Bariatric Surgery in End-Stage Heart Failure: Feasibility in Successful Attainment of a Target Body Mass Index.

INTRODUCTION: Orthotopic heart transplantation (OHT) is contraindicated in morbidly obese patients with end-stage heart failure (HF), for whom cardiac allograft is the only means for long-term survival. Bariatric surgery may allow them to achieve target body mass index (BMI) for OHT METHODS: From 4/2014 to 12/2018, 26 morbidly obese HF patients who did not meet BMI eligibility criteria for OHT underwent laparoscopic bariatric surgery. Outcomes of interest were median difference in BMI, number of patients achieving target BMI for OHT, and 30-day mortality. RESULTS: Median age was 49 (IQR 14) years, and 13 (50%) were women. HF was mainly systolic (15 patients, 58%). The median LVEF was 27% (IQR 37%). At the time of bariatric surgery, 12 (46%) patients had mechanical circulatory support: 2 (8%) concomitant left ventricular assist device (LVAD) placements, 8 (31%) LVAD already-in-place, and 2 (8%) intra-aortic balloon pumps. There was no 30-day mortality, but one mortality on postoperative day 48. Over a median follow-up of 6 months (range 0-36 months, IQR 17), there was a significant reduction in BMI (p<0.0001). The median postoperative BMI was 36.7 (IQR 8.7), compared to preoperative median BMI of 42.7 (IQR 9.4). Target BMI of < 35 was achieved in 11 (42%) patients. Three patients (12%) have undergone OHT. CONCLUSION: Bariatric surgery in end-stage HF is feasible and results in a high number of patients achieving target BMI, increasing their probability of undergoing OHT. The presence of a LVAD should not preclude these patients from undergoing a bariatric intervention.

Comparison of LACE and HOSPITAL Readmission Risk Scores for CMS Target and Nontarget Conditions.

This study evaluated the utility and performance of the LACE index and HOSPITAL score with consideration of the type of diagnoses and assessed the accuracy of these models for predicting readmission risks in patient cohorts from 2 large academic medical centers. Admissions to 2 hospitals from 2011 to 2015, derived from the Vizient Clinical Data Base and regional health information exchange, were included in this study (291 886 encounters). Models were assessed using Bayesian information criterion and area under the receiver operating characteristic curve. They were compared in CMS diagnosis-based cohorts and in 2 non-CMS cancer diagnosis-based cohorts. Overall, both models for readmission risk performed well, with LACE performing slightly better (area under the receiver operating characteristic curve 0.73 versus 0.69; P ≤ 0.001). HOSPITAL consistently outperformed LACE among 4 CMS target diagnoses, lung cancer, and colon cancer. Both LACE and HOSPITAL predict readmission risks well in the overall population, but performance varies by salient, diagnosis-based risk factors.

Diabetes Education Desert: Regional Disparity Between Diabetes Prevalence and Diabetes Self-Management Education Programs in Texas.

Diabetes is a major chronic disease that was the seventh leading cause of death in the United States in 2017. Although diabetes self-management education (DSME) programs have been implemented to promote patients' self-management skills, the disease continues to grow and some regions have a heavier burden of diabetes diagnoses than others. Focusing on the unbalanced diabetes prevalence across counties, this study aims to identify regional distribution of diabetes education programs in Texas counties, and explore whether diabetes prevalence is worse in certain counties that are geographically isolated from DSME programs. Data from the Centers for Disease Control and Prevention, American Diabetes Association, and American Association of Diabetes Educators were analyzed using ESRI ArcGIS software. When the authors geocoded 167 DSME programs in Texas, it was found that 47 programs (28.7%) were concentrated in 1 single county, and only 49 counties (19.3%) of the total counties (n = 254) had at least 1 DSME program. It also was revealed that the 25 counties (10%) with the highest diabetes prevalence had only 4 DSME programs (2.4%), indicating that there are still marginalized areas with no access to diabetes education programs. Considering the distance from each county's center to the nearest DSME program and diabetes prevalence, 3 counties were identified as diabetes education deserts. When designing, implementing, and evaluating strategies to reduce the burden of diabetes, policy makers and health care providers should account for the existing regional disparity in diabetes education and its impact on diabetes prevalence.

An exploration of community partnerships, safety-net hospitals, and readmission rates.

OBJECTIVE: To compare hospital-community partnerships among safety-net hospitals relative to non-safety-net hospitals, and explore whether hospital-community partnerships are associated with reductions in readmission rates. DATA SOURCES: Data from four nationwide hospital-level datasets for 2015-2016, including American Hospital Association (AHA) annual survey, Hospital Inpatient Prospective Payment System (IPPS) data, CMS Hospital Compare, and County Health Rankings National (CHRN) data. STUDY DESIGN: We first examined how safety-net hospitals partner with nine different community providers, and how the overall and individual partnership patterns differ from those in non-safety-net hospitals. We then explored their association with 30-day readmission rates by diagnosis and hospital wide. DATA COLLECTION/EXTRACTION METHODS: We included 1979 hospitals across 50 US states. PRINCIPAL FINDINGS: Safety-net hospitals were more engaged in hospital-community partnerships, especially with local public health, local governments, social services, nonprofits, and insurance companies, relative to their non-safety-net peers. However, we found that such partnerships were not significantly related to reductions in readmission rates. The findings indicated that merely partnering with various community organizations may not be associated with readmission rate reduction. CONCLUSIONS: Before promoting partnerships with various community organizations for its own sake, further prospective, longitudinal, and evidence-based guidance derived from the study of hospital-community partnerships is needed to make meaningful recommendations aimed at readmission rate reduction in safety-net hospitals.

Community Characteristics and Regional Variations in Diabetes Prevalence in Texas Counties.

Diabetes has become a critical population health issue in the United States. Although researchers have focused on diabetes prevalence at the individual level, few studies address community contexts of diabetes prevalence at the county level. The objective of this study is to explore the association between community characteristics and diabetes prevalence in 254 counties in Texas. Using 3 countywide data sets in 2012, the authors measured county-level community characteristics, including social, environmental, and health behavior factors, and examined how these county-level factors are associated with diabetes prevalence. Multivariate ordinary least squares models weighted with population of county were used for estimation. Rurality, physical inactivity prevalence, and obesity prevalence were positively associated with diabetes prevalence, while the percentage of nonphysician health care professionals was negatively associated with diabetes prevalence. The findings indicate that environmental and health behaviors are significantly associated with a high prevalence of diabetes, but more nonphysician health care professionals, including nurse practitioners, may mitigate diabetes prevalence. This study highlights the significance of community factors in diabetes prevalence and provides insights for diabetes prevention programs with nonphysician health care professionals.

How Leading Hospitals Operationalize Evidence-Based Readmission Reduction Strategies: A Mixed-Methods Comparative Study Using Systematic Review and Survey Design.

Although various interventions targeted at reducing hospital readmissions have been identified in the literature, little is known about actual operationalization of such evidence-based interventions. This study conducted a systematic review and a survey of key informants in 2 leading hospitals, Houston Methodist (HM) and MD Anderson Cancer Center (MDACC), to compare and contrast the most cited evidence-based interventions in the current literature with interventions reported by those hospitals. The authors found that both hospitals followed evidence-based practices reported as successful in the literature. Both hospitals have implemented interventions for inpatient settings, and the timing of interventions was very similar. Major implementation differences observed for post-discharge interventions focused on collaboration. It also was found that HM was more likely than MDACC to use medication reconciliation in outpatient (P = .018) and discharge planning for community/home patients (P = .032). Results will provide hospital professionals with insights for implementing the most effective interventions to reduce readmissions.

Quality indicators to measure the effect of opioid stewardship interventions in hospital and emergency department settings.

PURPOSE: The purpose of this project was to develop a set of valid and feasible quality indicators used to track opioid stewardship efforts in hospital and emergency department settings. METHODS: Candidate quality indicators were extracted from published literature. Feasibility screening excluded quality indicators that cannot be reliably extracted from the electronic health record or that are irrelevant to pain management in the hospital and emergency department settings. Validity screening used an electronic survey of key stakeholders including pharmacists, nurses, physicians, administrators, and researchers. Stakeholders used a 9-point Likert scale to rate the validity of each quality indicator based on predefined criteria. During expert panel discussions, stakeholders revised quality indicator wording, added new quality indicators, and voted to include or exclude each quality indicator. Priority ranking used a second electronic survey and a 9-point Likert scale to prioritize the included quality indicators. RESULTS: Literature search yielded 76 unique quality indicators. Feasibility screening excluded 9 quality indicators. The validity survey was completed by 46 (20%) of 228 stakeholders. Expert panel discussions yielded 19 valid and feasible quality indicators. The top 5 quality indicators by priority were: the proportion of patients with (1) naloxone administrations, (2) as needed opioids with duplicate indications, and (3) long acting or extended release opioids if opioid-naïve, (4) the average dose of morphine milligram equivalents administered per day, and (5) the proportion of opioid discharge prescriptions exceeding 7 days. CONCLUSION: Multi-professional stakeholders across a health system participated in this consensus process and developed a set of 19 valid and feasible quality indicators for opioid stewardship interventions in the hospital and emergency department settings.

Measuring Team Effectiveness in the Health Care Setting: An Inventory of Survey Tools.

BACKGROUND: Guidance for measuring team effectiveness in dynamic clinical settings is necessary; however, there are no consensus strategies to help health care organizations achieve optimal teamwork. This systematic review aims to identify validated survey instruments of team effectiveness by clinical settings. METHODS: PubMed, MEDLINE, and ISI Web of Knowledge were searched for team effectiveness surveys deployed from 1990 to 2016. Validity and reliability were evaluated using 4 psychometric properties: interrater agreement, internal consistency, content validity, and structural integrity. Two conceptual frameworks, the Donabedian model and the Command Team Effectiveness model, assess conceptual dimensions most measured in each health care setting. RESULTS: The 22 articles focused on surgical, primary care, and other health care settings. Few instruments report the required psychometric properties or feature non-self-reported outcomes. The major conceptual dimensions measured in the survey instruments differed across settings. Team cohesion and overall perceived team effectiveness can be found in all the team effectiveness measurement tools regardless of the health care setting. We found that surgical settings have distinctive conditions for measuring team effectiveness relative to primary or ambulatory care. DISCUSSION: Further development of setting-specific team effectiveness measurement tools can help further enhance continuous quality improvements and clinical outcomes in the future.