime ICER of $49,817 per QALY. CONCLUSION: M-PPM implantation is cost-effective over the lifespan of a M-PPM based on projected usage of MRI.

Longitudinal assessment of cardiac morphology and function following kidney transplantation.

BACKGROUND: Abnormal cardiac morphology is a risk factor for cardiovascular complications in kidney transplant patients. A supraphysiologic level of fibroblast growth factor 23 (FGF-23) has been associated with myocardial hypertrophy in this patient population. Our aim was to evaluate the change in cardiac morphology and function following kidney transplantation and to evaluate the association between the change in FGF-23 concentrations and cardiac morphology. METHODS: We performed a longitudinal, prospective cohort study of 143 kidney transplant recipients (73% male, 75% white) measuring left ventricular (LV) mass index, left atrial (LA) volume index, and ejection fraction (EF) by echocardiography at months 1, 12, and 24 post-transplant. FGF-23 levels were measured at months 1 and 24 post-transplant. RESULTS: Unadjusted and adjusted linear mixed-effects models were used to examine changes in outcomes over time. In the adjusted model, LV mass index (P<.001) and LA volume index (P<.001) decreased and EF (P=.009) increased significantly over time. There was a significant association between decreasing FGF-23 levels and improving LV mass index following transplant (P=.036) in the unadjusted model; however, there was no significant relationship in the adjusted model (0.195). CONCLUSION: Understanding the progression of unique cardiovascular risk factors associated with kidney transplantation may provide potential opportunities to improve survival.

Leucine disposal rate for assessment of amino acid metabolism in maintenance hemodialysis patients.

BACKGROUND: Protein energy wasting (PEW) is common in patients undergoing maintenance hemodialysis (MHD) and closely associated with poor outcomes. Insulin resistance and associated alterations in amino acid metabolism are potential pathways leading to PEW. We hypothesized that the measurement of leucine disposal during a hyperinsulinemic- euglycemic-euaminoacidemic clamp (HEAC) procedure would accurately measure the sensitivity to insulin for its actions on concomitant carbohydrate and protein metabolism in MHD patients. METHODS: We examined 35 MHD patients and 17 control subjects with normal kidney function by hyperinsulinemic-euglycemic clamp (HEGC) followed by HEAC clamp procedure to obtain leucine disposal rate (LDR) along with isotope tracer methodology to assess whole body protein turnover. RESULTS: The glucose disposal rate (GDR) by HEGC was 5.1 ± 2.1 mg/kg/min for the MHD patients compared to 6.3 ± 3.9 mg/kg/min for the controls (p = 0.38). The LDR during HEAC was 0.09 ± 0.03 mg/kg/min for the MHD patients compared to 0.11 ± 0.05 mg/kg/min for the controls (p = 0.009). The LDR level was correlated with whole body protein synthesis (r = 0.25; p = 0.08), with whole body protein breakdown (r = -0.38 p = 0.01) and net protein balance (r = 0.85; p < 0.001) in the overall study population. Correlations remained significant in subgroup analysis. The GDR derived by HEGC and LDR correlated well in the controls (r = 0.79, p < 0.001), but less so in the MHD patients (r = 0.58, p < 0.001). CONCLUSIONS: Leucine disposal rate reliably measures amino acid utilization in MHD patients and controls in response to high dose insulin.

Disparities in Electronic Health Record Patient Portal Use in Nephrology Clinics.

BACKGROUND AND OBJECTIVES: Electronic health record (EHR) patient portals allow individuals to access their medical information with the intent of patient empowerment. However, little is known about portal use in nephrology patients. We addressed this gap by characterizing adoption of an EHR portal, assessing secular trends, and examining the association of portal adoption and BP control (<140/90 mmHg). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients seen between January 1, 2010, and December 31, 2012, at any of four university-affiliated nephrology offices who had at least one additional nephrology follow-up visit before June 30, 2013, were included. Sociodemographic characteristics, comorbidities, clinical measurements, and office visits were abstracted from the EHR. Neighborhood median household income was obtained from the American Community Survey 2012. RESULTS: Of 2803 patients, 1098 (39%) accessed the portal. Over 87% of users reviewed laboratory results, 85% reviewed their medical information (e.g., medical history), 85% reviewed or altered appointments, 77% reviewed medications, 65% requested medication refills, and 31% requested medical advice from their renal provider. In adjusted models, older age, African-American race (odds ratio [OR], 0.50; 95% confidence interval [95% CI], 0.39 to 0.64), Medicaid status (OR, 0.53; 95% CI, 0.36 to 0.77), and lower neighborhood median household income were associated with not accessing the portal. Portal adoption increased over time (2011 versus 2010: OR, 1.38 [95% CI, 1.09 to 1.75]; 2012 versus 2010: OR, 1.95 [95% CI, 1.44 to 2.64]). Portal adoption was correlated with BP control in patients with a diagnosis of hypertension; however, in the fully adjusted model this was somewhat attenuated and no longer statistically significant (OR, 1.11; 95% CI, 0.99 to 1.24). CONCLUSION: While portal adoption appears to be increasing, greater attention is needed to understand why vulnerable populations do not access it. Future research should examine barriers to the use of e-health technologies in underserved patients with CKD, interventions to address them, and their potential to improve outcomes.