A multidisciplinary care model to increase access to neurologic ambulatory care.

BACKGROUND: Expert patient care has been associated with improved outcomes for neurology patients, yet timely access to specialists is challenging. The employment of nurse practitioners (NPs) holds great potential to increase access to neurologic ambulatory care, however little practical guidance exists to date for how this may be achieved. LOCAL PROBLEM: To improve timely care provision for patients with neurologic disease, we employed a multidisciplinary care utilization framework that used NPs to expand clinic appointment availability. METHODS AND INTERVENTION: After evaluating our baseline performance, we applied a standardized approach to the deployment of NPs in neurology clinic with regard to scheduling clinic sessions and patient appointments. The primary outcome measure was appointment availability measured over 6 months preintervention (June to November 2016) and 6 months postintervention (June to November 2017). Secondary measures included NP effort allocation. RESULTS: The postintervention period demonstrated an increase in available appointments (3,731 preintervention vs. 4,318 postintervention) and scheduled appointments (2,014 vs. 2,685). Nurse practitioners spent more time practicing at the fullest extent of their licensure. All improvements were accomplished without the hiring of additional staff. CONCLUSIONS: A multidisciplinary care utilization framework for NP employment across neurology subspecialties resulted in an increase in appointment availability. Furthermore, this model is likely to be sustainable due to provider satisfaction and financial viability.

Measurement of arterial activity on routine FDG PET/CT images improves prediction of risk of future CV events.

OBJECTIVES: This study sought to determine whether arterial inflammation measured by (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) improves prediction of cardiovascular disease (CVD) beyond traditional risk factors. BACKGROUND: It is unknown whether arterial (18)F-FDG uptake measured with routine PET imaging provides incremental value for predicting CVD events beyond Framingham risk score (FRS). METHODS: We consecutively identified 513 individuals from 6,088 patients who underwent (18)F-FDG-PET and computed tomography (CT) imaging at Massachusetts General Hospital between 2005 and 2008 and who met additional inclusion criteria: ≥30 years of age, no prior CVD, and free of cancer. CVD events were independently adjudicated, while blinded to clinical data, using medical records to determine incident stroke, transient ischemic attack, acute coronary syndrome, revascularization, new-onset angina, peripheral arterial disease, heart failure, or CVD death. FDG uptake was measured in the ascending aorta (as target-to-background-ratio [TBR]), while blinded to clinical data. RESULTS: During follow-up (median 4.2 years), 44 participants developed CVD (2 per 100 person-years at risk). TBR strongly predicted subsequent CVD independent of traditional risk factors (hazard ratio: 4.71; 95% confidence interval [CI]: 1.98 to 11.2; p < 0.001) and (hazard ratio: 4.13; 95% CI: 1.59 to 10.76; p = 0.004) after further adjustment for coronary calcium score. Addition of arterial PET measurement to FRS scores improved the C-statistic (mean ± standard error 0.62 ± 0.03 vs. 0.66 ± 0.03). Further, incorporation of TBR into a model with FRS variables resulted in an integrated discrimination of 5% (95% CI: 0.36 to 9.87). Net reclassification improvements were 27.48% (95% CI: 16.27 to 39.92) and 22.3% (95% CI: 11.54 to 35.42) for the 10% and 6% intermediate-risk cut points, respectively. Moreover, TBR was inversely associated with the timing of CVD (beta -0.096; p < 0.0001). CONCLUSIONS: Arterial FDG uptake, measured from routinely obtained PET/CT images, substantially improved incident CVD prediction beyond FRS among individuals undergoing cancer surveillance and provided information on the potential timing of such events.

Arterial inflammation in bronchial asthma.

BACKGROUND: Bronchial asthma is a chronic inflammatory condition associated with increased cardiovascular (CV) events. Here, we assess arterial inflammation, using 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging (FDG-PET/CT), in patients with bronchial asthma and low to intermediate Framingham risk scores (FRS). METHODS: A total of 102 patients underwent FDG-PET/CT imaging for clinical indications. Thirty-four patients (mean age 54.9 ± 16.1) with mild asthma and no known atherosclerotic disease were compared to 2 non-asthmatic groups. The first control group (n = 34) were matched by age, gender, and FRS. The second control group (n = 34) had clinical atherosclerosis and were matched by gender. Thereafter, arterial FDG uptake on PET images was determined, while blinded to patient identifiers. RESULTS: Target-to-background-ratio (TBR) in the aorta was higher in asthmatics vs non-asthmatic FRS-matched controls (1.96 ± 0.26 vs 1.76 ± 0.20; P < .001). The aortic TBR remained elevated in asthmatics vs non-asthmatic controls after adjusting traditional CV risk factors (P < .001). An inverse correlation was observed between FDG uptake and lung function, FEV1 (P = .02) and peak flow (P = .03). CONCLUSIONS: Bronchial asthma is associated with increased arterial inflammation beyond that estimated by current risk stratification tools. Further studies are required to evaluate whether attenuation of systemic inflammation will decrease CV events.