Managed care COVID-19 outcomes in a population health program.

OBJECTIVES: To determine (1) factors linked to hospitalizations among managed care patients (MCPs), (2) outcome improvement with use of outpatient off-label treatment, and (3) outcome comparison between MCPs and a mirror group. STUDY DESIGN: Retrospective cohort study comparing MCPs with an age- and gender-matched mirror group in Florida from April 1, 2020, to May 31, 2020. METHODS: A total of 38,193 MCPs in a Florida primary care group were monitored for COVID-19 incidence, hospitalization, and mortality. The highest-risk patients were managed by the medical group's COVID-19 Task Force. As part of a population health program, the COVID-19 Task Force contacted patients, conducted medical encounters, and tracked data including comorbidities and medical outcomes. The MCPs enrolled in the medical group were compared with a mirror group from the state of Florida. RESULTS: The mean (SD) age among the MCPs was 67.9 (15.2) years, and 60% were female. Older age and hypertension were the most important factors in predicting COVID-19. Obesity, chronic kidney disease (CKD), and congestive heart failure (CHF) were linked to higher rates of hospitalizations. Patients prescribed off-label outpatient medications had 73% lower likelihood of hospitalization (P < .05). Compared with the mirror group, MCPs had 60% lower COVID-19 mortality (P < .05). CONCLUSIONS: MCPs have risk factors similar to the general population for COVID-19 incidence and progression, including older age, hypertension, obesity, CHF, and CKD. Outpatient treatment with off-label medicines decreased hospitalizations. A comprehensive population health program decreased COVID-19 mortality.

Current Understanding of COVID-19 Clinical Course and Investigational Treatments.

Importance: Currently, there is no unified framework linking disease progression to established viral levels, clinical tests, inflammatory markers, and investigational treatment options. Objective: It may take many weeks or months to establish a standard treatment approach. Given the growing morbidity and mortality with respect to COVID-19, this systemic review presents a treatment approach based on a thorough review of scholarly articles and clinical reports. Our focus is on staged progression, clinical algorithms, and individualized treatment. Evidence Review: We followed the protocol for a quality review article proposed by Heyn et al. (1). A literature search was conducted to find all relevant studies related to COVID-19. The search was conducted between April 1, 2020, and April 13, 2020, using the following electronic databases: PubMed (1809 to present); Google Scholar (1900 to present); MEDLINE (1946 to present), CINAHL (1937 to present); and Embase (1980 to present). The keywords used included COVID-19, 2019-nCov, SARS-CoV-2, SARS-CoV, and MERS-CoV, with terms such as efficacy, seroconversion, microbiology, pathophysiology, viral levels, inflammation, survivability, and treatment and pharmacology. No language restriction was placed on the search. Reference lists were manually scanned for additional studies. Findings: Of the articles found in the literature search, 70 were selected for inclusion in this study (67 cited in the body of the manuscript and 3 additional unique references in the Figures). The articles represent work from China, Japan, Taiwan, Vietnam, Rwanda, Israel, France, the United Kingdom, the Netherlands, Canada, and the United States. Most of the articles were cohort or case studies, but we also drew upon other information, including guidelines from hospitals and clinics instructing their staff on procedures to follow. In addition, we based some decisions on data collected by organizations such as the CDC, FDA, IHME, IDSA, and Worldometer. None of the case studies or cohort studies used a large number of participants. The largest group of participants numbered <500 and some case studies had fewer than 30 patients. However, the review of the literature revealed the need for individualized treatment protocols due to the variability of patient clinical presentation and survivability. A number of factors appear to influence mortality: the stage at which the patient first presented for care, pre-existing health conditions, age, and the viral load the patient carried. Conclusion and Relevance: COVID-19 can be divided into three distinct stages, beginning at the time of infection (Stage I), sometimes progressing to pulmonary involvement (Stage II, with or without hypoxemia), and less frequently to systemic inflammation (Stage III). In addition to modeling the stages of disease progression along with diagnostic testing, we have also created a treatment algorithm that considers age, comorbidities, clinical presentation, and disease progression to suggest drug classes or treatment modalities. This paper presents the first evidence-based recommendations for individualized treatment for COVID-19.

ModelHeart: a resident-led implementation of metrics to reduce 30-day heart failure readmissions.

Hospitals have been penalised for excessive 30-day readmissions via Medicare payment penalties. As such there has been keen interest in finding ways of reducing readmissions. The basis for the study was a retrospective review of heart failure (HF) admissions at Cleveland Clinic Florida from 1 January 2010 to 31 December 2010. The result of this was a set of metrics associated with >30 day span between admissions: N-terminal pro-brain natriuretic peptide by at least 23%, fluid balance of ≤-1.3 L and sodium ≥135 mEq/L on discharge. The ModelHeart trial was a prospective resident-led validation of these criteria that consisted of education about and implementation of these metrics. A total of 200 patients carrying a diagnosis of HF, admitted between 1 November 2012 and 14 January 2014 were included in the trial. Of the 200 enrolled patients, 94% of discharged patients met at least one criteria, 58% met at least two criteria and 20% met all three. There were forty-eight all-cause 30-day readmissions. 30-day readmission rates between themore than equal to two criteria cohort and the remaining patients were not significantly different (p=0.71). Overall readmission rates were higher in the 2011-2012 retrospective patient pool (19%) versus the ModelHeart cohort (11%), and proportional differences were significant, (p<0.001). This may suggest that education provided sufficient awareness to alter discharge practices outside of the measured metrics. However, the lack of significant differences between groups with respect to discharge metrics suggests that further study is needed to refine the metrics and that reducing HF readmissions involves a continuum of care that spans the inpatient and outpatient setting.

Can adjusting BMI for age and sex provide for a better predictor of colonic neoplasia?

OBJECTIVE: The aim of this study was to evaluate the influence of BMI on colonic neoplasia in average-risk patients aged between 40 and 59 years, analyzed by sex. METHODS: A total of 4443 patients aged between 40 and 59 years undergoing a first-time screening or average-risk colonoscopy were included in this study. Data on demographics, smoking, and BMI were collected and correlated to the presence of adenomas and advanced adenomas. RESULTS: We evaluated 1197 colonoscopies in patients aged between 40 and 49 years, and 3246 in those aged between 50 and 59 years. Among men between 40 and 49 years, increasing BMI [odds ratio (OR)=1.05, 95% confidence interval (CI): 1.00-1.09] and BMI of at least 27 (OR=1.95, 95% CI: 1.15-3.29) were predictors of adenomas. Younger men with a BMI of at least 27 were more likely to have proximal adenomas (OR=2.23, 95% CI: 1.14-4.37) but not advanced adenomas. There was no relation between BMI and adenomas in younger women. Among women aged between 50 and 59 years, increasing BMI (OR=1.03, 95% CI: 1.01-1.05) and a BMI of at least 24 (OR=1.43, 95% CI: 1.06-2.94) was found to be correlated with adenomas, and increasing BMI was also found to be associated with proximal adenomas (OR=1.67, 95% CI: 1.13-2.45). Among men aged between 50 and 59 years, there was no relation between BMI and adenomas, but there was a positive correlation for advanced adenomas (OR=1.05, 95% CI: 1.002-1.09). Among women aged between 50 and 59 years, BMI was not predictive of advanced adenomas. CONCLUSION: The association between BMI and adenoma differs by age and sex. If BMI is utilized to refine screening practices for colorectal cancer, its influence on sex and age should be taken into account.

Efficacy of morning-only 4 liter sulfa free polyethylene glycol vs 2 liter polyethylene glycol with ascorbic acid for afternoon colonoscopy.

AIM: To compare the bowel cleansing efficacy of same day ingestion of 4-L sulfa-free polyethylene glycol (4-L SF-PEG) vs 2-L polyethylene glycol solution with ascorbic acid (2-L PEG + Asc) in patients undergoing afternoon colonoscopy. METHODS: 206 patients (mean age 56.7 years, 61% male) undergoing outpatient screening or surveillance colonoscopies were prospectively randomized to receive either 4-L SF-PEG (n = 104) or 2-L PEG + Asc solution (n = 102). Colonoscopies were performed by two blinded endoscopists. Bowel preparation was graded using the Ottawa scale. Each participant completed a satisfaction and side effect survey. RESULTS: There was no difference in patient demographics amongst groups. 4-L SF-PEG resulted in better Ottawa scores compared to 2-L PEG + Asc, 4.2 vs 4.9 (P = 0.0186); left colon: 1.33 vs 1.57 respectively (P = 0.0224), right colon: 1.38 vs 1.63 respectively (P = 0.0097). No difference in Ottawa scores was found for the mid colon or amount of fluid. Patient satisfaction was similar for both arms but those assigned to 4-L SF-PEG reported less bloating: 23.1% vs 11.5% (P = 0.0235). Overall polyp detection, adenomatous polyp and advanced adenoma detection rates were similar between the two groups. CONCLUSION: Morning only 4-L SF-PEG provided superior cleansing with less bloating as compared to 2-L PEG + Asc bowel preparation for afternoon colonoscopy. Thus, future studies evaluating efficacy of morning only preparation for afternoon colonoscopy should use 4-L SF-PEG as the standard comparator.

Risk of Clostridium difficile infection in hospitalized patients receiving metronidazole for a non-C difficile infection.

BACKGROUND & AIMS: Antibiotics often are given to prevent infections but also constitute a risk factor for Clostridium difficile infection (CDI). Metronidazole is an effective treatment for CDI. We investigated whether prophylactic administration of metronidazole to patients before they receive other antibiotics reduces the risk of CDI. METHODS: We performed a retrospective cohort analysis of data collected from 12,026 high-risk patients admitted to Cleveland Clinic Foundation Hospitals from 2008 through 2012. High-risk patients were defined as age 55 or older who received a broad-spectrum antibiotic (piperacillin-tazobactam or ciprofloxacin) and a gastric acid suppressant (a proton pump inhibitor or a histamine-2 receptor blocker) during their hospitalization. Development of CDI was compared between patients who received metronidazole for non-CDI indications before broad-spectrum antibiotics (n = 811) and those who did not (n = 11,215). Logistic regression was used to control for patient demographics and comorbidities. RESULTS: The rate of CDI was 1.4% (n = 11) among the patients who received metronidazole for non-CDI indications and 6.5% (n = 728) among those who did not. This was observed to be an 80% reduction in CDI among patients who received metronidazole (odds ratio, 0.21; 95% confidence interval, 0.11-0.38; P < .001), adjusted for age, sex, and comorbidities. CONCLUSIONS: Based on a retrospective analysis, metronidazole might be used to prevent CDI in certain high-risk patients. Prospective controlled trials are necessary before making further recommendations.

The day of the week does not affect the adenoma detection rate.

BACKGROUND: The role of operator fatigue on adenoma detection rate (ADR) is still controversial. AIMS: The purpose of this study was to determine if fatigue towards the end of the week affects the ADR. METHODS: A retrospective chart review of consecutive colonoscopies was done at a tertiary care teaching institution. Patients 45 years of age or older undergoing screening or surveillance colonoscopy from June 2007 to August 2010 were included in the study. RESULTS: A total of 3,085 patients were included in the study, with an overall 31 % ADR. ADR was between 31 and 32 % throughout the week, with no statistically significant variation (p = 0.8697). The total number of adenomas and advanced adenomas was also similar throughout the week (p = 0.8, p = 0.59, respectively). CONCLUSIONS: ADR is not influenced by the day of the week in which a colonoscopy is performed.

Predictors of 30-day readmission in patients hospitalized with decompensated heart failure.

BACKGROUND: Heart failure (HF) is the leading cause of hospitalizations and readmissions in the United States. Approximately one-third of patients admitted for HF are readmitted within 3 months; however, there are few markers that can identify those at highest risk for readmission. The purpose of this study was to identify clinical and laboratory markers associated with hospital readmission in decompensated HF. HYPOTHESIS: Clinical and laboratory markers are associated with readmission rates in decompensated HF. METHODS: Clinical and laboratory data from 412 patients admitted with HF were analyzed using a multivariable logistic regression analysis to find predictors of HF readmission by 30 days. RESULTS: HF readmission rates at 30 days were lowest in those with at least 2 of the following discharge criteria: net fluid reduction >1.3 L (odds ratio [OR]: 0.27, P = 0.019), serum sodium level >135 (OR: 0.46, P = 0.034), and N-terminal brain natriuretic peptide level reduction >23% (OR: 0.11, P = 0.048). In multivariate analysis, those patients meeting ≥2 criteria had a very low risk of 30-day readmission (OR: 0.10, 95% confidence interval: 0.01-0.68, P = 0.019) compared to patients who failed to meet 2 criteria. CONCLUSIONS: A negative fluid balance, normal serum sodium, and net reduction in N-terminal brain natriuretic peptide level during hospitalization may be important indices to target to help reduce the likelihood of HF readmission within 30 days.

African american race and prevalence of atrial fibrillation:a meta-analysis.

Background. It has been observed that African American race is associated with a lower prevalence of atrial fibrillation (AF) compared to Caucasian race. To better quantify the association between African American race and AF, we performed a meta-analysis of published studies among different patient populations which reported the presence of AF by race. Methods. A literature search was conducted using electronic databases between January 1999 and January 2011. The search was limited to published studies in English conducted in the United States, which clearly defined the presence of AF in African American and Caucasian subjects. A meta-analysis was performed with prevalence of AF as the primary endpoint. Results. In total, 10 studies involving 1,031,351 subjects were included. According to a random effects analysis, African American race was associated with a protective effect with regard to AF as compared to Caucasian race (odds ratio 0.51, 95% CI 0.44 to 0.59, P < 0.001). In subgroup analyses, African American race was significantly associated with a lower prevalence of AF in the general population, those hospitalized or greater than 60 years old, postcoronary artery bypass surgery patients, and subjects with heart failure. Conclusions. In a broad sweep of subjects in the general population and hospitalized patients, the prevalence of AF in African Americans is consistently lower than in Caucasians.

Management of suppurative cervical lymphadenitis in a healthy 24-year-old man.

Unilateral suppurative cervical lymphadenitis is characterized by acute onset of 1 or more tender cervical lymph nodes and can lead to fever, cellulitis, abscess formation, and bacteremia. This form of lymphadenitis is usually caused by gram-positive bacteria. The present case details the treatment of a previously healthy 24-year-old man who presented with an acutely inflamed cervical lymph node. The patient did not respond to antibiotic monotherapy or combination antibiotics but recovered rapidly after methylprednisolone and osteopathic manipulative treatment were added to his care.