Predictors of Success in the Bundled Payments for Care Improvement Program.

BACKGROUND: Hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program were incented to reduce Medicare payments for episodes of care. OBJECTIVE: To identify factors that influenced whether or not hospitals were able to save in the BPCI program, how the cost of different services changed to produce those savings, and if "savers" had lower or decreased quality of care. DESIGN: Retrospective cohort study. PARTICIPANTS: BPCI-participating hospitals. MAIN MEASURES: We designated hospitals that met the program goal of decreasing costs by at least 2% from baseline in average Medicare payments per 90-day episode as "savers." We used regression models to determine condition-level, patient-level, hospital-level, and market-level characteristics associated with savings. KEY RESULTS: In total, 421 hospitals participated in BPCI, resulting in 2974 hospital-condition combinations. Major joint replacement of the lower extremity had the highest proportion of savers (77.6%, average change in payments -$2235) and complex non-cervical spinal fusion had the lowest (22.2%, average change +$8106). Medical conditions had a higher proportion of savers than surgical conditions (11% more likely to save, P=0.001). Conditions that were mostly urgent/emergent had a higher proportion of savers than conditions that were mostly elective (6% more likely to save, P=0.007). Having higher than median costs at baseline was associated with saving (OR: 3.02, P<0.001). Hospitals with more complex patients were less likely to save (OR: 0.77, P=0.003). Savings occurred across both inpatient and post-acute care, and there were no decrements in clinical care associated with being a saver. CONCLUSIONS: Certain conditions may be more amenable than others to saving under bundled payments, and hospitals with high costs at baseline may perform well under programs which use hospitals' own baseline costs to set targets. Findings may have implications for the BPCI-Advanced program and for policymakers seeking to use payment models to drive improvements in care.

Pulmonary vascular resistance determines mortality in end-stage renal disease patients with pulmonary hypertension.

The multifactorial etiology of pulmonary hypertension (PH) in end-stage renal disease (ESRD) includes patients with and without elevated pulmonary vascular resistance (PVR). We explored the prognostic implication of this distinction by evaluating pretransplant ESRD patients who underwent right heart catheterization and echocardiography. Demographics, clinical data, and test results were analyzed. All-cause mortality data were obtained. Median follow-up was 4 years. Of the 150 patients evaluated, echocardiography identified 99 patients (66%) with estimated pulmonary artery (PA) systolic pressure > 36 mm Hg, which correlated poorly with mortality (HR = 1.28, 95% CI 0.72-2.27, P = .387). Right heart catheterization identified 88 (59%) patients with mean PA pressure ≥ 25 mm Hg. Of these, 70 had PVR ≤ 3 Wood units and 18 had PVR > 3 Wood units. Survival analysis demonstrated a significant prognostic effect of an elevated PVR in patients with high mean PA pressures (HR = 2.26, 95% CI 1.07-4.77, P = .03), while patients with high mean PA pressure and normal PVR had equivalent survival to those with normal PA pressure. Despite the high prevalence of PH in ESRD patients, elevated PVR is uncommon and is a determinant of prognosis in patients with PH. Patients with normal PVR had survival equivalent to those with normal PA pressures.

Lead related complications in quadripolar versus bipolar left ventricular leads.

BACKGROUND: Quadripolar left ventricular (LV) leads are capable of pacing from four different electrodes which allows for easier and more stable intra-operative lead positioning with optimal pacing parameters. We therefore investigated the rate of combined intra-operative and post-operative LV lead related events in quadripolar vs. bipolar LV lead cardiac resynchronization therapy (CRT) recipients in the real world setting. METHODS: We retrospectively collected data for N = 1441 patients at our institution implanted with quadripolar (n = 292) or bipolar (n = 1149) LV leads from 2012 to 2014 and followed them to the primary end-point of composite lead outcome defined as intra-operative lead implant failure or post-operative lead dislodgement or deactivations. RESULTS: Patients implanted with a quadripolar lead were younger (70.6 ± 11.4 vs 72.5 ± 11.6, p = 0.014) and had higher incidence of diabetes (41.8% vs 32.8%, p = 0.004) compared to those with bipolar leads. All other baseline characteristics were comparable. Patients implanted with a quadripolar were significantly less likely to reach the primary endpoint in the first 12 months after LV lead implantation (Hazard Ratio 0.22, 95% Confidence Interval 0.08-0.60, p = 0.001). There were no differences between the two groups in rates of hospitalization for any cause or in mortality. CONCLUSION: In this real world study, quadripolar LV leads have significantly lower rates of implantation failure and post-operative lead dislodgement or deactivation. These results have important clinical implications to CRT recipients.

Cutaneous metastatic breast carcinoma with clear cell features.

Breast carcinoma remains one of the most common sources of skin metastases in women. Cutaneous breast carcinoma metastases have variable clinical and histopathologic presentations that can make diagnosis challenging. We report a unique case of metastatic breast carcinoma with prominent clear cell features, thus mimicking a xanthomatous process. Dermatopathologists should be aware of this entity given its resemblance to other clear cell infiltrates and neoplasms.

Hemodynamic Predictors of Stabilization When Using Temporary Mechanical Support for Cardiogenic Shock from Acute on Chronic Heart Failure.

Cardiogenic shock from acute on chronic heart failure is a lethal condition that frequently requires temporary mechanical circulatory support devices (tMCS) as a bridge to stabilization, durable support, or heart transplantation. However, there are limited data on methods to optimize use of tMCS in this population. We identified patients who received tMCS devices for cardiogenic shock from acute on chronic heart failure at a single center from August 2016 to July 2020. All the patients had invasive hemodynamic data before and immediately after tMCS placement. We classified patients according to whether they showed stabilization or decompensation with tMCS. We then evaluated hemodynamics pre-tMCS, post-tMCS, and the change in hemodynamics with tMCS (∆-tMCS) and assessed their relationship with clinical outcomes. Among 111 patients who received tMCS, 71 stabilized, and 40 decompensated. Post-tMCS hemodynamics were more likely than were pre-tMCS or ∆-tMCS to predict stabilization. Post-tMCS cardiac index >2.1 (area under the curve: 92.2) and cardiac power index >0.3 (area under the curve: 89.6) were the best predictors of stabilization. Patients who decompensated had increased in-hospital all-cause mortality (hazard ratio 3.06 [1.29 to 7.24], p = 0.011), cardiovascular mortality, and increased hospital and intensive care unit length of stay and were less likely to receive left ventricular assist device or heart transplant (hazard ratio 0.56 [0.36 to 0.88], p = 0.01). In conclusion, among patients with cardiogenic shock from acute on chronic heart failure who received tMCS, post-tMCS cardiac index and cardiac power index were highly predictive of stabilization. Those who decompensated had increased mortality, hospital length of stay, and intensive care unit length of stay and were less likely to receive heart replacement therapy.

Variation in the Use of Targeted Temperature Management for Cardiac Arrest.

Targeted temperature management (TTM) is recommended for patients who do not respond after return of spontaneous circulation after cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is not known. Understanding hospital- and patient-level factors associated with receipt of TTM could inform interventions to improve access to this treatment among appropriate patients. Therefore, we performed a retrospective analysis using National Inpatient Sample data from 2016 to 2019. We used International Classification of Diseases, Tenth Edition diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of TTM. We evaluated patient and hospital factors associated with receiving TTM. We identified 478,419 patients with cardiac arrest. Of those, 4,088 (0.85%) received TTM. Hospital use of TTM was driven by large, nonprofit, urban, teaching hospitals, with less use at other hospital types. There was significant regional variation in TTM capabilities, with the proportion of hospitals providing TTM ranging from >21% in the Mid-Atlantic region to <11% in the East and West South Central and Mountain regions. At the patient level, age >74 years (odds ratio [OR] 0.54, p <0.001), female gender (OR 0.89, p >0.001), and Hispanic ethnicity (OR 0.74, p <0.001) were all associated with decreased odds of receiving TTM. Patients with Medicare (OR 0.75, p <0.001) and Medicaid (OR 0.89, p = 0.027) were less likely than patients with private insurance to receive TTM. Part of these differences was driven by inequitable access to TTM-capable hospitals. In conclusion, TTM is rarely used after cardiac arrest. Hospital use of TTM is predominately limited to a subset of academic hospitals with substantial regional variation. Older age, female gender, Hispanic ethnicity, and Medicare or Medicaid insurance are all associated with a decreased likelihood of receiving TTM.

The Association of the UNOS Heart Allocation Policy Change With Transplant and Left Ventricular Assist Device Access and Outcomes.

In October 2018, the allocation policy for adult orthotopic heart transplant (OHTx) in the United States was changed, with the goal of reducing waitlist mortality and providing broader sharing of donor organs within the United States. This study aimed to assess the association of this policy change with changes in access to OHTx versus left ventricular assist devices (LVADs), overall and in key sociodemographic subgroups, in the United States from 2016 to 2019. We identified all patients receiving OHTx or LVAD between 2016 and 2019 using the National Inpatient Sample. Controlling for medical co-morbidities, prepolicy trends, and within-hospital-year effects, we fit a dynamic logistic regression model to evaluate patient and hospital factors associated with receiving OHTx versus LVAD before versus after policy change. We also examined the frequency of temporary mechanical circulatory support in the same fashion. We identified 2,264 patients who received OHTx and 3,157 who received LVADs during the study period. In its first year of implementation, the United Network for Organ Sharing policy change of 2018 was associated with no overall change utilization of OHTx versus LVAD. In OHTx recipients, the frequency of use of temporary mechanical circulatory support changed from 15.6% in the before period to 42.6% in the after period (p <0.001). Although the policy change was associated with differences in the odds of receiving an OHTx versus LVAD between different regions of the country, there were no significant changes based on age, gender, race/ethnicity, insurance status, or rurality. In conclusion, the United Network for Organ Sharing policy change on access to OHTx was associated with no overall change in OHTx versus LVAD use in its first year of implementation although we observed small changes in relative odds of transplant based on rurality. Shifts in regional allocation were not significant overall, although certain regions appeared to have a relative increase in their use of OHTx.

Vibrational spectroscopy of N-methyliminodiacetic acid (MIDA)-protected boronate ester: examination of the B-N dative bond.

N-methyliminodiacetic acid (MIDA)-protected boronate esters are a new class of reagents that offer great promise in iterative Suzuki-Miyaura cross-coupling reactions. Compared to earlier reagents, MIDA esters are easily handled and are benchtop stable under air indefinitely. The success of this new species is tied to its unique molecular architecture. Compared to the simpler B-N containing molecules ammonia borane and trimethylamine borane, MIDA esters are much larger, and the sp(3) hybridized boron atom is secured by two five membered rings, making this molecular class stable for spectroscopic study. Here, we present infrared, Raman, and surface enhanced Raman (SERS) spectra of methylboronic acid MIDA ester. Comparisons of the spectroscopic results to those from electronic structure calculations suggest that the B-N stretching mode in this molecule lies in the range 560-650 cm(-1), making it among the lowest energy vibrations observed to date that can be primarily attributed to B-N stretching.

Characteristics of Inpatient Units Associated With Sustained Hand Hygiene Compliance.

OBJECTIVES: Following institution of a hand hygiene (HH) program at an academic medical center, HH compliance increased from 58% to 92% for 3 years. Some inpatient units modeled early, sustained increases, and others exhibited protracted improvement rates. We examined the association between patterns of HH compliance improvement and unit characteristics. METHODS: Adult inpatient units (N = 35) were categorized into the following three tiers based on their pattern of HH compliance: early adopters, nonsustained and late adopters, and laggards. Unit-based culture measures were collected, including nursing practice environment scores (National Database of Nursing Quality Indicators [NDNQI]), patient rated quality and teamwork (Hospital Consumer Assessment of Healthcare Provider and Systems), patient complaint rates, case mix index, staff turnover rates, and patient volume. Associations between variables and the binary outcome of laggard (n = 18) versus nonlaggard (n = 17) were tested using a Mann-Whitney U test. Multivariate analysis was performed using an ordinal regression model. RESULTS: In direct comparison, laggard units had clinically relevant differences in NDNQI scores, Hospital Consumer Assessment of Healthcare Provider and Systems scores, case mix index, patient complaints, patient volume, and staff turnover. The results were not statistically significant. In the multivariate model, the predictor variables explained a significant proportion of the variability associated with laggard status, (R2 = 0.35, P = 0.0481) and identified NDNQI scores and patient complaints as statistically significant. CONCLUSIONS: Uptake of an HH program was associated with factors related to a unit's safety culture. In particular, NDNQI scores and patient complaint rates might be used to assist in identifying units that may require additional attention during implementation of an HH quality improvement program.

Filament-associated TSGA10 protein is expressed in professional antigen presenting cells and interacts with vimentin.

Testis-specific gene antigen 10 (TSGA10) encodes an 82-kDa protein expressed during development, and in testis and brain tissues. We report its expression in human monocyte-derived dendritic cells (DC) and macrophages in vitro and in murine spleen CD11c(+) cells ex vivo. An interaction between DC/macrophage-derived TSGA10 and vimentin, as well as a few other major cytoskeletal proteins (e.g., actin-γ1), was identified by pull-down and mass spectroscopy assays. The interaction between TSGA10 and vimentin was further confirmed by immunoprecipitation and immunolocalisation in transfected RAW267 and HEK293 cell lines. TSGA10 formed filamentous structures in transfected COS-1 cells and was observed in cellular projections. We propose that TSGA10 could influence the function of antigen presenting cells (APC) via its interaction with cytoskeletal proteins such as vimentin.

Perioperative care of the geriatric patient for noncardiac surgery.

Adults age 65 and over are the fastest growing segment of the population in the United States and around the world. As the size of this population expands, the number of older adults referred for surgical procedures will continue to increase. Due to the physiologic changes of aging and the increased frequency of comorbidities, older adults are at increased risk for adverse outcomes, and perioperative care is inherently more complex than in younger individuals. In this review, we discuss the physiologic changes of aging relevant to the surgical patient, comprehensive preoperative assessment, and postoperative management of common complications in older adults in order to promote optimal clinical outcomes both perioperatively and long-term.

Heart Failure and the Affordable Care Act: Past, Present, and Future.

The Affordable Care Act (ACA) and other major health care legislative acts have had an important impact on the care of heart failure patients in the United States. The main effects of the ACA include regulation of the health insurance industry, expansion of access to health care, and health care delivery system reform, which included the creation of several alternative payment models. Particular components of the ACA, such as the elimination of annual and lifetime caps on spending, Medicaid expansion, and the individual and employer mandate, could have positive effects for heart failure patients. However, the benefits of value-based and alternative payment models such as the Hospital Readmissions Reduction Program and bundled payment programs for heart failure outcomes are less clear, and controversy exists regarding whether some of these programs may even worsen outcomes. As the population ages and the prevalence of heart failure continues to rise, this syndrome will likely remain a key clinical focus for policymakers. Therefore, heart failure clinicians should be aware of how legislation affects clinical practice and be prepared to adapt to continued changes in health policy.

TSGA10 prevents nuclear localization of the hypoxia-inducible factor (HIF)-1alpha.

The hypoxia-inducible factor (HIF)-1 is a transcriptional regulator of genes involved in oxygen homeostasis. We previously described testis-specific isoforms of HIF-1alpha (mHIF-1alphaI.1 and hHIF-1alphaTe). Using mHIF-1alpha exon I.1 knock-out mice we confirmed the specific expression of mHIF-1alphaI.1 in the sperm tail. A protein-protein interaction between HIF-1alpha and the testis specific gene antigen 10 (TSGA10) was identified by yeast two-hybrid screening. TSGA10 is expressed in testis but also in other organs and malignant tissues. Immunofluorescence analysis indicated that the C-terminal part of TSGA10 accumulates in the midpiece of spermatozoa, where it co-localizes with HIF-1alpha. HIF-1alpha nuclear localization and HIF-1 transcriptional activity were significantly affected by overexpressed TSGA10.

Cu2O Photocathode for Low Bias Photoelectrochemical Water Splitting Enabled by NiFe-Layered Double Hydroxide Co-Catalyst.

Layered double hydroxides (LDHs) are bimetallic hydroxides that currently attract considerable attention as co-catalysts in photoelectrochemical (PEC) systems in view of water splitting under solar light. A wide spectrum of LDHs can be easily prepared on demand by tuning their chemical composition and structural morphology. We describe here the electrochemical growth of NiFe-LDH overlayers on Cu2O electrodes and study their PEC behavior. By using the modified Cu2O/NiFe-LDH electrodes we observe a remarkable seven-fold increase of the photocurrent intensity under an applied voltage as low as -0.2 V vs Ag/AgCl. The origin of such a pronounced effect is the improved electron transfer towards the electrolyte brought by the NiFe-LDH overlayer due to an appropriate energy level alignment. Long-term photostability tests reveal that Cu2O/NiFe-LDH photocathodes show no photocurrent loss after 40 hours of operation under light at -0.2 V vs Ag/AgCl low bias condition. These improved performances make Cu2O/NiFe-LDH a suitable photocathode material for low voltage H2 production. Indeed, after 8 hours of H2 production under -0.2 V vs Ag/AgCl the PEC cell delivers a 78% faradaic efficiency. This unprecedented use of Cu2O/NiFe-LDH as an efficient photocathode opens new perspectives in view of low biasd or self-biased PEC water splitting under sunlight illumination.

Does T'ai Chi Gait Reduce External Knee Adduction Moment?

INTRODUCTION: T'ai chi chuan is a beneficial exercise of improving health and function. Biomechanical insights of t'ai chi chuan are less understood. OBJECTIVES: To study t'ai chi gait (TCG), a common form of t'ai chi chuan in order to quantify external knee adduction moment (EKAM) as a key indicator of mechanical loading of the medial compartment of the knee compared with normal walking (NW). DESIGN: A quantitative biomechanics approach to determine peak EKAM for NW and TCG. RESULTS: There were a tri-modal pattern of EKAM during TCG and a bimodal pattern of EKAM during normal walking. In addition, subsequent analysis showed a 25%-47% reduction in peak EKAM during double support phases of TCG compared with NW; the peak EKAM of TCG during single-limb support phase showed significantly higher magnitude than the other two double-support phases. CONCLUSION: These results indicate that t'ai chi chuan might be a beneficial intervention for reducing the medial mechanical load at the knee joint, particularly during the first double-support phases of TCG, but the special consideration of higher peak EKAM of single-limb support phase is needed during regular t'ai chi chuan practice.

Chronic pain management in the surgical patient.

Managing surgical patients who have chronic pain that results from their surgical disease and its treatment can bring a new and rewarding dimension to surgical practice. Patients appreciate their surgeon's continued interest and involvement with them, and the surgeon can overcome a sense of abandonment that may accompany the discharge of a patient who is not healed fully. Patients who have chronic pain often understand that their pain will not disappear. That their surgeon will not disappear can help them to accept and live with their pain.

Opioid use in the management of diabetic peripheral neuropathy (DPN) in a large commercially insured population.

OBJECTIVE: To examine the proportion of diabetic peripheral neuropathy (DPN) patients receiving pharmacologic DPN treatments and specifically to identify the rates and factors associated with opioid use and first-line opioid use. METHODS: A 10% sample of IMS-LifeLink claims data from 1998 through 2008 was used. The study population consisted of diabetic patients who met DPN criteria using a validated DPN algorithm. Multivariable logistic regression controlling for demographics, comorbidities, and other clinical characteristics was used to identify factors associated with any DPN pharmacologic treatment, any opioid use, and first-line opioid treatment. Sensitivity analyses were conducted to explore variations in exclusion criteria as well as opioid use definitions. RESULTS: A total of 666 DPN patients met inclusion criteria and pharmacologic treatment was received by 288 patients (43.24%) and of those, 154 (53.47%) had DPN-related opioid use and 96 (33.33%) received opioid as first-line treatment. Persons with diabetic complications were more likely to use opioids (odds ratio=4.53; 95% confidence interval, 1.09-18.92). Food and Drug Administration-approved DPN agents duloxetine 1.04% (n=3) and pregabalin 5.56% (n=16) had much lower rates of use. DPN-related drug use and DPN-related opioid usage increased as we used less restrictive samples in sensitivity analyses. CONCLUSIONS: Opioids were the most frequently prescribed first-line agents for DPN. More than 50% of DPN patients remained untreated with pharmacologic agents 1 year after a DPN diagnosis.