Oral diet management for carcinoma at the base of tongue with radiotherapy and chemotherapy associated dysphagia: a case report.

Introduction: Tongue cancer is one of the common malignancy of the head and neck, and directly impacts chewing, swallowing, and other eating activities. Based on the evidence-based guidelines and clinical management, this paper presents nutrition management experience of a patient with tongue cancer who had a dysphagia and feeding reflux while undergoing radiotherapy and chemotherapy. Methods: Nutritional risk screening and comprehensive nutritional assessment were performed based on the patient's medical history, and personalized nutritional programs were developed under the guidance of the clinical pharmaceutical consensus of parenteral nutrition and nutritional treatment guidelines for patients with tumors during radiotherapy. For the management of oral feeding, the patient's swallowing function was evaluated to manage oral feeding. Thickening powders were used to improve the consistency of the patient's food, which successfully achieved oral feeding of the patient. Results: The patient finally ate five meals a day by mouth, and energy requirements were met using industrialized nutritional supplements, and homogenized food was added in between the meals. The energy provided by enteral nutrition can reached approximately 60-75%. The patient's weight and albumin levels had increased significantly at the time of discharge. Discussion: The nutritional management of patients with dysphagia should be jointly managed by clinicians, nurses, nutritionists, and family members to effectively improve the quality of life (QOL) and nutritional status of patients. To ensure adequate nutritional supply, appropriate swallowing training may delay the deterioration of the chewing function and improve the eating experience of such patients.

Association Between Capitated Payments and Preventive Care Among U.S. Adults.

Introduction: There is increasing interest in using capitation rather than fee for service to promote primary care and population health. The goal of this study was to examine the association between practice reimbursement mix (majority fee for service versus majority capitation versus other) and receipt of common preventive screening examinations and health counseling from 2012 to 2018. Methods: Using the National Ambulatory Medical Care Survey, a retrospective cross-sectional study of 24,864 visits with primary care clinicians among patients aged 18-75 years without a cancer diagnosis was conducted. The main dependent measures were age- and sex-appropriate receipt of breast cancer screening, osteoporosis screening, cervical cancer screening, chlamydia testing, colon cancer screening, diabetes screening, and hyperlipidemia screening as well as 3 health counseling items. Multivariable logistic regression was performed to assess the association between reimbursement mix and receipt of preventive care, adjusted for patient, visit, and practice characteristics. Results: Majority capitation reimbursement was associated with a greater likelihood of receiving breast cancer screening (AOR=2.11, 95% CI=1.16, 3.84, p=0.014) and osteoporosis screening (AOR=4.34, 95% CI=1.74, 10.8, p=0.0017) than majority fee-for-service or other reimbursement mixes. Reimbursement mix was not associated with the likelihood of receiving 9 other preventive care or health counseling services. Conclusions: Larger amounts of capitation reimbursement may improve some but not all aspects of preventive care compared with fee for service.

Progression of aortic regurgitation following transcatheter closure of intracristal ventricular septal defects in children: a mid- to long-term follow-up study.

Background: Early surgical closure is warranted to prevent aortic valve lesion and aortic regurgitation (AR) in intracristal ventricular septal defects (icVSDs). Experiences for transcatheter device closure of icVSDs are still limited. Our objectives are to investigate AR progression following transcatheter closure of icVSDs in children and to explore the risk factors for AR progression. Methods and results: From January 2007 to December 2017, 50 children with icVSD who had successfully undergone transcatheter closure were enrolled. With 4.0 (interquartile range: 3.0-6.2) years of follow-up, AR progression was observed in 20% (10/50) of patients after icVSD occlusion, among which 16% (8/50) remained in mild level and 4% (2/50) evolved to moderate. None progressed to severe AR. Freedom from AR progression was 84.0%, 79.5%, and 79.5% at 1, 5, and 10 years of follow-up. A multivariate Cox proportional-hazards model revealed that x-ray exposure time [hazard ratio (HR): 1.11, 95% confidence interval (CI): 1.04-1.18, P = 0.001] and the ratio of pulmonary to systemic blood flows (HR: 3.38, 95% CI: 1.11-10.29, P = 0.032) were independent predictors for AR progression. Conclusions: Our study suggested that transcatheter closure of icVSD in children is safe and feasible in mid- to long-term follow-up. No serious AR progression occurred after icVSD device closure. Greater left-to-right shunting and longer x-ray exposure time were both risk factors for AR progression.

Comparison of GLIM, SGA, PG-SGA, and PNI in diagnosing malnutrition among hepatobiliary-pancreatic surgery patients.

Objective: To compare the diagnostic value of four tools-the Global Leadership Initiative on Malnutrition (GLIM) criteria, the subjective global assessment (SGA), patient-generated subjective global assessment (PG-SGA), and prognostic nutritional index (PNI) in malnutrition among hospitalized patients undergoing hepatobiliary-pancreatic surgery. Meanwhile, to observe the nutritional intervention of these patients. Methods: Present study was a cross-sectional study, including 506 hospitalized patients who underwent hepatobiliary-pancreatic surgery between December 2020 and February 2022 at Ningbo Medical Center Lihuili Hospital, China. The incidence rate of malnutrition was diagnosed using the four tools. The consistency of the four tools was analyzed by Cohen's kappa statistic. Data, including nutritional characteristics and nutritional interventions, were collected. The nutritional intervention was observed according to the principles of Five Steps Nutritional Treatment. Results: The prevalence was 36.75, 44.58, and 60.24%, as diagnosed by the GLIM, PG-SGA, and PNI, respectively, among 332 tumor patients. Among the 174 non-tumor patients, the prevalence was 9.77, 10.92, and 32.18% as diagnosed by the GLIM, SGA, and PNI. The diagnostic concordance of PG-SGA and GLIM was higher (Kappa = 0.814, <0.001) than SGA vs. GLIM (Kappa = 0.752, P < 0.001) and PNI vs. GLIM (Kappa = 0.265, P < 0.001). The univariate analysis revealed that older age, lower BMI and tumorous were significantly associated with nutritional risks and malnutrition. Among 170 patients with nutritional risk, most of patients (118/170, 69.41%) did not meet the nutritional support standard. Conclusion: The incidence of nutritional risk and malnutrition is high among patients with hepatobiliary and pancreatic diseases, specifically those with tumors. The GLIM showed the lowest prevalence of malnutrition among the four tools. The PG-SGA and GLIM had a relative high level of agreement. There was a low proportion of nutritional support in patients. More prospective and well-designed cohort studies are needed to confirm the relevance of these criteria in clinical practice in the future.

Organizational capacity among hospitals in Medicare and commercial bundled payments.

OBJECTIVES: Hospitals must strategically build organizational capacities to succeed in bundled payment arrangements. Given differences between Medicare and commercial arrangements, capacities may vary between hospitals in Medicare vs both Medicare and commercial bundled payment programs. This study compared organizational capacities between these 2 hospital groups. STUDY DESIGN: National survey of American Hospital Association (AHA) member hospitals with experience in bundled payment programs. METHODS: We analyzed data from October 31, 2017, to April 30, 2018, collected from AHA member hospitals with bundled payment experience in only Medicare (Medicare-only hospitals) or in both Medicare and commercial insurers (multipayer hospitals). Survey questions examined capacity in 4 areas: (1) physician performance feedback, (2) care management, (3) postacute care provider utilization, and (4) health information technology. RESULTS: Our sample included 114 hospitals reporting experience in Medicare or commercial bundled payment programs. Both Medicare-only and multipayer hospitals reported high organizational capacities in performance measurement of physician-level quality and cost feedback and in incorporation of health information technology. More multipayer hospitals reported high capacity for coordinating hospital to postacute care settings (88% vs 52%). Although nearly all hospitals in both groups reported formalized relationships with skilled nursing facilities (98%), fewer hospitals reported such relationships with long-term acute care hospitals (83%) and inpatient rehabilitation facilities (80%). CONCLUSIONS: Although they have similar capacity in a number of areas, Medicare-only and multipayer hospitals differed with respect to other aspects of organizational capacity.

Whole-course nutritional support therapy and indicators in head and neck cancer surgery.

BACKGROUND AND OBJECTIVES: This study investigated the effect of continuous perioperative nutritional support provided by a multidisciplinary team (MDT) to patients who underwent surgery for head and neck cancer (HNC). METHODS AND STUDY DESIGN: This study enrolled 99 patients with HNC and divided them into two groups: a management group (n=48), comprising patients who underwent surgery between August and December 2020 and received continuous perioperative nutritional support from the MDT; and a control group (n=51), comprising patients who underwent surgery between June and December 2017 and received routine nutritional guidance. Data on weight, nutritional indicators, and the prognostic nutritional index (PNI) were collected. We compared the changes in weight, nutritional indicators, PNI, Patient-Generated Subjective Global Assessment (PG-SGA) scores, and body composition. Factors influencing the PNI were analysed. RESULTS: The minimum weight, nutritional indicator, and PNI values observed postoperatively and at discharge were lower than those observed at admission. The serum nutritional index values observed at discharge and minimum PNI values observed postoperatively and at discharge were higher in the management group than in the control group. The PG-SGA score at 2 weeks postoperatively was higher than that on the day of surgery in the management group. The discharge PNI was influenced by management and age in these HNC surgical patients. In the management group, body composition data did not differ significantly between the preoperative and 1-, 2-, and 3-week postoperative time points. CONCLUSIONS: Continuous perioperative nutritional support by an MDT can improve the weight and serum nutritional index of patients receiving surgery for HNC and improve the PNI at discharge.

Organizational Capacity of Hospitals Co-Participating in Accountable Care Organizations and Bundled Payments.

Building organizational capacity is critical for hospitals participating in payment models such as bundled payments and accountable care organizations, particularly "co-participant" hospitals with experience in both models. This study used a national survey of American Hospital Association member hospitals with bundled payment experience, with (co-participant hospitals) or without (bundled payment hospitals) accountable care organization experience. Questions examined capacity in 4 domains: performance feedback, postacute care provider utilization, care management, and health information technology. Of 424 hospitals, 38% responded. Both co-participant and bundled payment hospitals reported high capacity for performance feedback and risk stratification and predictive risk assessment using health information technology systems. The hospital groups did not differ in care management capacity, but bundled payment hospitals reported higher postacute care provider utilization capacity. Experience with multiple payment models may prompt hospitals to make different investments or adopt different strategies than hospitals with experience in a single model.

State-Level Evaluation of Washington's State Innovation Models (SIM) Initiative.

The Washington State Innovation Models (SIM) $65 million Test Award from the Center for Medicare & Medicaid Services' Innovation Center is a statewide intervention expected to improve population health, quality of care, and cost growth through four initiatives: 1) regional accountable communities of health linking health and social services to address local needs; 2) a practice transformation support hub; 3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and 4) data and analytic infrastructure development to support system transformation with common measures. We develop a conceptual model based on diffusion theory and apply the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) to structure our evaluation. We find that in three years (2016-2018), SIM built the infrastructure for system transformation and increased Washington's readiness for health system change in the next decade. However, the initiatives have not spread statewide, which may take over 10 years.

The one-year impact of accountable care networks among Washington State employees.

OBJECTIVE: To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families. DATA SOURCES/STUDY SETTING: Administrative data (January 2013-December 2016) on Washington State employees. STUDY DESIGN: We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64). DATA COLLECTION/EXTRACTION METHODS: We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. PRINCIPAL FINDINGS: We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. CONCLUSIONS: Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.

Safety and Efficacy of Transcatheter Occlusion of Perimembranous Ventricular Septal Defect with Aortic Valve Prolapse: A Six-Year Follow-Up Study.

BACKGROUND: With the rapid development of transcatheter techniques and instruments, transcatheter occlusion for patients with perimembranous ventricular septal defect (pVSD) and aortic valve prolapse (AVP) was constantly being tried, while the efficacy and safety of pVSD with AVP remain controversial. OBJECTIVE: The aim of this study was to evaluate long-term efficacy and safety of transcatheter occlusion of pVSD with AVP. METHODS: We retrospectively analyzed 164 children with pVSD and AVP who underwent transcatheter occlusion between January 2013 and November 2014. AVP was divided into 3 degrees according to right coronary leaflet morphology at end-diastole during aortic root angiography. Patient demographic and clinical data were collected. RESULTS: There were 97 males and 67 females (median age, 40.0 (30.0-62.7) months; average weight, 16.94 ± 9.02 kg). Mild (n = 63), moderate (n = 89), and severe (n = 12) AVP success rates were 93.7%, 89.9%, and 58.3%, respectively. Immediately after procedure, there was no new-onset aortic regurgitation (AR) above trivial degree, residual shunt above mild degree, or complications requiring medication or operation, except for 1 patient who developed transient complete atrioventricular block. During follow-up, 1 mild AVP patient aggravated from mild to moderate AR and 1 moderate AVP patient aggravated from trivial to moderate AR. The new-onset AR in mild, moderate, and severe AVP was 2%, 1.8%, and 20%, respectively. AR disappeared in 17 patients. Residual shunt occurred in 9 patients after procedure, 4 of which disappeared during the follow-up period. No serious complications occurred in any patient during follow-up. Five-year cardiovascular event-free survival rates for mild, moderate, and severe AVP were 89.6%, 94.5%, and 80.0%, respectively. CONCLUSION: Transcatheter occlusion of pVSD with mild and moderate AVP has a high success rate and few complications, which is safe and effective in long-term follow-up. Transcatheter occlusion of pVSD with severe AVP has low success rates and high AR incidence. Therefore, transcatheter occlusion of pVSD with AVP is recommended for mild to moderate, but not severe, AVP.

Provision of Collaborative Care Model and General Behavioral Health Integration Services in Medicare.

OBJECTIVE: The authors sought to describe the early use of collaborative care model (CoCM) and general behavioral health integration (BHI) billing codes among clinicians. METHODS: Counts and payments were calculated for accepted and denied claims for CoCM and general BHI services delivered to Medicare beneficiaries nationwide in 2017-2018. Payment and utilization data were stratified by clinical specialty and site of service. RESULTS: Overall, 10,294 CoCM and general BHI services were delivered in 2017, totaling $626,292 in payments, and 81,433 CoCM and general BHI services were delivered in 2018, totaling $7,442,985 in payments. Medicare denied 5% of services in 2017 and 32% in 2018. Most CoCM and general BHI services were delivered by primary care physicians in office-based settings. CONCLUSIONS: This study of codes designed to promote BHI revealed an eightfold increase in CoCM and general BHI use between 2017 and 2018. However, denied services represent a barrier, and use among eligible beneficiaries remains low.

Nationwide Hospital Performance on Publicly Reported Episode Spending Measures.

BACKGROUND: Medicare has implemented strategies to improve value by containing hospital spending for episodes of care. Compared with payment models, publicly reported episode-based spending measures are underrecognized strategies. OBJECTIVE: To provide the first nationwide description of hospitals' episode-based spending based on publicly reported Clinical Episode-Based Payment (CEBP) measures. DESIGN, SETTING, AND PARTICIPANTS: We used 2017 Hospital Compare data to assess spending on six CEBPs among 1,778 hospitals. We examined spending variation and its drivers, correlation between CEBPs, and spending by cost performance categories (for individual CEBPs, below vs above average spending; for across-CEBP comparisons, high vs low vs mixed cost). We also compared hospital spending performance on CEBPs with a global Medicare Spending Per Beneficiary measure. MAIN OUTCOMES AND MEASURES: Episode spending. RESULTS: Episode spending varied by CEBP type, with skilled nursing facility (SNF) care accounting for the majority of spending variation for procedural episodes but not for condition episodes. Across CEBPs, greater proportions of episode spending were attributed to SNF care at high-(18.1%) vs mixed-(10.7%) vs low-cost (9.2%) hospitals (P > .001). There was low within-hospital CEBP correlation and low correlation and concordance between hospitals' CEBP and Medicare Spending Per Beneficiary performance. CONCLUSIONS: Variation reduction and savings opportunities in SNF care for procedural episodes suggest that they may be better suited for existing payment models than condition episodes are. Spending performance was not hospital specific, which highlights the potential utility of episode spending measures beyond global measures.

[Assessing soil pH in Anhui Province based on different features mining methods combined with generalized boosted regression models]. / 基于不同特征挖掘方法结合广义提升回归模型估测安徽省土壤pH.

We explored the application of different feature mining methods combined with genera-lized boosted regression models in digital soil mapping. Environmental covariates were selected by two feature selection methods i.e., recursive feature elimination and selection by filtering. Using the original environmental covariates and the selected optimal variable combination as independent varia-bles, soil pH prediction model of Anhui Province was established and mapped based on the genera-lized boosted regression model and random forest model. The results showed that both kinds of feature mining methods could effectively improve the accuracy of soil pH prediction by generalized boosted regression models and random forest model, and could reduce dimensionality. Compared with the random forest model, the prediction accuracy of the validation set of the generalized boosted regression model was slightly lower. In the training set, the accuracy of the generalized boosted regression models was much higher than that of the random forest model, with higher interpretation and better overall effect. The main parameters of the random forest model, ntree and mtry, had limi-ted effect on the model. Different parameters and their combination could affect the prediction accuracy of the generalized boosted regression models, and thus should be tuned before modeling. The results of spatial mapping showed that soil pH in Anhui Province showed a pattern of "south acid and north alkali".

Hospital safety-net status and performance on publicly reported episode spending measures.

OBJECTIVES: As part of its strategy to improve health care value and contain hospital costs, Medicare trialed public reporting for episode-based spending via 6 novel Clinical Episode-Based Payment (CEBP) measures for cellulitis, kidney/urinary tract infection, gastrointestinal hemorrhage, spinal fusion, cholecystectomy, and aortic aneurysm. Because safety-net hospitals may fare more poorly than other hospitals under value-based reforms, we evaluated the relationship between safety-net status and CEBP episode spending. STUDY DESIGN: Observational study. METHODS: We used data from Medicare and the American Hospital Association to identify and describe characteristics of safety-net and non-safety-net hospitals subject to CEBP measures nationwide. Multivariable linear regression, controlled for hospital characteristics, was used to evaluate the association between hospital safety-net status and risk-adjusted, standardized episode spending for each CEBP episode type. RESULTS: Of 1771 hospitals eligible for CEBPs, 28% (491) were safety-net and 72% (1280) were non-safety-net hospitals, with the former being larger and more likely to be nonprofit, nonteaching hospitals. The magnitude of episode spending varied by episode type, ranging from the lowest for cellulitis episodes to the highest for aortic aneurysm episodes. Skilled nursing facility care accounted for a considerable proportion of spending variation for procedure-based episodes but not condition-based episodes. In multivariable analysis, safety-net status was not associated with risk-adjusted episode spending for any of the 6 episode types (spending differences ranging from -$111 to $638 by episode; P > .05 for all). CONCLUSIONS: These findings provide the first description of baseline episode spending patterns for safety-net hospitals and suggest that such spending does not vary by safety-net status.

Use of Chronic Care Management Among Primary Care Clinicians.

The Centers for Medicare and Medicade Services (CMS) initiated chronic care management (CCM) codes to reimburse clinicians for coordination activities, but little is known about uptake over time. We find that primary care clinicians drove increasing use over 4 years-a trend that may reflect either new coordination activities or new reimbursements for existing activities. That 5% of chronic care management was denied by Medicare underscores the need for future work evaluating facilitators and barriers to use. Such insight is especially vital given the large number of eligible beneficiaries that have not received chronic care management to date, as well as the limited number of clinicians who currently deliver these services.