Effects of Primary Care-Led, Integrated Palliative Care for Medicare Patients in a Value-Based Model.

CONTEXT: Faced with a projected shortage of specialized palliative care physicians, scalable palliative solutions are required to better meet the aging population's needs. OBJECTIVES: To determine whether a multi-site, primary care-led, integrated palliative care model improves clinical, utilization, and economic outcomes. METHODS: Propensity score-matched comparison group formed from participants who were Medicare beneficiaries, died January 1, 2021-January 31, 2023, were patients of eight primary care practices that partner with agilon health, and enrolled in palliative care for at least seven days. Each practice operates in a value-based model, where primary care providers (PCPs) take on full-risk for the cost and quality of patient outcomes. Each program includes symptom management, defining goals of care/advance directives, PCP care coordination, and assistance with care transitions if patients enroll in hospice. RESULTS: Final sample included 1778 decedents, with 889 in both enrolled and matched cohorts, average age 83. Palliative care is associated with improved patient outcomes from palliative care enrollment until death, including 5.4 more days at home (p < 0.001), 0.4 fewer hospitalizations (p < 0.001), 17% fewer deaths in a hospital (p < 0.001), and $10,393 lower overall healthcare costs (p < 0.001). CONCLUSION: A primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the healthcare needs of an aging population by impacting patient outcomes and reducing avoidable utilization and cost at the end of life. These findings demonstrate that PCPs in a scaled, full-risk model can simultaneously improve care for patients while reducing costs to the healthcare system.

Penile urethra replacement with autologous cell-seeded tubularized collagen matrices.

Acellular collagen matrices have been used as an onlay material for urethral reconstruction. However, cell-seeded matrices have been recommended for tubularized urethral repairs. In this study we investigated whether long segmental penile urethral replacement using autologous cell-seeded tubularized collagen-based matrix is feasible. Autologous bladder epithelial and smooth muscle cells from nine male rabbits were grown and seeded onto preconfigured tubular matrices constructed from decellularized bladder matrices obtained from lamina propria. The entire anterior penile urethra was resected in 15 rabbits. Urethroplasties were performed with tubularized matrices seeded with cells in nine animals, and with matrices without cells in six. Serial urethrograms were performed at 1, 3 and 6 months. Retrieved urethral tissues were analysed using histo- and immunohistochemistry, western blot analyses and organ bath studies. The urethrograms showed that animals implanted with cell-seeded matrices maintained a wide urethral calibre without strictures. In contrast, the urethras with unseeded scaffolds collapsed and developed strictures. Histologically, a transitional cell layer surrounded by muscle was observed in the cell-seeded constructs. The epithelial and smooth muscle phenotypes were confirmed with AE1/AE3 and α-actin antibodies. Organ bath studies of the neourethras confirmed both physiological contractility and the presence of neurotransmitters. Tubularized collagen matrices seeded with autologous cells can be used successfully for long segmental penile urethra replacement, while implantation of tubularized collagen matrices without cells leads to poor tissue development and stricture formation. The cell-seeded collagen matrices are able to form new tissue, which is histologically similar to native urethra.

Prevalence of meperidine use in older surgical patients.

HYPOTHESIS: The unique toxic and adverse effects of meperidine hydrochloride have prompted a number of expert panels convened by national health care policy organizations to recommend that meperidine not be used in older patients. We hypothesized that the prescription of meperidine was less likely to reflect these recommendations in older surgical patients than in older medical patients. The current study examined the use of meperidine in 2 urban hospitals as 1 quality indicator of the care of older adults, measuring the prevalence of its use and characteristics of the patients to whom it is administered. DESIGN: Retrospective analysis. SETTING: Two urban hospitals: a large private tertiary care teaching hospital and a smaller academically affiliated Veterans Affairs medical center. PATIENTS: Patients 65 years or older and hospitalized on medical and surgical services between February 19, 2001, and February 14, 2003. MAIN OUTCOME MEASURES: Patient demographics, medication administration, and department of admitting physician. RESULTS: Meperidine was administered to approximately 1 in 8 older surgical patients at both institutions. Surgical patients were more likely than medical patients to receive a dose of meperidine (hospital A, 12.2% vs 4.3%, P<.001; hospital B, 12.9% vs 1.9%, P<.001). Of those administered meperidine, surgical patients were also more likely than medical patients to receive multiple doses (hospital A, 86.0% vs 65.5%, P = .045; hospital B, 73.8% vs 48.4%, P = .02). CONCLUSIONS: Contrary to national recommendations, meperidine continues to be administered to many hospitalized older adults, particularly those on surgical services. Several alternatives to meperidine exist that provide equal or better pain relief with fewer toxic effects. Hospitals and, in particular, departments of surgery should address this cause of preventable morbidity in this vulnerable population.

Improving the adjustment of educationally disadvantaged students to medical school: the Summer Enrichment Program.

The Summer Enrichment Program (SEP) is a 6-week pre-matriculation program that targets students who may be at an educational disadvantage and/or may have difficulties adjusting to the rigors of medical school. The objective of the current study was to determine whether the SEP (a) eased the transition to the first year of medical school and (b) had an impact on academic performance during the first year of medical school. All students from groups underrepresented in medicine, who had been invited to participate in the SEP, and all Humanities and Medicine Program students who matriculated at Mount Sinai School of Medicine between 1999 and 2003 and were still matriculated during the 2003-2004 academic year were asked to respond to a survey distributed in the spring of 2004. In addition, student academic profiles were reviewed. Responses to the survey indicated that the SEP provided important emotional benefits for those students who chose to attend the program. Virtually all students who had attended had praise for the program and felt that it eased the transition to medical school, helped build confidence and facilitated social connections. In addition, those students from groups underrepresented in medicine who attended the SEP had less academic difficulty (fewer course failures) in their first year of medical school.