Diagnosis and Management of Cardiovascular Risk in Individuals With Spinal Cord Injury: A Narrative Review.

More than 16 000 Americans experience spinal cord injury (SCI), resulting in chronic disability and other secondary sequelae, each year. Improvements in acute medical management have increased life expectancy. Cardiovascular disease is a leading cause of death in this population, and seems to occur earlier in individuals with SCI compared with the general population. People with SCI experience a high burden of traditional cardiovascular disease risk factors, including dyslipidemia and diabetes, and demonstrate anatomic, metabolic, and physiologic changes alongside stark reductions in physical activity after injury. They also experience multiple, complex barriers to care relating to disability and, in many cases, compounding effects of intersecting racial and socioeconomic health inequities. Given this combination of risk factors, some investigators have proposed that people with SCI are at increased risk for cardiovascular disease, beyond that associated with traditional risk factors, and SCI could be considered a risk-enhancing factor, analogous to other risk-enhancing factors defined by the 2019 American Heart Association/American College of Cardiology Primary Prevention Guidelines. However, more research is needed in this population to clarify the role of traditional risk factors, novel risk factors, health care access, social determinants of health, and intersectionality of disability, race, and socioeconomic status. There is an urgent need for primary care physicians and cardiologists to have awareness of the importance of timely diagnosis and management of cardiac risk factors for people with SCI.

"I Just Wanted Nothing More Than to Get in a Real Shower": Patient Experience of the Inpatient Wait for a Heart Transplant.

BACKGROUND: Patients waiting for heart transplant may be hospitalized for weeks to months before undergoing transplantation. This high-stress period is further complicated by restrictions of daily privileges including diet, rooming, access to the outdoors, and hygiene (eg, limited in ability to shower). However, there is a paucity of research on the experience of this waiting period. We sought to describe the inpatient experience among patients awaiting heart transplantation and to better understand the needs of inpatients waiting for heart transplant. METHODS AND RESULTS: We conducted in-depth, semistructured phone interviews with a purposeful sample of patients who received a heart transplant in the past 10 years and waited in the hospital for at least 2 weeks before surgery. Using the prior literature, the lived experience of the lead author, and input from qualitative experts, we developed an interview guide. Interviews were recorded, transcribed, and analyzed in an iterative process until theoretical saturation was achieved. A 3-person coding team identified, discussed, and reconciled emergent themes. We conducted interviews with 15 patients. Overarching themes included food, hygiene, relationship with health care professionals, living environment, and stressors. Patients reported that strong bonds were formed between the patients and the staff, and the overwhelming majority only had positive comments about these relationships. However, many expressed negative comments about the experience of the food and limitations in personal hygiene. Other stressors included the unknown length of the waiting period, lack of communication about position on the transplant list, worry about family, and concerns that their life must be saved by the death of another. Many participants described that they would benefit from more interaction with recent heart transplant recipients. CONCLUSIONS: Hospitals and care units have the opportunity to make small changes that could greatly benefit the experience of waiting for a heart transplant, as well as the experience of hospitalization more generally.

Association Between End-Stage Liver Disease and Incident Heart Failure in an Integrated Health System.

BACKGROUND: End-stage liver disease (ESLD) and heart failure (HF) often coexist and are associated with significant morbidity and mortality. However, the true incidence of HF among patients with ESLD remains understudied. OBJECTIVE: This study aims to evaluate the association between ESLD and incident HF in a real-world clinical cohort. DESIGN AND PARTICIPANTS: A retrospective electronic health records database analysis of individuals with ESLD and frequency-matched controls without ESLD in a large integrated health system. MAIN MEASURES: The primary outcome was incident HF, which was defined by the International Classification of Disease codes and manually adjudicated by physician reviewers. The Kaplan-Meier method was used to estimate the cumulative incidence of HF. Multivariate proportional hazards models adjusted for shared metabolic factors (diabetes, hypertension, chronic kidney disease, coronary heart disease, body mass index) were used to compare the risk of HF in patients with and without ESLD. KEY RESULTS: Of 5004 patients (2502 with ESLD and 2502 without ESLD), the median (Q1-Q3) age was 57.0 (55.0-65.0) years, 59% were male, and 18% had diabetes. Over a median (Q1-Q3) follow-up of 2.3 (0.6-6.0) years, 121 incident HF cases occurred. Risk for incident HF was significantly higher for patients with ESLD compared with the non-ESLD group (adjusted HR: 4.67; 95% CI: 2.82-7.75; p < 0.001), with the majority of the ESLD group (70.7%) having HF with preserved ejection fraction (ejection fraction ≥ 50%). CONCLUSION: ESLD was significantly associated with a higher risk of incident HF, independent of shared metabolic risk factors, with the predominant phenotype being HF with preserved ejection fraction.

Etiology, Treatments, and Outcomes of Patients With Severe Community-Acquired Pneumonia in a Large U.S. Sample.

OBJECTIVES: Compare the clinical practice and outcomes in severe community-acquired pneumonia (sCAP) patients to those in non-sCAP patients using guideline-defined criteria for sCAP. DESIGN: Retrospective observational cohort study. SETTING: One hundred seventy-seven U.S. hospitals within the Premier Healthcare Database. PATIENTS: Hospitalized adult (≥ 18 yr old) patients with pneumonia. MEASUREMENTS AND MAIN RESULTS: Adult patients (≥ 18 yr old) with a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia paired with a principal diagnosis of sepsis or respiratory failure were included. Patients with at least one guideline-defined major criterion for severe pneumonia were compared with patients with nonsevere disease. Among 154,799 patients with pneumonia, 21,805 (14.1%) met criteria for sCAP. They had higher organ failure scores (1.9 vs 0.63; p < 0.001) and inpatient mortality (22.0 vs 5.0%; p < 0.001), longer lengths of stay (8 vs 5 d; p < 0.001), and higher costs ($20,046 vs $7,543; p < 0.001) than those with nonsevere disease. Patients with sCAP had twice the rate of positive blood cultures (10.0% vs 4.5%; p < 0.001) and respiratory cultures (34.2 vs 21.1%; p < 0.001) and more often had isolates resistant to first-line community-acquired pneumonia antibiotics (10% of severe vs 3.1% of nonsevere; p < 0.001). Regardless of disease severity, Streptococcus pneumoniae was the most common pathogen recovered from blood cultures and Staphylococcus aureus and Pseudomonas species were the most common pathogens recovered from the respiratory tract. Although few patients with sCAP had cultures positive for a resistant organism, 65% received vancomycin and 42.8% received piperacillin-tazobactam. CONCLUSIONS: sCAP patients had worse outcomes and twice the rate of culture positivity. S. aureus and S. pneumoniae were the most common organisms in respiratory and blood specimens, respectively. Although only recommended for sCAP patients, nearly all pneumonia patients received blood cultures, a quarter of nonsevere patients received sputum cultures, and treatment with broad-spectrum agents was widespread, indicating fertile ground for antimicrobial and diagnostic stewardship programs.

The Relationship Between Governing Board Composition and Medicare Shared Savings Program Accountable Care Organizations Outcomes: an Observational Study.

BACKGROUND: Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs' publicly reported outcomes. OBJECTIVE: To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes. DESIGN: Cross-sectional observational study. PARTICIPANTS: All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF). MAIN MEASURES: We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes. KEY RESULTS: Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = - 0.26, p < 0.001) and for patients with multiple chronic conditions (p = - 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. CONCLUSIONS: MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards.

Association between Initiation of Pulmonary Rehabilitation and Rehospitalizations in Patients Hospitalized with Chronic Obstructive Pulmonary Disease.

Rationale: Although clinical trials have found that pulmonary rehabilitation (PR) can reduce the risk of readmissions after hospitalization for a chronic obstructive pulmonary disease (COPD) exacerbation, less is known about PR's impact in routine clinical practice. Objectives: To evaluate the association between initiation of PR within 90 days of discharge and rehospitalization(s). Methods: We analyzed a retrospective cohort of Medicare beneficiaries (66 years of age or older) hospitalized for COPD in 2014 who survived at least 30 days after discharge. Measurements and Main Results: We used propensity score matching and estimated the risk of recurrent all-cause rehospitalizations at 1 year using a multistate model to account for the competing risk of death. Of 197,376 total patients hospitalized in 4,446 hospitals, 2,721 patients (1.5%) initiated PR within 90 days of discharge. Overall, 1,534 (56.4%) patients who initiated PR and 125,720 (64.6%) who did not were rehospitalized one or more times within 1 year of discharge. In the propensity-score-matched analysis, PR initiation was associated with a lower risk of readmission in the year after PR initiation (hazard ratio, 0.83; 95% confidence interval, 0.77-0.90). The mean cumulative number of rehospitalizations at 1 year was 0.95 for those who initiated PR within 90 days and 1.15 for those who did not (P < 0.001). Conclusions: After hospitalization for COPD, Medicare beneficiaries who initiated PR within 90 days of discharge experienced fewer rehospitalizations over 1 year. These results support findings from randomized controlled clinical trials and highlight the need to identify effective strategies to increase PR participation.

Neighborhood Poverty and Incident Heart Failure: an Analysis of Electronic Health Records from 2005 to 2018.

BACKGROUND: Neighborhood-level characteristics, such as poverty, have been associated with risk factors for heart failure (HF), including hypertension and diabetes mellitus. However, the independent association between neighborhood poverty and incident HF remains understudied. OBJECTIVE: To evaluate the association between neighborhood poverty and incident HF using a "real-world" clinical cohort. DESIGN: Retrospective cohort study of electronic health records from a large healthcare network. Individuals' residential addresses were geocoded at the census-tract level and categorized by poverty tertiles based on American Community Survey data (2007-2011). PARTICIPANTS: Patients from Northwestern Medicine who were 30-80 years, free of cardiovascular disease at index visit (January 1, 2005-December 1, 2013), and followed for at least 5 years. MAIN MEASURES: The association of neighborhood-level poverty tertile (low, intermediate, and high) and incident HF was analyzed using generalized linear mixed effect models adjusting for demographics (age, sex, race/ethnicity) and HF risk factors (body mass index, diabetes mellitus, hypertension, smoking status). KEY RESULTS: Of 28,858 patients included, 75% were non-Hispanic (NH) White, 43% were men, 15% lived in a high-poverty neighborhood, and 522 (1.8%) were diagnosed with incident HF. High-poverty neighborhoods were associated with a 1.80 (1.35, 2.39) times higher risk of incident HF compared with low-poverty neighborhoods after adjustment for demographics and HF risk factors. CONCLUSIONS: In a large healthcare network, incident HF was associated with neighborhood poverty independent of demographic and clinical risk factors. Neighborhood-level interventions may be needed to complement individual-level strategies to prevent and curb the growing burden of HF.

Use of MASCC score in the inpatient management of febrile neutropenia: a single-center retrospective study.

PURPOSE: The Multinational Association for Supportive Care in Cancer (MASCC) score is used to risk stratify outpatients with febrile neutropenia (FN). However, it is rarely used in hospital settings. We aimed to describe management, use of MASCC score, and outcomes among hospitalized patients with FN. METHODS: We conducted a retrospective cohort study of patients with cancer and FN. We collected patient demographics, cancer characteristics, microbiological profile, MASCC score, utilization of critical care therapies, documentation of goals of care (GOC), and inpatient deaths. Outcomes associated with low- (≥ 21) versus high-risk (< 21) MASCC scores are presented as absolute differences. RESULTS: Of 193 patients, few (2%, n = 3) had MASCC scores documented, but when calculated, 52% (n = 101) had a high-risk score (< 21). GOC were discussed in 12% (n = 24) of patients. Twenty one percent (n = 40) required intermediate/ICU level of care, and 12% (n = 23) died in the hospital. Those with a low-risk score were 33% less likely to require intermediate/ICU care (95% CI 23 to 44%) and 19% less likely to die in the hospital (95% CI 10% to 27%) compared to those with high-risk score. CONCLUSIONS: MASCC score was rarely used for hospitalized patients with FN, but high-risk score was associated with worse outcomes. Education efforts to incorporate MASCC score into the workflow may help identify patients at high risk for complications and help clinicians admit these patients to a higher level of care (e.g., intermediate/ICU care) or guide them to initiate earlier GOC discussions.

A scoring system derived from electronic health records to identify patients at high risk for noninvasive ventilation failure.

OBJECTIVE: To develop and validate a clinical risk prediction score for noninvasive ventilation (NIV) failure defined as intubation after a trial of NIV in non-surgical patients. DESIGN: Retrospective cohort study of a multihospital electronic health record database. PATIENTS: Non-surgical adult patients receiving NIV as the first method of ventilation within two days of hospitalization. MEASUREMENT: Primary outcome was intubation after a trial of NIV. We used a non-random split of the cohort based on year of admission for model development and validation. We included subjects admitted in years 2010-2014 to develop a risk prediction model and built a parsimonious risk scoring model using multivariable logistic regression. We validated the model in the cohort of subjects hospitalized in 2015 and 2016. MAIN RESULTS: Of all the 47,749 patients started on NIV, 11.7% were intubated. Compared with NIV success, those who were intubated had worse mortality (25.2% vs. 8.9%). Strongest independent predictors for intubation were organ failure, principal diagnosis group (substance abuse/psychosis, neurological conditions, pneumonia, and sepsis), use of invasive ventilation in the prior year, low body mass index, and tachypnea. The c-statistic was 0.81, 0.80 and 0.81 respectively, in the derivation, validation and full cohorts. We constructed three risk categories of the scoring system built on the full cohort; the median and interquartile range of risk of intubation was: 2.3% [1.9%-2.8%] for low risk group; 9.3% [6.3%-13.5%] for intermediate risk category; and 35.7% [31.0%-45.8%] for high risk category. CONCLUSIONS: In patients started on NIV, we found that in addition to factors known to be associated with intubation, neurological, substance abuse, or psychiatric diagnoses were highly predictive for intubation. The prognostic score that we have developed may provide quantitative guidance for decision-making in patients who are started on NIV.

Barriers to Hematopoietic Cell Transplantation for Adults in the United States: A Systematic Review with a Focus on Age.

Hematopoietic cell transplantation (HCT) is an effective treatment for many hematologic malignancies, and its utilization continues to rise. However, due to the difficult logistics and high cost of HCT, there are significant barriers to accessing the procedure; these barriers are likely greater for older patients. Although numerous factors may influence HCT access, no formal analysis has detailed the cumulative barriers that have been studied thus far. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to better categorize the barriers to access and referral to HCT, with a focus on the subgroup of older patients. We searched for articles published in English from PubMed, Embase, Cumulative Index for Nursing and Allied Health, and Cochrane Central Register of Controlled Trials between the database inception and January 31, 2020. We selected articles that met the following inclusion criteria: (1) study design: qualitative, cross-sectional, observational cohort, or mixed-method study designs; (2) outcomes: barriers related to patient and physician access to HCT; and (3) population: adults aged ≥18 years with hematologic malignancies within the United States. Abstracts without full text were excluded. QUALSYST methodology was used to determine article quality. Data on the barriers to access and referral for HCT were extracted, along with other study characteristics. We summarized the findings using descriptive statistics. We included 26 of 3859 studies screened for inclusion criteria. Twenty studies were retrospective cohorts and 4 were cross-sectional. There was 1 prospective cohort study and 1 mixed-method study. Only 1 study was rated as high quality, and 16 were rated as fair. Seventeen studies analyzed age as a potential barrier to HCT referral and access, with 16 finding older age to be a barrier. Other consistent barriers to HCT referral and access included nonwhite race (n = 16/20 studies), insurance status (n = 13/14 studies), comorbidities (n = 10/11 studies), and lower socioeconomic status (n = 7/8 studies). High-quality studies are lacking related to HCT barriers. Older age and nonwhite race were consistently linked to reduced access to HCT. To produce a more just health care system, strategies to overcome these barriers for vulnerable populations should be prioritized. Examples include patient and physician education, as well as geriatric assessment guided care models that can be readily incorporated into clinical practice.

Association Between Initiation of Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival Among Medicare Beneficiaries.

Importance: Meta-analyses have suggested that initiating pulmonary rehabilitation after an exacerbation of chronic obstructive pulmonary disease (COPD) was associated with improved survival, although the number of patients studied was small and heterogeneity was high. Current guidelines recommend that patients enroll in pulmonary rehabilitation after hospital discharge. Objective: To determine the association between the initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival. Design, Setting, and Patients: This retrospective, inception cohort study used claims data from fee-for-service Medicare beneficiaries hospitalized for COPD in 2014, at 4446 acute care hospitals in the US. The final date of follow-up was December 31, 2015. Exposures: Initiation of pulmonary rehabilitation within 90 days of hospital discharge. Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. Time from discharge to death was modeled using Cox regression with time-varying exposure to pulmonary rehabilitation, adjusting for mortality and for unbalanced characteristics and propensity to initiate pulmonary rehabilitation. Additional analyses evaluated the association between timing of pulmonary rehabilitation and mortality and between number of sessions completed and mortality. Results: Of 197 376 patients (mean age, 76.9 years; 115 690 [58.6%] women), 2721 (1.5%) initiated pulmonary rehabilitation within 90 days of discharge. A total of 38 302 (19.4%) died within 1 year of discharge, including 7.3% of patients who initiated pulmonary rehabilitation within 90 days and 19.6% of patients who initiated pulmonary rehabilitation after 90 days or not at all. Initiation within 90 days was significantly associated with lower risk of death over 1 year (absolute risk difference [ARD], -6.7% [95% CI, -7.9% to -5.6%]; hazard ratio [HR], 0.63 [95% CI, 0.57 to 0.69]; P < .001). Initiation of pulmonary rehabilitation was significantly associated with lower mortality across start dates ranging from 30 days or less (ARD, -4.6% [95% CI, -5.9% to -3.2%]; HR, 0.74 [95% CI, 0.67 to 0.82]; P < .001) to 61 to 90 days after discharge (ARD, -11.1% [95% CI, -13.2% to -8.4%]; HR, 0.40 [95% CI, 0.30 to 0.54]; P < .001). Every 3 additional sessions was significantly associated with lower risk of death (HR, 0.91 [95% CI, 0.85 to 0.98]; P = .01). Conclusions and Relevance: Among fee-for-service Medicare beneficiaries hospitalized for COPD, initiation of pulmonary rehabilitation within 3 months of discharge was significantly associated with lower risk of mortality at 1 year. These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

Ensuring the Reproductive Rights of Women with Intellectual Disability.

BACKGROUND: Women with intellectual disability experience disparities in sexual and reproductive health care services. METHODS: To explore perceptions of caring for persons with disability, including individuals with intellectual disability, we conducted open-ended individual interviews with 20 practicing physicians and three video-based focus group interviews with an additional 22 practicing physicians, which reached data saturation. Interviews were transcribed verbatim. We used conventional content analysis methods to analyse transcripts. RESULT: Physicians indicated that intellectual disability can pose challenges to providing sexual and reproductive health care. Observations coalesced around four themes: (1) communication; (2) routine preventive care; (3) contraception and sterilization; and (4) conception and parenthood. Observations raised concerns about equity of access to reproductive care for women with intellectual disability. CONCLUSIONS: In our sample of physicians, we found attitudes that might compromise reproductive care for women with intellectual disability, suggesting that gaps remain in ensuring reproductive rights of women with intellectual disability.

Physician Beliefs About Online Reporting of Quality and Experience Data.

IMPORTANCE: Physician attitudes about websites that publicly report health care quality and experience data have not been recently described. OBJECTIVES: To examine physician attitudes about the accuracy of websites that report information about quality of care and patient experience and to describe physician beliefs about the helpfulness of these data for patients choosing a physician. DESIGN, PARTICIPANTS, AND MEASURES: The Rhode Island Department of Health (RIDOH) and a multi-stakeholder group developed and piloted two questions that were added to RIDOH's biennial physician survey of all 4197 practicing physicians in Rhode Island: (1) "How accurate of a picture do you feel that the following types of online resources give about the quality of care that physicians provide?" (with choices) and (2) "Which types of physician-specific information (i.e., not about the practice overall) would be helpful to include in online resources for patients to help them choose a new physician? (Select all that apply)." Responses were stratified by primary care vs. subspecialty clinicians. Summary statistics and chi-squared tests were used to analyze the results. RESULTS: Among 1792 respondents (response rate 43%), 45% were unaware of RIDOH's site and 54% were unaware of the Centers for Medicare & Medicaid Services (CMS)' quality reporting sites. Only 2% felt that Medicare sites were "very accurate" in depicting physician quality. Most physicians supported public reporting of general information about physicians (e.g., board certification), but just over one-third of physicians felt that performance-based quality measures are "helpful" (and a similar percentage reported that patient reviews felt are "helpful") for patients choosing a physician. CONCLUSIONS: Physician-respondents were either uninformed or skeptical about public reporting websites. In contrast to prior reports that a majority of patients value some forms of publicly reported data, most physicians do not consider quality metrics and patient-generated reviews helpful for patients who are choosing a physician.

What Words Convey: The Potential for Patient Narratives to Inform Quality Improvement.

Policy Points Narratives about patients' experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers' patients, and health system administrators can identify and respond to patterns in patients' accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two-part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication-related questions on existing surveys. Three-quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients' experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient-centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Association of in-hospital resource utilization with post-acute spending in Medicare beneficiaries hospitalized for acute myocardial infarction: a cross-sectional study.

BACKGROUND: Efforts to decrease hospitalization costs could increase post-acute care costs. This effect could undermine initiatives to reduce overall episode costs and have implications for the design of health care under alternative payment models. METHODS: Among Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with acute myocardial infarction (AMI) between July 2010 and June 2013 in the Premier Healthcare Database, we studied the association of in-hospital and post-acute care resource utilization and outcomes by in-hospital cost tertiles. RESULTS: Among patients with AMI at 326 hospitals, the median (range) of each hospital's mean per-patient in-hospital risk-standardized cost (RSC) for the low, medium, and high cost tertiles were $16,257 ($13,097-$17,648), $18,544 ($17,663-$19,875), and $21,831 ($19,923-$31,296), respectively. There was no difference in the median (IQR) of risk-standardized post-acute payments across cost-tertiles: $5014 (4295-6051), $4980 (4349-5931) and $4922 (4056-5457) for the low (n = 90), medium (n = 98), and high (n = 86) in-hospital RSC tertiles (p = 0.21), respectively. In-hospital and 30-day mortality rates did not differ significantly across the in-hospital RSC tertiles; however, 30-day readmission rates were higher at hospitals with higher in-hospital RSCs: median = 17.5, 17.8, and 18.0% at low, medium, and high in-hospital RSC tertiles, respectively (p = 0.005 for test of trend across tertiles). CONCLUSIONS: In our study of patients hospitalized with AMI, greater resource utilization during the hospitalization was not associated with meaningful differences in costs or mortality during the post-acute period. These findings suggest that it may be possible for higher cost hospitals to improve efficiency in care without increasing post-acute care utilization or worsening outcomes.

Reporting of Patient Experience Data on Health Systems' Websites and Commercial Physician-Rating Websites: Mixed-Methods Analysis.

BACKGROUND: Some hospitals' and health systems' websites report physician-level ratings and comments drawn from the Consumer Assessment of Healthcare Providers and Systems surveys. OBJECTIVE: The aim was to examine the prevalence and content of health system websites reporting these data and compare narratives from these sites to narratives from commercial physician-rating sites. METHODS: We identified health system websites active between June 1 and 30, 2016, that posted clinician reviews. For 140 randomly selected clinicians, we extracted the number of star ratings and narrative comments. We conducted a qualitative analysis of a random sample of these physicians' narrative reviews and compared these to a random sample of reviews from commercial physician-rating websites. We described composite quantitative scores for sampled physicians and compared the frequency of themes between reviews drawn from health systems' and commercial physician-rating websites. RESULTS: We identified 42 health systems that published composite star ratings (42/42, 100%) or narratives (33/42, 79%). Most (27/42, 64%) stated that they excluded narratives deemed offensive. Of 140 clinicians, the majority had composite scores listed (star ratings: 122/140, 87.1%; narrative reviews: 114/140, 81.4%), with medians of 110 star ratings (IQR 42-175) and 25.5 (IQR 13-48) narratives. The rating median was 4.8 (IQR 4.7-4.9) out of five stars, and no clinician had a score less than 4.2. Compared to commercial physician-rating websites, we found significantly fewer negative comments on health system websites (35.5%, 76/214 vs 12.8%, 72/561, respectively; P<.001). CONCLUSIONS: The lack of variation in star ratings on health system sites may make it difficult to differentiate between clinicians. Most health systems report that they remove offensive comments, and we notably found fewer negative comments on health system websites compared to commercial physician-rating sites.

Use of Rheumatologic Testing in Patients Who Eventually Receive a Diagnosis of Rheumatoid Arthritis.

OBJECTIVES: Anti-cyclic citrullinated peptide antibody (ACPA) has excellent specificity and prognostic value in patients with early rheumatoid arthritis (RA). The American College of Rheumatology included ACPA in their 2010 classification criteria for RA, but we hypothesize that primary care physicians (PCPs) underuse ACPA, even when clinical suspicion for RA is high. We aimed to describe their use of diagnostic testing in patients who were referred to a rheumatologist and eventually diagnosed as having RA. METHODS: In this retrospective cohort study, a systematic abstraction tool was used to review the medical records of patients seen between January 1, 2010 and June 15, 2014 in two rheumatology clinics: one private practice and one community health center associated with an academic medical center. For purposes of hypothesis generation, we compared the characteristics of patients with and without testing using unpaired t tests or Fisher exact tests. RESULTS: We identified 173 patients with RA referred from 141 different PCPs: 82.7% were women with a mean ± standard deviation age of 55.5 ± 18.6 years. ACPA and rheumatoid factor were ordered in 28.9% (95% confidence interval 22.6-36.2) and 41.0% (95% confidence interval 33.9-48.6) of patients, respectively. Imaging was underused. Almost half (45.7%, or 37/81) of the patients with documented symptom duration had a delay of at least 1 year before referral; however, ACPA utilization was not associated with the delay to treatment initiation. CONCLUSIONS: Most PCPs failed to order diagnostic tests for RA before referring a patient with polyarthritis who eventually received a diagnosis of RA. We also observed delays in diagnosis, with half of the patients waiting >1 year from symptom onset to diagnosis. These findings suggest educational efforts for PCPs should focus on emphasizing earlier diagnostic workups, especially ACPA, in patients suspected to have RA.

Use of Inpatient Palliative Care Services in Patients With Advanced Cancer Receiving Critical Care Therapies.

Background: Invasive mechanical ventilation (IMV), dialysis for acute kidney failure, and other critical care therapies (CCTs) are associated with a high risk for complications in patients with metastatic cancer. Inpatient palliative care (IPC) can assist in assessing patients' preferences for life-prolonging treatment at the end of life. This study investigated the use pattern of IPC, outcomes (in-hospital mortality, length of stay [LOS], discharge destination, and cost of care), and predictors of IPC use in patients with metastatic cancer who received CCTs. We hypothesized that IPC services are underused in this cohort. Methods: In this retrospective cohort study, we used the 2010 California State Inpatient Databases to identify adults with metastatic cancer who received CCTs that are common and reliably coded (IMV, tracheostomy, percutaneous endoscopic gastrostomy tube, dialysis for acute kidney failure, and total parenteral nutrition). We determined IPC use in all patients, in those who received IMV, and across 4 cancer subtypes (lung, breast, colorectal, and genitourinary). Outcomes were assessed based on IPC use. Multivariable analyses were used to investigate factors associated with IPC use. Results: We identified 5,862 hospitalizations, 19.8% of which used IPC services. IPC use varied across cancer subtypes (lung, 28.3%; breast, 22.4%; colorectal, 12.8%; genitourinary, 16.1%; P<.01). Patients who received and did not receive IPC services had high in-hospital mortality rates (63.9% and 29.8%, respectively), and costs of care and LOS were lower in survivors who received IPC compared with those who did not. Predictors of IPC use were lung cancer (vs colorectal or genitourinary cancer), higher comorbidity score, do-not-resuscitate status on admission or within 24 hours of admission, infections (vs cancer-related diagnoses), and higher hospital bed count. Conclusions: Use of IPC was low in the cohort who received CCTs with poor outcomes, although data on outpatient palliative care services is lacking. Predictors of IPC use may be used to identify patients who may benefit from these services.

Use of Systematic Methods to Improve Disease Identification in Administrative Data: The Case of Severe Sepsis.

BACKGROUND: Selection of International Classification of Diseases (ICD)-based coded information for complex conditions such as severe sepsis is a subjective process and the results are sensitive to the codes selected. We use an innovative data exploration method to guide ICD-based case selection for severe sepsis. METHODS: Using the Nationwide Inpatient Sample, we applied Latent Class Analysis (LCA) to determine if medical coders follow any uniform and sensible coding for observations with severe sepsis. We examined whether ICD-9 codes specific to sepsis (038.xx for septicemia, a subset of 995.9 codes representing Systemic Inflammatory Response syndrome, and 785.52 for septic shock) could all be members of the same latent class. RESULTS: Hospitalizations coded with sepsis-specific codes could be assigned to a latent class of their own. This class constituted 22.8% of all potential sepsis observations. The probability of an observation with any sepsis-specific codes being assigned to the residual class was near 0. The chance of an observation in the residual class having a sepsis-specific code as the principal diagnosis was close to 0. Validity of sepsis class assignment is supported by empirical results, which indicated that in-hospital deaths in the sepsis-specific class were around 4 times as likely as that in the residual class. CONCLUSIONS: The conventional methods of defining severe sepsis cases in observational data substantially misclassify sepsis cases. We suggest a methodology that helps reliable selection of ICD codes for conditions that require complex coding.

Use of Accessible Examination Tables in the Primary Care Setting: A Survey of Physical Evaluations and Patient Attitudes.

BACKGROUND: Accessible diagnostic equipment, including height-adjustable examination tables, is necessary to accommodate patients with disabilities. Studies demonstrate that only a minority of clinics provide accessible equipment. For clinics with this equipment, no studies have examined the use of such equipment in routine clinical care. OBJECTIVE: In primary care clinics with and without height-adjustable examination tables, we compared the frequency and variation in physical evaluations on examination tables and patients' perceptions of quality care. DESIGN: Survey administered to patients at two primary care clinics in Rochester, MN, in 2015. One clinic had height-adjustable examination tables in every exam room; the other clinic had none. PATIENTS: A total of 399 English-speaking adult primary care patients (61% participation). MAIN MEASURES: Participants were asked whether they were physically evaluated on a table during their clinical encounter. In addition, they completed two subscales of the Patient Perception of Quality of Care survey: Perceptions of Provider's Bedside Manner and Perceptions of Provider's Work. KEY RESULTS: Overall, there were no differences between clinics in the likelihood of patients being examined on an exam table or in their perceptions of quality of care. Across both clinics, patients who reported a disability were 27% less likely to be examined on a table, were less likely to rate their provider's bedside manner favorably (74% vs. 59%) and to have positive perceptions of their provider's work (46% vs. 32%) than patients without disabilities. CONCLUSIONS: The presence of accessible medical equipment was not associated with care delivered to patients. While this might not be meaningful for most patients, it could be problematic for patients with disabilities, who are less likely to be examined. Therefore, accessible equipment alone may not be sufficient to reduce disparities in the care experience. Provider- and organization-level factors must thus be considered in efforts to provide equitable care to patients with disabilities.