Clinical and Economic Implications of Interventions in Pancreatic Fluid Collections: An Assessment From a National Claims Database.

OBJECTIVE: To compare clinical and economic implications of percutaneous and endoscopic treatment approaches in patients with pancreatic fluid collections (PFCs). MATERIALS AND METHODS: This is a retrospective claims analysis of Medicare beneficiaries who underwent inpatient endoscopic or percutaneous PFC drainage procedures (2016-2020). We performed longitudinal analysis of claims for all-cause mortality and rehospitalization during 180-day follow-up. Main outcome was mortality. Other outcomes were rehospitalization and direct costs. RESULTS: A total of 1311 patients underwent endoscopic (n = 727) or percutaneous (n = 584) drainage. Percutaneous as compared with endoscopic approach was associated with higher mortality (23.08% vs 16.7%, P = 0.004), rehospitalization (58.9% vs 53.3%, P = 0.04), and mean direct hospital costs ($37,107 [SD = $67,833] vs $27,800 [SD = $43,854], P = 0.004). On multivariable analysis, percutaneous drainage (adjusted hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.02-1.86; P = 0.039), older age (hazard ratio [HR], 1.04; 95% CI, 1.01-1.04; P < 0.001), intensive care unit stay (HR, 1.02; 95% CI, 1.01-1.03; P < 0.001), and multiple comorbidities (HR, 1.07; 95% CI, 1.05-1.09; P < 0.001) were significantly associated with mortality. Percutaneous drainage (adjusted odds ratio [OR], 1.30; 95% CI, 1.04-1.63; P = 0.027) and older age (OR, 0.98; 95% CI, 0.97-0.99; P < 0.001) were significantly associated with rehospitalizations. CONCLUSIONS: As percutaneous drainage may be associated with higher mortality, rehospitalization, and costs, when requisite expertise is available, endoscopy should be preferred for treatment of PFC amenable to such an approach. Randomized trials are required to validate these findings.

Validation of the Greek translation of the multicultural quality of life index (MQLI-gr).

BACKGROUND: The aim of the current study was to examine the internal structure and convergent and discriminant validity of the Multicultural Quality of Life Index (MQLI) in a Greek sample of community-dwelling adults in a major Greek city. METHODS: The authors developed a Greek version of the Multicultural Quality of Life Index (MQLI-Gr). It was translated following cross-cultural adaptation procedures for self-report measures and administered to community members (N = 884). Participants completed a brief demographic survey, the MQLI-Gr, and the Depression Anxiety Stress Scales (DASS-42). RESULTS: The MQLI-Gr is brief, easy to use, and demonstrates strong internal consistency (Cronbach alpha = .90). In terms of internal structure there were mixed results. In terms of discriminant validity, statistically significant differences in mean MQLI-Gr scores were observed between two groups: those with none-mild symptoms versus those with severe symptoms of depression, anxiety, and stress (p < .05). The MQLI-Gr was also able to discriminate among groups assumed to vary on quality of life; marital status, income, and employment. In terms of convergent validity, results were in the expected direction, with participants reporting high levels of depression, anxiety, and stress, also reporting lower quality of life on the MQLI-Gr (p < .001). CONCLUSION: Consistent with other translations, the MQLI-Gr demonstrated feasibility, strong internal consistency, and good convergent and discriminant validity. This is the first step in the development of a psychometrically sound measure to assess quality of life in a community-dwelling population in Greece. With the addition of further validation studies, this measure will be a useful tool for assessing the quality of life in the Greek community.

African American perspectives on racial disparities in child removals.

BACKGROUND: African American children are overrepresented in foster care at twice to three times the rate of white children. Scholars argue that racism and oppression underlie disproportionality (Kriz & Skivenes, 2011). OBJECTIVE: This study explored disproportionality as seen through the eyes of African American parents in the child welfare system. The aim was to understand why African American families are over-represented in child custody statistics and to improve family and parenting support for African American communities. PARTICIPANTS & SETTING: Participants included twenty-one African Americans--12 women and 9 men, two of whom were foster parents and 19 of whom were parents involved with child welfare services. All participants reside in two impoverished areas in southern United States. Focus groups were used to collect data and were conducted at a community center. METHODS: The method of analysis was constant comparison analysis (Strauss) and thematic analysis of the focus group discussions in the context of institutional policy. FINDINGS: Six themes (profound lack of trust; overwhelming trauma; severe and persistent poverty; health and mental health; socio-economic conditions; and sense of social isolation were identified, along with three participant suggestions to improve child welfare services (family support services, economic revival, and better communication). CONCLUSIONS: In the current study we note the strong link between poverty, child maltreatment, and child removal and conclude with an exploration of practice and policy implications with recommendations for a way forward. The need for culturally competent and trauma informed child welfare services is also discussed.

The clinical and cost implications of failed endoscopic hemostasis in gastroduodenal ulcer bleeding.

AIM: The aim of this article is to evaluate the clinical and cost implications of failed endoscopic hemostasis in patients with gastroduodenal ulcer bleeding. METHODS: A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) file was conducted to identify all hospitalizations for gastroduodenal ulcer bleeding in the year 2012. The main outcome measures were to compare all-cause mortality, total length of hospital stay (LOS), hospital costs and payment between patients managed with one upper gastrointestinal (UGI) endoscopy versus more than one UGI endoscopy or requiring interventional radiology-guided hemostasis (IRH) or surgery after failed endoscopic attempt. RESULTS: The MedPAR claims data evaluated 13,501 hospitalizations, of which 12,242 (90.6%) reported one UGI endoscopy, 817 (6.05%) reported >1 UGI endoscopy, 303 (2.24%) reported IRH after failed endoscopy and 139 (1.03%) reported surgeries after failed endoscopy. All cause-mortality was significantly lower for patients who underwent only one UGI endoscopy (3%) compared to patients requiring >1 endoscopy (6%), IRH (9%) or surgery (14%), p < 0.0001. The median LOS was significantly lower for patients who underwent only one UGI endoscopy (four days) compared to patients requiring >1 endoscopy (eight days), IRH (nine days) or surgery (15 days), p < 0.0001. The median hospital costs were significantly lower for patients who underwent one UGI endoscopy ($10,518) compared to patients requiring >1 endoscopy ($20,055), IRH ($34,730) or surgery ($47,589), p < 0.0001. CONCLUSIONS: Failure to achieve hemostasis at the index endoscopy has significant clinical and cost implications. When feasible, a repeat endoscopy must be attempted followed by IRH. Surgery should preferably be reserved as a last resort for patients who fail other treatment measures.

Changing trends in tissue acquisition in malignant pancreatic neoplasms.

BACKGROUND AND AIM: To compare the frequency of use, hospital costs, and resource availability between endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), percutaneous, and surgical techniques for tissue acquisition in malignant pancreatic neoplasms. METHODS: This is a retrospective claims analysis of Medicare patients undergoing biopsy of malignant pancreatic neoplasms over 5 years (2006-2010). The primary outcome measure was to compare the utilization of EUS, percutaneous techniques, and surgery for performing pancreatic biopsies. The secondary outcome measures were to compare treatment costs and variations in availability of resources between the three techniques over a 1-year period (2010). RESULTS: Over 5 years, the use of EUS-FNA increased by 69.3% (7100 to 12 020) and the use of percutaneous biopsy by 1.8% (4480 to 4560) compared to decrease in surgical biopsy (720 to 420) by 41.7% (P < 0.0001). When compared to percutaneous and surgical biopsies ($9639 and $21 947, respectively) the median hospital cost/claim for EUS-FNA ($1794) was significantly lower (P < 0.0001). More EUS-FNA procedures were performed in urban and teaching hospitals compared to rural and non-teaching hospitals (P < 0.001). CONCLUSIONS: Although EUS-FNA is increasingly performed and is less costly, and the rate of surgical biopsies has declined precipitously, the utilization of percutaneous techniques remains prevalent. Training and education are required to disseminate the use of EUS-FNA outside major teaching institutions or foster referral of patients to EUS centers because of implications for patient care and resource use.

How effective is "code freeze" in post-cardiac arrest patients?

The use of therapeutic hypothermia or "code freeze" dates back to over 100 years in attempts to resuscitate injured soldiers, preserve limbs, and to provide analgesia for amputations. The purpose of this study was to determine the effectiveness of code freeze through a retrospective review of 187 charts of patients who had a cardiac arrest while hospitalized in a 1-year period. Data were collected to determine which post-cardiac arrest patients received the induced therapeutic hypothermia intervention and why they were selected for induced therapeutic hypothermia. The data were compared with post-cardiac arrest patients who did not receive the code-freeze intervention and why they were not eligible for the intervention. Mortality rates between the 2 patient populations were also compared. The results from this study are presented in this article.

Improving influenza immunization rates through a specialized clinic review.

PURPOSE: The purpose of this capstone project was to determine if alternative access by way of a focused immunization clinic rather than a regular physician office visit caused an increase from 2009 to 2010 in the number of people in a rural community who received the influenza vaccine. Reasons why the immunization clinic was chosen by the patient for immunization were identified. METHODS: This project was conducted by using a descriptive survey design. A questionnaire was given to individuals who participated in an influenza immunization clinic in a rural community in a southeastern state. Data were collected using a seven-item questionnaire completed by participants. RESULTS: Evaluation of data revealed that 40% of individuals who did not receive their vaccine in 2009 received a flu shot in 2010 through access to the immunization clinic. CONCLUSION: Evidence suggests that providing alternative access to immunizations in a rural community could potentially improve the rate of participation of individuals.

Creating a successful environment for preparing doctoral-level nurse educators.

The ongoing nursing shortage requires that universities be creative in developing alternative methods to enhance the supply of nursing faculty. We report on an innovative collaborative program between colleges of nursing and education to prepare future nursing faculty. The evaluation of this initiative was accomplished using comparative data from doctoral students in other non-nursing programs. We found that the nurse educator program was positive in influencing students' knowledge and skill development and perceptions of faculty support, compared with other non-nursing doctoral programs.

Providing mental health care to veterans in rural areas: using telehealth in mobile clinics.

The purpose of this article is to provide information to improve the quality of care of veterans living in geographically isolated areas who require treatment for mental health issues. Because interactive care solutions are currently hot topics in the health care community, they should be viewed as possible strategies to meet the needs of this specialty group of veterans. An intervention using a mobile clinic and clinical video telehealth reduces distance barriers by making it possible for mental health specialists to come to rural veterans instead of the veteran attempting to find a way to get to the practitioner, who may be located in a clinic or hospital many miles away. This article focuses on an alternate strategy-telehealth in mobile clinics-as a possible solution to the mental health crisis of veterans in rural areas.

Stenting versus gastrojejunostomy for management of malignant gastric outlet obstruction: comparison of clinical outcomes and costs.

BACKGROUND: Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ) is still considered the gold standard for relief of malignant gastric outlet obstruction (GOO). The aim of this study is to compare clinical outcomes and hospital costs between patients undergoing GJ or stenting for management of malignant GOO. METHODS: A retrospective claims analysis of the Medicare (MedPAR) database was conducted to identify all inpatient hospitalizations for GJ or endoscopic stenting for malignant GOO during 2007-2008. The main outcome measure evaluated using the MedPAR database was a comparison of the total length of hospital stay (LOS) and costs associated with both techniques. As MedPAR is a claims database that does not provide outcomes at patient level, a single-institution retrospective study was conducted to compare the rates of technical and treatment success, post-procedure LOS, and delayed complications per patient between the two techniques. RESULTS: The MedPAR claims data evaluated 425 stenting and 339 GJ hospitalizations. Compared with GJ, median LOS (8 vs. 16 days; p < 0.0001) and median cost (US $15,366 vs. US $27,391; p < 0.0001) per claim were both significantly lower for stenting. Stenting was more commonly performed at urban versus rural hospitals (89 % vs. 11 %; p < 0.0001), teaching versus non-teaching hospitals (59 % vs. 41 %, p = 0.0005), and academic institutions (56 % vs. 44 %; p = 0.0157). The institutional patient data analysis included 29 patients who underwent stenting and 75 who underwent surgical GJ. While both modalities were technically successful and relieved gastric outlet obstruction in all cases, compared with surgical GJ, the median post-procedure LOS was significantly lower for enteral stenting (1.5 vs. 10.7 days, p < 0.0001). There was no difference in rates of delayed complications between stenting and surgical GJ (13.8 % vs. 6.7 %; p = 0.26). CONCLUSIONS: While the technical and clinical outcomes of surgical GJ and endoscopic stenting appear comparable, stent placement is less costly and is associated with shorter length of hospital stay. Dissemination of endoscopic stenting beyond teaching, academic hospitals located in urban areas as a treatment for malignant GOO is important given its implications for patient care and resource utilization.

Male infertility: an exploratory comparison of African American and white men.

PURPOSE: This study's purpose was to provide information regarding differences in AA and White men's attitude about not fathering a child, receipt and type of infertility services, and diagnosed infertility problem. METHODS: A descriptive study using Cycle 6 National Survey of Family Growth male interview data with Chi Square analysis was conducted. FINDINGS: There was a statistically significant difference in attitude about not fathering a child, but no other statistically significant differences. CONCLUSION: AA men have stronger attitudes about not fathering a child. Study limitations make other findings insufficient to conclude that infertility is the same for AA and White men.

Endoscopic stenting versus surgical colostomy for the management of malignant colonic obstruction: comparison of hospital costs and clinical outcomes.

BACKGROUND: Although stent placement is increasingly performed, colostomy still is considered the gold standard for emergent relief of malignant colonic obstruction (MCO). This study aimed to compare hospital costs and clinical outcomes between patients undergoing colostomy and those undergoing stenting for the management of MCO. METHODS: A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) data set was conducted to identify inpatient hospitalizations for colostomy or stent placement for the treatment of colon cancer (2007-2008). The outcomes evaluated using MedPAR compared the total length of hospital stay (LOS) and the costs associated with both techniques. Because MedPAR is a claims data set that does not provide outcomes at a patient level, a single-institution retrospective case-control study was conducted in which each stent placement patient was matched with two colostomy patients during the same period. Outcome measures (institutional data) were used to compare rates of treatment success, postprocedure LOS, and reinterventions between the two cohorts. RESULTS: The MedPAR data evaluated 778 stent placements and 5,868 colostomy hospitalizations. There were no differences in gender, age distribution, or comorbidity between the two groups. Compared with colostomy, the median LOS (8 vs. 12 days; p<0.0001) and the median cost ($15,071 vs. $24,695; p<0.001) per claim were significantly less for stent placement. Stent placement was more commonly performed at urban versus rural hospitals (84% vs. 16%; p<0.0001), teaching versus nonteaching hospitals (56% vs. 44%; p=0.0058) and larger versus smaller institutions (mean bed capacity, 331 vs. 227; p<0.0001). The institution data included 12 patients who underwent stent placement and 24 who underwent colostomy. Although both methods were technically successful, the median postprocedure LOS (2.17 vs. 10.58 days; p=0.0004) and the rate of readmissions for complications (0% vs. 25%; p=0.01) were significantly lower for stent placement. CONCLUSION: Although the technical and clinical outcomes for colostomy and stent placement appear comparable, stent placement is less costly and associated with shorter LOS and fewer complications. Dissemination of stent placement beyond large teaching hospitals located in urban areas as a treatment for MCO is important given its implications for patient care and resource use.

A simple method to predict pretracheal tissue thickness to prevent accidental decannulation in the obese.

OBJECTIVE: Accidental decannulation is the most common and serious complication associated with tracheostomy in obese patients. We lack a simple way to choose appropriate-size tracheostomy tubes in this patient subset. Our purpose was to 1) establish the range of trachea-to-skin soft tissue thickness (TTSSTT) in obese patients and 2) determine which easily obtained anthropometric measurements are most predictive of TTSSTT. STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary care center. SUBJECTS AND METHODS: Forty consenting patients with body mass index ranging from 30 to 70 were evaluated. These patients, from a bariatric clinic, underwent ultrasound (US) of the neck in predetermined sitting, supine, and neck-extended positions (as for tracheostomy). US was performed by a qualified radiologist. Standard anthropometric measurements of weight, height, arm, hip, waist, and neck sizes were performed. Multiple regression analysis was used to determine which anthropometric measurements best correlated with TTSSTT. RESULTS: The TTSSTT, as measured by US in the supine position, ranged from 0.65 to 3.53 cm. Although the anthropometric measurement most predictive of TTSSTT was waist circumference, a combination of the more practical arm and neck circumferences resulted in an equivalent correlation (r = 0.82). The average root mean squared error was 0.4 cm. From the fitted regression equation, a table predicting TTSSTT from neck and arm circumference was prepared. CONCLUSION: TTSSTT can be closely predicted using simple anthropometric tape measures. The predicted TTSSTT can be used to select appropriate tracheostomy tube size in obese patients. Use of this simple tool is expected to significantly reduce the incidence of accidental decannulation in obese patients.

Dissecting dementia, depression, and drug effects in older adults.

As adults age, many changes in functioning occur, and dementia and/or depression may develop. Medications used to manage dementia and depression include selective serotonin reuptake inhibitors. The challenge for nurses is recognizing which behaviors, signs, and symptoms are the result of the dementia or depression and which are the result of the drug therapy. The purpose of this article is to present information to increase awareness of the complexities of care for older adults with dementia and/or depression and identify possible implications for practicing nurses.

Using data from the internet to teach ethical principles for critiquing research studies.

Qualitative researchers are increasingly using the Internet to conduct their studies; however, they need to adhere to the same ethical principles used when conducting traditional research studies. Students also must be aware of these ethical principles and know how to critique research reports for adherence to them. The authors describe selected ethical principles as they relate to Internet qualitative research, what students need to know, what faculty must teach them to critique those studies, and what decisions students must make once the critique is completed.

Leadership experiences for baccalaureate nursing students: improving quality in a nurse-managed rural health clinic.

Nurse educators need practical, effective methods to help nursing students understand the importance of quality improvement activities and their relationship to the financial viability of organizations. This article describes a project designed to provide students with an opportunity to apply quality improvement principles in a rural, nurse-managed clinic with the ultimate goal of improving potential reimbursement for services through improved documentation. Implications for students, nurse educators, and rural clinics are provided.

Male infertility: the element of disguise.

The purpose of this descriptive study was to explore the element of disguise in the infertility experience of men. I conducted a secondary analysis of data from a previous study of 10 men experiencing infertility. Three categories of disguise were identmifed: disguise to protect themselves, disgise to protect their partner, and disguise to protect both themselves and their partner. This study's results indicate that health care professionals need to increase their awareness of the element of disguise and provide interventions for men experiencing infertility.