Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Ischemic Stroke With Blood Pressure-Dependent Symptoms.

The efficacy of extracranial-intracranial (EC-IC) bypass in preventing ischemic stroke progression and recurrence is controversial. As per the current hypothesis, EC-IC bypass is most beneficial for patients with persistent hemodynamic insufficiency. Hence, various approaches have been used to evaluate hemodynamic insufficiency, including repeated single photon emission CT (SPECT) imaging or continuous monitoring of cerebral flow with transcranial Doppler ultrasound (TCD). However, both modalities are time- and resource-intensive. In this report, we discuss how EC-IC bypass turned out to be beneficial for a patient presenting with blood pressure-dependent severe aphasia and right hemiparesis due to middle cerebral artery (MCA) occlusion that failed thrombectomy. CT perfusion (CTP) scan at admission demonstrated a persistent volume of delayed perfusion without core infarct. Following the superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, the patient's National Institute of Health Stroke Scale (NIHSS) score improved from 12 to 1. Ischemic penumbra, as seen on CTP imaging, also improved after the STA-MCA bypass. Our case suggests that persistent volume of delayed perfusion and blood pressure-dependent neurological deficits can be used in tandem as selection criteria for EC-IC bypass.

Racial Disparities in Employment Status After Moderate/Severe Traumatic Brain Injuries in Southeast Michigan.

OBJECTIVE: To examine the progress made in recent decades by assessing the employment rates of Black and non-Hispanic White (NHW) patients after traumatic brain injury (TBI), controlling for pre-TBI employment status and education status. DESIGN: Retrospective analysis in a cohort of patients treated in Southeast Michigan at major trauma centers in more recent years (February 2010 to December 2019). SETTING: Southeastern Michigan Traumatic Brain Injury Model System (TBIMS): 1 of 16 TBIMSs across the United States. PARTICIPANTS: NHW (n=81) and Black (n=188) patients with moderate/severe TBI (N=269). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Employment status, which is separated into 2 categories: student plus competitive employment and noncompetitive employment. RESULTS: In 269 patients, NHW patients had more severe initial TBI, measured by percentage brain computed tomography with compression causing >5-mm midline shift (P<.001). Controlling for pre-TBI employment status, we found NHW participants who were students or had competitive employment prior to TBI had higher rates of competitive employment at 2-year (P=.03) follow-up. Controlling for pre-TBI education status, we found no difference in competitive and noncompetitive employment rates between NHW and Black participants at all follow-up years. CONCLUSIONS: Black patients who were students or had competitive employment before TBI experience worse employment outcomes than their NHW counterparts after TBI at 2 years post TBI. Further research is needed to understand better the factors driving these disparities and how social determinants of health affect these racial differences after TBI.

Cerebral infarction following bee stings: Case report and literature review.

Background: To date, only 25 cases of cerebral infarction following a bee or wasp sting have been reported. Due to its rarity, undefined pathogenesis, and unique clinical features, we report a case of a 62-year-old man with progressive cerebral infarction following bee stings, possibly related to vasospasm. Furthermore, we review relevant literature on stroke following bee or wasp stings. Case presentation: A 62-year-old retired male presented with progressive ischemic stroke after bee stings to the ear and face. Initial magnetic resonance imaging of the brain showed small punctate infarcts in the left medulla oblongata. Head and neck computed tomography angiography showed significant stenosis in the basilar artery and occlusion in the left V4 vertebral artery. The patient received intravenous alteplase (0.9 mg/kg) without symptomatic improvement. Digital subtraction angiography later demonstrated additional near occlusion in the left posterior cerebral artery (PCA). Thrombectomy was considered initially but was aborted due to hemodynamic instability. Repeated CT brain after 24 h showed acute infarcts in the left parieto-occipital region and left thalamus. The near occluded PCA was found to be patent again on magnetic resonance angiography (MRA) 25 days later. This reversibility suggests that vasospasm may have been the underlying mechanism. Unfortunately, the patient had persistent significant neurological deficits after rehabilitation one year later. Conclusion: Cerebral infarction following bee stings is rare. There are several proposed pathophysiological mechanisms. While the natural course of this phenomenon is not well characterized, early diagnosis and treatment are essential. Furthermore, it is important to establish standardized care procedures for this unique entity.

Shadow Coaching Improves Patient Experience With Care, But Gains Erode Later.

BACKGROUND: Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors. OBJECTIVE: We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center. RESEARCH DESIGN: Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach. SUBJECTS: A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0. MEASURES: CAHPS overall provider rating and provider communication composite (scaled 0-100). RESULTS: Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach. CONCLUSIONS: Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.

Multiple sclerosis: Frequency, cost, and economic burden in the United States.

Multiple sclerosis (MS) is one of the most common neurological diseases, affecting young and middle-aged adults. The full economic cost of managing chronic MS is substantial. To investigate the recent trend of medical cost and economic burden of MS management in the United States (U.S.), we inquired for available data from the National Inpatient Sample database (NIS; from 1994 to 2013). The annual rates of changes were determined by linear regression analysis. We found an estimated half million increase in MS admissions, annually, which was projected to exceed 43.5 million by the end of year 2017. We also found the charge and the costs associated with MS care increased at rates of US$ 40 million a year and US$ 8 million a year, respectively. We revealed a 1.6 fold increase in the inflation of medical bill in the past decade, and the inflation of medical bills was inversely correlated to the cost-to-charge ratios. In sum, we outline the national trends of medical care use and the expenditure of caring for patients with MS. Periodic reviews and characterizations of expenditure trends are critical for formulating future policy.

Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

OBJECTIVE: Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience. SUBJECTS: Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10). METHODS: Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items. RESULTS: We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation. CONCLUSIONS: PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

Patient Experiences with Care Differ with Chronic Care Management in a Federally Qualified Community Health Center.

This study compares patient experience among practices that vary in adoption of the chronic care management (CCM) dimension of the patient-centered medical home (PCMH) model that focuses on care coordination and management of chronic diseases. Study participants were 2903 adult patients (ages 18 years or older) at 14 primary care centers in California. Seven of the sites were classified as high (more CCM) and the other 7 low on a CCM index. Hypotheses were tested using ordinary least squares regression models. After adjusting for the number of providers at the sites, high CCM scores were associated with significantly better overall ratings of providers, provider communication, follow-up on test results, and willingness to recommend the provider (differences of 5.82, 6.85, 9.81, and 4.56, respectively on the 0-100 scale scores). The results of this study provide support for the value of the PCMH for patient experiences with care.

Development and Testing of the Pediatric Respiratory Illness Measurement System (PRIMES) Quality Indicators.

OBJECTIVES: To develop and test quality indicators for assessing care in pediatric hospital settings for common respiratory illnesses. PATIENTS: A sample of 2796 children discharged from the emergency department or inpatient setting at 1 of the 3 participating hospitals with a primary diagnosis of asthma, bronchiolitis, croup, or community-acquired pneumonia (CAP) between January 1, 2010, and December 31, 2011. SETTING: Three tertiary care children's hospitals in the United States. METHODS: We developed evidence-based quality indicators for asthma, bronchiolitis, croup, and CAP. Expert panel-endorsed indicators were included in the Pediatric Respiratory Illness Measurement System (PRIMES). This new set of pediatric quality measures was tested to assess feasibility of implementation and sensitivity to variations in care. Medical records data were extracted by trained abstractors. Quality measure scores (0-100 scale) were calculated by dividing the number of times indicated care was received by the number of eligible cases. Score differences within and between hospitals were determined by using the Student's t-test or analysis of variance. RESULTS: CAP and croup condition-level PRIMES scores demonstrated significant between-hospital variations (P < .001). Asthma and bronchiolitis condition-level PRIMES scores demonstrated significant within-hospital variation with emergency department scores (means [SD] 82.2(6.1)-100.0 (14.4)] exceeding inpatient scores (means [SD] 71.1 (2.0)-90.8 (1.3); P < .001). CONCLUSIONS: PRIMES is a new set of measures available for assessing the quality of hospital-based care for common pediatric respiratory illnesses.

Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients.

BACKGROUND: Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform. METHODS: We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns. RESULTS: We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients. CONCLUSIONS: NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.

Development and Validation of a Method to Identify Children With Social Complexity Risk Factors.

OBJECTIVES: We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination. METHODS: A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics. RESULTS: Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37). CONCLUSIONS: Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.

Use of CAHPS® patient experience survey data as part of a patient-centered medical home quality improvement initiative.

OBJECTIVE: To describe how practice leaders used Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician and Group (CG-CAHPS) data in transitioning toward a patient-centered medical home (PCMH). STUDY DESIGN: Interviews conducted at 14 primary care practices within a large urban Federally Qualified Health Center in California. PARTICIPANTS: Thirty-eight interviews were conducted with lead physicians (n=13), site clinic administrators (n=13), nurse supervisors (n=10), and executive leadership (n=2). RESULTS: Seven themes were identified on how practice leaders used CG-CAHPS data for PCMH transformation. CAHPS® was used: 1) for quality improvement (QI) and focusing changes for PCMH transformation; 2) to maintain focus on patient experience; 3) alongside other data; 4) for monitoring site-level trends and changes; 5) to identify, analyze, and monitor areas for improvement; 6) for provider-level performance monitoring and individual coaching within a transparent environment of accountability; and 7) for PCMH transformation, but changes to instrument length, reading level, and the wording of specific items were suggested. CONCLUSION: Practice leaders used CG-CAHPS data to implement QI, develop a shared vision, and coach providers and staff on performance. They described how CAHPS® helped to improve the patient experience in the PCMH model, including access to routine and urgent care, wait times, provider spending enough time and listening carefully, and courteousness of staff. Regular reporting, reviewing, and discussing of patient-experience data alongside other clinical quality and productivity measures at multilevels of the organization was critical in maximizing the use of CAHPS® data as PCMH changes were made. In sum, this study found that a system-wide accountability and data-monitoring structure relying on a standardized and actionable patient-experience survey, such as CG-CAHPS, is key to supporting the continuous QI needed for moving beyond formal PCMH recognition to maximizing primary care medical home transformation.

Olfactory deficits in an alpha-synuclein fly model of Parkinson's disease.

Parkinson's disease (PD) is the most common motor neurodegenerative disorder. Olfactory dysfunction is a prevalent feature of PD. It often precedes motor symptoms by several years and is used in assisting PD diagnosis. However, the cellular and molecular bases of olfactory dysfunction in PD are not known. The fruit fly Drosophila melanogaster, expressing human alpha-synuclein protein or its mutant, A30P, captures several hallmarks of PD and has been successfully used to model PD in numerous studies. First, we report olfactory deficits in fly expressing A30P (A30P), showing deficits in two out of three olfactory modalities, tested--olfactory acuity and odor discrimination. The remaining third modality is odor identification/naming. Second, oxidative stress is an important environmental risk factor of PD. We show that oxidative stress exacerbated the two affected olfactory modalities in younger A30P flies. Third, different olfactory receptor neurons are activated differentially by different odors in flies. In a separate experiment, we show that the odor discrimination deficit in A30P flies is general and not restricted to a specific class of chemical structure. Lastly, by restricting A30P expression to dopamine, serotonin or olfactory receptor neurons, we show that A30P expression in dopamine neurons is necessary for development of both acuity and discrimination deficits, while serotonin and olfactory receptor neurons appeared not involved. Our data demonstrate olfactory deficits in a synuclein fly PD model for exploring olfactory pathology and physiology, and for monitoring PD progression and treatment.

Pediatric medical complexity algorithm: a new method to stratify children by medical complexity.

OBJECTIVES: The goal of this study was to develop an algorithm based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes for classifying children with chronic disease (CD) according to level of medical complexity and to assess the algorithm's sensitivity and specificity. METHODS: A retrospective observational study was conducted among 700 children insured by Washington State Medicaid with ≥1 Seattle Children's Hospital emergency department and/or inpatient encounter in 2010. The gold standard population included 350 children with complex chronic disease (C-CD), 100 with noncomplex chronic disease (NC-CD), and 250 without CD. An existing ICD-9-CM-based algorithm called the Chronic Disability Payment System was modified to develop a new algorithm called the Pediatric Medical Complexity Algorithm (PMCA). The sensitivity and specificity of PMCA were assessed. RESULTS: Using hospital discharge data, PMCA's sensitivity for correctly classifying children was 84% for C-CD, 41% for NC-CD, and 96% for those without CD. Using Medicaid claims data, PMCA's sensitivity was 89% for C-CD, 45% for NC-CD, and 80% for those without CD. Specificity was 90% to 92% in hospital discharge data and 85% to 91% in Medicaid claims data for all 3 groups. CONCLUSIONS: PMCA identified children with C-CD (who have accessed tertiary hospital care) with good sensitivity and good to excellent specificity when applied to hospital discharge or Medicaid claims data. PMCA may be useful for targeting resources such as care coordination to children with C-CD.

Hospital costs and inpatient mortality among children undergoing surgery for congenital heart disease.

OBJECTIVE: To determine the association between hospital costs and risk-adjusted inpatient mortality among children undergoing surgery for congenital heart disease (CHD) in U.S. acute-care hospitals. DATA SOURCES/STUDY SETTINGS: Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids' Inpatient Database (KID). STUDY DESIGN: Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders. DATA COLLECTION/EXTRACTION METHODS: We identified relevant discharges in the KID using the AHRQ Pediatric Quality Indicator for pediatric heart surgery mortality, and linked these records to hospital characteristics from American Hospital Association Surveys and community characteristics from the Census. PRINCIPAL FINDINGS: Children undergoing CHD surgery in higher cost hospitals had lower risk-adjusted inpatient mortality (p=.002). An increase from the 25th percentile of treatment costs to the 75th percentile was associated with a 13.6 percent reduction in risk-adjusted mortality. CONCLUSIONS: Greater hospital costs are associated with lower risk-adjusted inpatient mortality for children undergoing CHD surgery. The specific mechanisms by which greater costs improve mortality merit further exploration.

Family structure and childhood obesity: an analysis through 8th grade.

Research on the effect of family structure on childhood obesity is scarce. This study examines the effect of number of parents and number of siblings on US children's body mass index (BMI) and risk of obesity. We conducted a secondary data analysis of the Early Childhood Longitudinal Study-Kindergarten Cohort (ECLS-K), which consists of a nationally representative cohort of children who entered kindergarten in 1998-1999, to examine the effect of family structure on children's body mass index and risk of obesity from kindergarten through 8th grade. Study outcomes were BMI in kindergarten and 8th grade, obesity status in kindergarten and 8th grade, and change in BMI from kindergarten through 8th grade. Multivariate regressions were used to assess the association between family structure and study outcomes while adjusting for other covariates. In 8th grade, children with no siblings had higher BMI (23.7 vs. 22.6; P ≤ 0.01) and higher probability of being obese (25.8 vs. 19.7 %; P ≤ 0.05) than their counterparts with two or more siblings. They also had a larger increase in BMI from kindergarten through 8th grade than children living with two or more siblings (7.3 vs. 6.3; P = 0.02). Our analysis suggests that the association between family structure and obesity persists and even intensifies through 8th grade. These findings have important implications for targeting obesity support and counseling for families.

Differences in CAHPS reports and ratings of health care provided to adults and children.

BACKGROUND: Consumer assessment of health care is an important metric for evaluating quality of care. These assessments can help purchasers, health plans, and providers deliver care that fits patients' needs. OBJECTIVE: To examine differences in reports and ratings of care delivered to adults and children and whether they vary by site. RESEARCH DESIGN: This observational study compares adult and child experiences with care at a large west coast medical center and affiliated clinics and a large mid-western health plan using Consumer Assessment of Healthcare Providers and Systems Clinician & Group 1.0 Survey data. RESULTS: Office staff helpfulness and courtesy was perceived more positively for adult than pediatric care in the west coast site. In contrast, more positive perceptions of pediatric care were observed in both sites for coordination of care, shared decision making, overall rating of the doctor, and willingness to recommend the doctor to family and friends. In addition, pediatric care was perceived more positively in the mid-west site for access to care, provider communication, and office staff helpfulness and courtesy. The differences between pediatric care and adult care were larger in the mid-western site than the west coast site. CONCLUSIONS: There are significant differences in the perception of care for children and adults with care provided to children tending to be perceived more positively. Further research is needed to identify the reasons for these differences and provide more definitive information at sites throughout the United States.