Transforming Health Care from Volume to Value: Targeting Essential Therapies for Improved Health.

The healthcare landscape is evolving rapidly due to escalating costs from the traditional fee-for-service model. Value-based care has emerged as a viable solution, and initiatives focus on areas prone to overuse, waste, or high costs, such as advanced imaging and avoidable acute care resource utilization. Improving medication use is an important component of this work, and it requires organizational commitment, interdisciplinary collaboration, and targeted strategies for specific therapeutic areas. This review article discusses the value-based care approach to optimizing medications and blood product prescribing, spotlighting opportunities to reduce the overuse of opioid, antimicrobial, and proton pump inhibitor medications, alongside the underuse of guideline-based medical therapies in managing chronic diseases like coronary artery disease, heart failure, and chronic obstructive pulmonary disease.

Is it time for the death knell of single-unit plasma?

BACKGROUND AND OBJECTIVES: A plasma transfusion dose should be weight-based (10-20 mL/kg), which equates to three to four units in an average-sized adult; therefore, the transfusion of single units under most circumstances is sub-therapeutic. MATERIALS AND METHODS: This retrospective observational study examined the prevalence of single-unit plasma transfusion in adults within a 12-hospital system from 1 January 2018, to 31 December 2019. RESULTS: During the study period, 5791 patients received plasma transfusions. The overall prevalence of single-unit plasma was 17.1% for 988 patients. The majority, 3047 (52.6%), occurred at one hospital, 2132 (36.9%) among five hospitals and 612 (10.7%) at the remaining six hospitals. Cardiac and gastrointestinal (GI)/transplant transfused 2707 (46.8%), combined respiratory, neurological, orthopaedic and congenital/dermatology/other comprised 2133 (36.9%) of the six hospitals that transfused less than 200 patients, four (66.7%) transfused single units above the overall prevalence. CONCLUSION: In this hospital system, more than one in six patients received a transfusion of a single plasma unit. Six of the 12 hospitals had 89.5% of the patients who were transfused plasma. Six service lines transfused 83.7% of all patients receiving plasma. Hospitals that infrequently transfused plasma were more likely to under-dose.

Blood Management: A Current Opportunity in Perioperative Medicine.

The purpose of this viewpoint is to provide awareness of the current opportunities to enhance a high-value care approach to blood product transfusion. It provides a historical context to the evolution of blood management, as well as of the patient safety and high-value care movement. Leveraging current technology for enhanced education, as well as clinical decision support, is also discussed.

Management of Clostridioides difficile Infection: Diagnosis, Treatment, and Future Perspectives.

Clostridioides difficile infection is the most common healthcare-associated infection in the United States, with potential life-threatening complications and a significant impact on the costs of care. Antibiotic stewardship as well as discontinuation of chronic acid suppressive therapy are key for its prevention and treatment. Effective infection management requires appropriate interpretation of diagnostic tests, as well as the use of vancomycin and fidaxomicin as first-line treatment. Novel treatments such as Bezlotoxumab, fecal microbiota transplant, and live biotherapeutic products are proven effective in recurrent C. difficile infection and address dysbiosis.

Plasma: indications, controversies, and opportunities.

Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.

Association between preoperative anemia optimization and major complications after non-cardiac surgery: a retrospective analysis.

BACKGROUND: Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. METHODS: In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl-1 in women and 13.0 g.dl-1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. RESULTS: Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. CONCLUSION: Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.

Association between preoperative anemia optimization and major complications after non-cardiac surgery: a retrospective analysis

Abstract Background: Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. Methods: In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl−1 in women and 13.0 g.dl−1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. Results: Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86-1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. Conclusion: Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.

Transfusion therapy of neonatal and paediatric patients: They are not just little adults.

Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/µl) compared to a lower (25 000/µl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/µl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/µl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/µl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.

Addressing the Challenges of Cross-Cultural Communication.

Cross-cultural communication has many challenges due to the complexity of culture, communication, and language. Improving cross-cultural communication in health care is critical to reducing disparities and improving health equity. Specifically, improving cross-cultural communication must be prioritized to overcome systemic barriers and to eliminate disparities that stem from stigma and biases. Communication must be improved, ideally via a cultural humility framework. Unconscious bias and communication training must be intentional. Culture is an attribute and should be celebrated and incorporated into health practice at all levels to prioritize health equity.

ACR Appropriateness Criteria® Post-Treatment Follow-up and Active Surveillance of Clinically Localized Renal Cell Carcinoma: 2021 Update.

Renal cell carcinoma (RCC) accounts for most malignant renal tumors and is considered the most lethal of all urologic cancers. For follow-up of patients with treated or untreated RCC and those with neoplasms suspected to represent RCC, radiologic imaging is the most valuable component of surveillance, as most relapses and cases of disease progression are identified when patients are asymptomatic. Understanding the strengths and limitations of the various imaging modalities for the detection of disease, recurrence, or progression is essential when planning follow-up regimens. This document addresses the appropriate imaging examinations for asymptomatic patients who have been treated for RCC with radical or partial nephrectomy or ablative therapies. It also discusses the appropriate imaging examinations for asymptomatic patients with localized biopsy-proven or suspected RCC undergoing active surveillance. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

PICC vs. midline catheter use for short-term indications was linked to major complications at ≤30 d.

SOURCE CITATION: Swaminathan L, Flanders S, Horowitz J, et al. Safety and outcomes of midline catheters vs peripherally inserted central catheters for patients with short-term indications: a multicenter study. JAMA Intern Med. 2022;182:50-8. 34842905.

Liver dysfunction and SARS-CoV-2 infection.

Severe acute respiratory syndrome coronavirus 2 infection is the cause of coronavirus disease 2019 (COVID-19), which predominantly affects the respiratory system; it also causes systemic and multi-organic disease. Liver damage is among the main extrapulmonary manifestations. COVID-19-associated liver injury is defined as any liver damage occurring during the disease course and treatment of COVID-19 in patients with or without pre-existing liver disease, and occurs in approximately one in five patients. Abnormal liver test results have been associated with a more severe course of COVID-19 and other complications, including death. Mechanisms linking COVID-19 to liver injury are diverse. Particular consideration should be made for patients with pre-existing liver disease, such as metabolic dysfunction-associated fatty liver disease, chronic liver disease due to viral or autoimmune disease, liver transplant carriers, or cirrhosis, given the risk for more severe outcomes. This manuscript summarizes the current lines of evidence on COVID-19-associated liver injury regarding pathophysiology, clinical significance, and management in both patients with or without pre-existing liver disease, to facilitate clinicians' access to updated information and patient care. Finally, we mention the ideas and recommendations to be considered for future research.

Preoperative Pulmonary Risk Assessment.

Postoperative pulmonary complications have a significant impact on perioperative morbidity and mortality and contribute substantially to health care costs. Surgical stress and anesthesia lead to changes in respiratory physiology, altering lung volumes, respiratory drive, and muscle function that can cumulatively increase the risk of postoperative pulmonary complications. Preoperative medical evaluation requires a structured approach to identify patient-, procedure-, and anesthesia-related risk factors for postoperative pulmonary complications. Validated risk prediction models can be used for risk stratification and to help tailor the preoperative investigation. Optimization of pulmonary comorbidities, smoking cessation, and correction of anemia are risk-mitigation strategies. Lung-protective ventilation, moderate PEEP application, and conservative use of neuromuscular blocking drugs are intra-operative preventive strategies. Postoperative early mobilization, chest physiotherapy, oral care, and appropriate analgesia speed up recovery. High-risk patients should receive inspiratory muscle training prior to surgery, and there should be a focus to minimize surgery time.

Perioperative management of pregnant women undergoing nonobstetric surgery.

Nonobstetric surgery during pregnancy should be avoided if possible, but when surgery is required, an obstetrician should be part of the perioperative team. In general, preoperative assessment is similar regardless of whether a woman is pregnant, but cardiovascular, pulmonary, hematologic, and renal changes of pregnancy can increase surgical risk and must be taken into account. Special management considerations include pregnancy-associated laboratory changes, timing of surgery, anesthesia choice, intubation precautions, patient positioning, preoperative blood typing, intraoperative fetal monitoring, and venous thromboembolism prophylaxis.

Improving Documentation of Inpatient Problem List in Electronic Health Record: A Quality Improvement Project.

BACKGROUND: The problem list is critical in electronic documentation. It is a powerful tool for clinical decision-making because it provides a concise view of all patient problems in one place and is also a criterion for the Medicare meaningful use incentive program. OBJECTIVE: To measure the rate of utilization of problem list in electronic health records (EHR) in a pediatric hospital medicine unit and implement sequential interventions to increase the rate of use of problem list to more than 80% by the end of 2015, as measured by at least one documented hospital problem at discharge. METHODS: We performed a quality improvement process starting with a series of educational interventions. Gradual electronic changes were also made in our EHR to reach our goal. RESULTS: The use of the problem list for pediatric hospital medicine rose from 47% to 100% in June 2015 and continues to maintain well above the goal of 80%. The problem list usage throughout the children's hospital also rose to 100% within 9 months of project implementation. CONCLUSIONS: Educational interventions and technology leveraging allowed us to achieve and sustain improvement in appropriate problem list usage.