Implementation of the Affordable Care Act: A Comparison of Outcomes in Patients With Severe Sepsis and Septic Shock Using the National Inpatient Sample.

OBJECTIVES: Sepsis is the most common and costly diagnosis in U.S.' hospitals. Despite quality improvement programs and heightened awareness, sepsis accounts for greater than 50% of all hospital deaths. A key modifier of outcomes is access to healthcare. The Affordable Care Act, passed in 2010, expanded access to health insurance coverage. The purpose of this study was to evaluate changes in insurance coverage and outcomes in patients with severe sepsis and septic shock as a result of the full implementation of the Affordable Care Act. DESIGN: This retrospective study uses data from the Healthcare Cost and Utilization Project National Inpatient Sample during 2011-2016. Data were divided into two groups: 2011-2013 (pre Affordable Care Act) and 2014-2016 (post Affordable Care Act). Outcomes were in-hospital mortality, mortality rates based on insurance type, and hospital length of stay. PATIENTS: Hospitalized adults between the ages 18 and 64. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 361,323 severe sepsis or septic shock hospital discharges were included. Comparing pre-Affordable Care Act with post-Affordable Care Act, there was a 4.75% increase in medicaid coverage and a 1.91% decrease in the uninsured. Overall in-hospital mortality decreased from 22.90% pre-Affordable Care Act to 18.59% post-Affordable Care Act. Pre-Affordable Care Act uninsured patients had the highest mortality (25.68%). Patients with medicaid had the greatest reduction in mortality (5.71%) and length of stay (2.45 d). The mean (SD) length of stay pre Affordable Care Act was 13.92 (17.42) days, compared with 12.35 (15.76) days post Affordable Care Act. All results were statistically significant (p < 0.0001). CONCLUSIONS: In this cohort, there was an increase in insured patients with severe sepsis and septic shock post Affordable Care Act. Mortality and length of stay decreased in the post-Affordable Care Act period with the greatest reduction identified in the medicaid population. The improvement in outcomes could be attributed to advances in management, earlier presentation, patients being less severely ill and receiving treatment sooner.

Diffuse melanosis cutis: a rare manifestation of metastatic melanoma.

Diffuse melanosis cutis (DMC) is an extremely rare and late complication of metastatic melanoma (MM). It involves the progressive blue-grey discolouration of the skin and mucous membranes, occurring approximately 1 year after diagnosis of MM. The pathogenesis of DMC is unknown, although specific growth factors, such as alpha-melanocyte stimulating hormone, hepatocyte growth factor and endothelin-1, released by cancer cells, along with release of melanin precursors in the bloodstream and dermal MM micrometastases producing melanin have been attributed. Even with appropriate therapy, DMC seems to be a poor prognostic factor, with a mean survival time of 4-5 months. Here, we report a case of BRAF-mutated MM who presented with DMC. The patient underwent BRAF/MEK inhibition followed by anti-PDL1 therapy, yet passed away approximately 1 year after diagnosis.

Outpatient Management of Chronic Obstructive Pulmonary Disease: Physician Adherence to the 2017 Global Initiative for Chronic Obstructive Lung Disease Guidelines and its Effect on Patient Outcomes.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common and preventable illness that carries significant economic and social burden. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides a comprehensive review of the available literature for the diagnosis and management of COPD. Despite being considered the standard of care, adherence to the GOLD guidelines varies among practitioners. In addition, there is yet to be a clear correlation between misalignment with GOLD practicing guidelines and patient outcomes. We studied the outpatient management of COPD, with special attention paid to whether or not adherence to the 2017 GOLD guidelines affected patient outcomes. METHODS: This retrospective electronic medical record review study observed the outpatient management of patients with COPD, aged 18 year or older, who presented to the suburban primary care office. Patients who received treatment according to the GOLD guidelines were compared with the patients who did not. Categorical data were analyzed as frequencies with percentages. Frequencies were compared using Chi-square and Fisher's exact tests. A P value < 0.05 was used to determine statistical significance. RESULTS: A total of 158 patients were included in this study. Thirty-six percent of the patients were treated according to the GOLD guidelines. There was no significant difference in the mortality, exacerbations or hospitalizations between the patients who were treated according to the GOLD guidelines and those who were not. Comparing prescribing practices for those treated according to the GOLD guidelines versus those who were not, a significant difference in management occurred in regards to long acting beta agonist (P < 0.05) and inhaled corticosteroid therapy (P < 0.001). The differences in the use of other pharmacological and nonpharmacological agents were not significant. CONCLUSIONS: Adherence to the 2017 GOLD guidelines had no statistically significant difference in patient outcomes. GOLD nonadherent patients received long-acting beta agonist and inhaled corticosteroid therapy at a significantly higher frequency compared to GOLD-adherent patients.