Prophylactic Tranexamic Acid Prevents Postpartum Hemorrhage and Transfusions in Cesarean Deliveries: A Systematic Review and Meta-analysis.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and PPH resulting in transfusion is the most common maternal morbidity in the United States. Literature demonstrates that tranexamic acid (TXA) can reduce blood loss in cesarean deliveries; however, there is little consensus on the impact on major morbidities like PPH and transfusions. We conducted a systematic review/meta-analysis of randomized controlled trials (RCTs) to evaluate if administration of prophylactic intravenous (IV) TXA prevents PPH and/or transfusions following low-risk cesarean delivery. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Five databases were searched: Cochrane, EBSCO, Ovid, PubMed, and ClinicalKey. RCTs published in English between January 2000 and December 2021 were included. Studies compared PPH and transfusions in cesarean deliveries between prophylactic IV TXA and control (placebo or no placebo). The primary outcome was PPH, and the secondary outcome was transfusions. Random effects models were used to calculate effect size (ES) of exposure in Mantel-Haenszel risk ratios (RR). All analysis was done at a confidence level (CI) of α = 0.5. Modeling showed that TXA led to significantly less risk of PPH than control (RR: 0.43; 95% CI: 0.28-0.67). The effect on transfusion was comparable (RR: 0.39; 95% CI: 0.21-0.73). Heterogeneity was minimal (I 2 = 0%). Due to the large sample sizes needed, many RCTs are not powered to interpret TXA's effect on PPH and transfusions. Pooling these studies in a meta-analysis allows for more power and analysis but is limited by the heterogeneity of studies. Our results minimize heterogeneity while demonstrating that prophylactic TXA can lower PPH occurrence and reduce the need for blood transfusion. We suggest considering prophylactic IV TXA as the standard of care in low-risk cesarean deliveries. KEY POINTS: · Consider TXA prior to incision for singleton, term pregnancies undergoing elective cesarean.. · Prophylactic TXA is effective in preventing PPH and blood transfusions.. · Routine use of TXA has the potential to decrease transfusion-related complications and costs..

Using the Practical Robust Implementation and Sustainability Model (PRISM) to Identify and Address Provider-Perceived Barriers to Optimal Statin Prescribing and Use in Community Health Centers.

Statins are an important but underutilized therapy to prevent cardiovascular events, particularly in high-risk patients. To increase use of statin therapy in high-risk patients, the Centers for Disease Control and Prevention funded a project led by the National Association of Community Health Centers to discover reasons for statin underuse in health centers and identify possible leverage points, particularly among vulnerable and underserved patients. The project further sought to develop training and educational materials to improve statin prescribing for and acceptance in eligible high-risk patients. As a first step, investigators implemented a questionnaire to clinical providers (n = 45) at health centers participating in the project to obtain their perspective on barriers to optimal statin use. We used the practical robust implementation and sustainability model (PRISM) domains to frame the overall project and guide the development of our questionnaire. This paper summarizes top perceived barriers to patient and health system/provider statin initiation and sustainment, as well as facilitators to prescribing, using PRISM as an organizing framework. Our questionnaire yielded important suggestions related to public awareness, education materials, health information technology (HIT)/data solutions, and clinical guidelines as key factors in optimizing statin use. It also informed the design of patient education resources and provider training tools. Future directions include using the full application of the PRISM implementation science model to assess how well our educational and training resources help overcome barriers to statin use in high-risk patients, including evaluating how key contextual factors influence successful implementation.

Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers.

BACKGROUND: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled. METHODS: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). RESULTS: The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). CONCLUSIONS: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes.

Accelerating Use of Self-measured Blood Pressure Monitoring (SMBP) Through Clinical-Community Care Models.

Self-measured blood pressure monitoring (SMBP), the regular measurement of blood pressure by a patient outside the clinical setting, plus additional support, is a proven, cost-effective but underutilized strategy to improve hypertension outcomes. To accelerate SMBP use, the Centers for Disease Control and Prevention (CDC) funded the National Association of Community Health Centers, the YMCA of the USA, and Association of State and Territorial Health Officials to develop cross-sector care models to offer SMBP to patients with hypertension. The project aimed to increase the use of SMBP through the coordinated action of health department leaders, community organizations and clinical providers. From 1/31/2017 to 6/30/2018, nine health centers in Kentucky, Missouri, and New York partnered with seven local Y associations (local Y) and their local health departments to design and implement care models that adapted existing primary care SMBP practices by leveraging capacities and resources in community and public health organizations. Nine collaborative care models emerged, shaped by available community assets, strategic priorities, and organizational culture. Overall, 1421 patients were recommended for SMBP; of those, 795 completed at least one cycle of SMBP (BP measurements morning and evening for at least three consecutive days). Of those recommended for SMBP, 308 patients were referred to a local Y to receive additional SMBP and healthy lifestyle support. Community and public health organizations can be brought into the health care delivery process and can play valuable roles in supporting patients in SMBP.

Vaccination Capability Inventory of Community, Migrant, and Homeless Health Centers: A Survey Report.

CONTEXT: Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults. PROGRAM: We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders' perceptions regarding best practices and policy recommendations for adult vaccinations. IMPLEMENTATION: A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018. EVALUATION: A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided. DISCUSSION: Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

Self-Measured Blood Pressure Monitoring During the COVID-19 Pandemic: Perspectives From Community Health Center Clinicians.

ABSTRACT: The early period of the COVID-19 pandemic necessitated a rapid increase in out-of-office care. To capture the impact from COVID-19 on care for patients with hypertension, a questionnaire was disseminated to community health center clinicians. The extent, types, and causes of care delays and disruptions were assessed along with adaptations and innovations used to address them. Clinician attitudinal changes and perspectives on future hypertension care were also assessed. Of the 65 respondents, most (90.8%) reported their patients with hypertension experienced care delays or disruptions, including lack of follow-up, lack of blood pressure assessment, and missed medication refills or orders. To address care delays and disruptions for patients with hypertension, respondents indicated that their health center increased the use of telehealth or other technology, made home blood pressure devices available to patients, expanded outreach and care coordination, provided medication refills for longer periods of time, and used new care delivery options. The use of self-measured blood pressure monitoring (58.5%) and telehealth (43.1%) was identified as the top adaptations that should be sustained to increase access to and patient engagement with hypertension care; however, barriers to both remain. Policy and system level changes are needed to support value-based care models that include self-measured blood pressure and telehealth.

Secondary Vasculitis Attributable to Post-COVID Syndrome.

While the acute phase of the COVID-19 pandemic has largely come to pass, the chronic physiologic effects of the coronavirus continue to unfold. Specifically, the number of COVID-19-associated vasculitis cases has steadily increased since the onset of the pandemic. Data have shown that vasculitis may develop less than two weeks after COVID-19 or during a later onset of the disease. At this time, research has demonstrated that the novel coronavirus invades more than just the lungs; it can also attack the nervous system, cardiovascular system, and kidneys. In addition, there is a greater understanding of the pathogenesis regarding COVID-19-induced vasculitis via humoral immunity and immune complex disease. Recent case reports have shown an association between COVID-19 and secondary vasculitis. This review paper discusses case reports and data that suggest that COVID-19 may lead to specific vasculitis diseases such as giant cell arteritis, ophthalmic arteritis, aortitis, and Kawasaki-like disease. More research needs to be performed on this association to aid in diagnosis and treatment.

Are Community Health Center Patients Interested in Self-Measured Blood Pressure Monitoring (SMBP) - And Can They Do It?

INTRODUCTION: Self-measured blood pressure monitoring (SMBP) helps diagnose and manage hypertension from outside the clinic, which has implications for patient empowerment and outcomes, continuity of care, and resilience in care communities catering to vulnerable populations. METHODS: We instituted a protocol for SMBP among hypertensive patients at 9 community health centers in 3 states and administered questionnaires to patients before and after the protocol was instituted to assess knowledge and engagement with disease management, beliefs and attitudes towards, and experience doing SMBP. Questionnaires included 16 items designed to evaluate patient perceptions and beliefs about SMBP. These included a series of questions using a 5-point Likert scale, binary questions related to their perceived ability to comply with specific SMBP guidelines and open-ended questions to obtain descriptions of experiences with SMBP. RESULTS: The pre-questionnaire was completed by 478 patients and the post-questionnaire was completed by 372. Seventy-seven percent of respondents knew their ideal blood pressure and their engagement with blood pressure management increased significantly (p=0.0024) after completing the protocol. Additionally, 85% of respondents said that they had a positive experience doing SMBP. Open-ended responses revealed insight regarding why patients chose to do SMBP and factors patients appreciated about SMBP. DISCUSSION: When trained properly and supported, community health center patients are capable of and motivated to perform accurate SMBP. Our study provides evidence that health center patients can follow detailed SMBP protocols and monitor their own blood pressure from the safety of their homes, which is critical to their care continuum, particularly in days of a pandemic.

Teaching students to identify and document social determinants of health.

PURPOSE: Social determinants of health (SDH) are responsible for significant health disparities, morbidity and mortality. It is important to acculturate trainees to identify and document SDH. This can elevate their perceptions related to the importance and relevance of SDH. Documentation can encourage trainees to see SDH as factors which medical providers should address. PATIENTS AND METHODS: Researchers devised a novel approach to demonstrate the value of SDH to undergraduate medical students. Proprietary diagnostic codes for SDH and procedure codes for action taken to address them, were developed. Students were encouraged to log these into electronic records for clinical encounters. Students' voluntary use of these codes was evaluated. Additionally, students were surveyed on their familiarity with the concept of SDH, their perceptions of the importance of SDH, as well as documenting SDH, twice in the study period, and results were compared. In their second year of use, proprietary codes were compared to newly available SDH related ICD-10 codes. RESULTS: Students utilized proprietary codes more often than SDH related ICD-10 codes. Over 20,000 codes were logged. Comparison of survey items showed modest increases in students' positive perception about the role of SDH in patient health. CONCLUSION: Students' voluntary logging of SDH codes demonstrates they perceived these factors to be important and relevant to patient encounters. Future analyses will examine students' knowledge, attitudes, beliefs and practice patterns related to SDH.

One-year Prevalence, Comorbidities, and Cost of Hospitalizations for Alpha-1 Antitrypsin Deficiency among Patients with Chronic Obstructive Pulmonary Disease in the United States.

Objectives: Little is known about severe chronic obstructive pulmonary disease (COPD) exacerbations among patients with Alpha-1 Antitrypsin Deficiency (AATD). We assessed inpatients with AATD and COPD among a sample of COPD inpatients to ascertain demographic, clinical and economic differences in the course of disease and treatment. Methods: Using data from the 2009 Nationwide Inpatient Sample (NIS), we identified COPD (ICD-9-CM: 491.xx, 492.xx, or 496.xx) patients with AATD (273.4). We compared patient demographics and healthcare outcomes (eg, length of stay, inpatient death, type and number of procedures, and cost of care) between COPD patients with and without alpha-1 antitrypsin deficiency. Frequencies and percentages for patient demographics were compared using bivariate statistics (eg, chi-square test). Recognizing the non-parametric nature of length of stay and cost, we calculated median values and interquartile ranges for these variables for each group of patients. Finally, the risk of inpatient death was estimated using logistic regression. Results: Of 840 242 patients with COPD (10.8% of the NIS sample population), 0.08% (684) had a primary or secondary diagnosis code for AATD. COPD+AATD were younger (56 vs 70, p<0.0001) and as a result, less likely to be covered by Medicare (44% vs 62%, p<0.0001). AATD patients were also more likely to have comorbid non-alcoholic liver disease (7% vs 2%, p<0.0001), depression (17% vs 13%, p=0.0328), and pulmonary circulation disorders (7% vs 4%, p=0.0299). Patients with AATD had a 14% longer length of stay (IRR = 1.14, 95% CI 1.07, 1.21) and a mean cost of $1487 (p=0.0251) more than COPD inpatients without AATD. Conclusions: AATD is associated with increased mean length of stay and cost, as well as higher frequency of comorbid non-alcoholic liver disease, depression, and pulmonary circulation disorders. Future research should assess other differences between AATD and the general COPD population such as natural history of disease, treatment responsiveness and disease progression.

Cachexia among US cancer patients.

BACKGROUND: Cancer cachexia is a debilitating condition and results in poor prognosis. The purpose of this study was to assess hospitalization incidence, patient characteristics, and medical cost and burden of cancer cachexia in the US. METHODS: This study used a cross-sectional analysis of the Nationwide Inpatient Sample (NIS) for 2009. Five cancers reported to have the highest cachexia incidence were assessed. The hospitalization incidence related to cachexia was estimated by cancer type, cost and length of stay were compared, and descriptive statistics were reported for each cancer type, as well as differences being compared between patients with and without cachexia. RESULTS: Risk of inpatient death was higher for patients with cachexia in lung cancer (OR = 1.32; CI = 1.20-1.46) and in all cancers combined (OR = 1.76; CI = 1.67-1.85). The presence of cachexia increased length of stay in lung (IRR = 1.05; CI = 1.03-1.08), Kaposi's sarcoma (IRR = 1.47; CI = 1.14-1.89) and all cancers combined (IRR = 1.09; CI = 1.08-1.10). Additionally, cachectic patients in the composite category had a longer hospitalization stay compared to non-cachectic patients (3-9 days for those with cachexia and 2-7 days for those without cachexia). The cost of inpatient stay was significantly higher in cachexic than non-cachexic lung cancer patients ($13,560 vs $13 190; p < 0.0001), as well as cachexic vs non-cachexic cancer patients in general (14 751 vs 13 928; p < 0.0001). CONCLUSIONS: Cachexia increases hospitalization costs and length of stay in several cancer types. Identifying the medical burden associated with cancer cachexia will assist in developing an international consensus for recognition and coding by the medical community and ultimately an effective treatment plans for cancer cachexia.

End-stage renal disease in autosomal dominant polycystic kidney disease: a comparison of dialysis-related utilization and costs with other chronic kidney diseases.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the leading inheritable cause of end-stage renal disease (ESRD) and one of the leading causes of ESRD overall. ADPKD patients differ from the overall dialysis population; however, there is little published data regarding health care costs for ADPKD patients on dialysis. METHODS: This retrospective observational cohort study was designed to quantify health care utilization and costs for ADPKD patients with ESRD who received initial services at a single large dialysis organization between January 1, 2007 and December 31, 2009. Parallel results and baseline patient characteristics for control patients with ESRD etiologies other than ADPKD were performed for reference. Dialysis-related utilization and health care costs for patients with ADPKD in ESRD overall and during time horizons that correspond to Medicare-eligibility benchmarks were analyzed. Baseline patient characteristics were described for all patients and included demographics, comorbid illnesses, and clinical characteristics. Dialysis-related utilization, hospitalization rates, and health care costs were considered longitudinally. RESULTS: Total health care costs for ADPKD patients were high at US$51,048 per patient-year based on the overall analysis. Total health care costs were lower for ADPKD patients than for control patients on dialysis. Patients with ADPKD were generally younger, had a lower Charlson Comorbidity Index, and had lower rates of comorbid conditions, which may have contributed to the lower overall costs seen for patients with ADPKD. CONCLUSION: Health care resource utilization and costs for patients with ADPKD in ESRD requiring dialysis were high, and therapeutic interventions that can prevent or delay the progression to ESRD may increase dialysis-free life for patients with ADPKD.

Cachexia & debility diagnoses in hospitalized children and adolescents with complex chronic conditions: evidence from the Kids' Inpatient Database.

OBJECTIVE: To characterize the frequency, cost, and hospital-reported outcomes of cachexia and debility in children and adolescents with complex chronic conditions (CCCs). METHODS: We identified children and adolescents (aged ≤20 years) with CCCs, cachexia, and debility in the Kids' Inpatient Database [Healthcare Cost and Utilization Project, Agency for Healthcare Research & Quality]. We then compared the characteristics of patients and hospitalizations, including cost and duration of stay, for CCCs with and without cachexia and/or debility. We examined factors that predict risk of inpatient mortality in children and adolescents with CCCs using a logistic regression model. We examined factors that impact duration of stay and cost in children and adolescents with CCCs using negative binomial regression models. All costs are reported in US dollars in 2014 using Consumer Price Index inflation adjustment. RESULTS: We estimated the incidence of hospitalization of cachexia in children and adolescents with CCCs at 1,395 discharges during the sample period, which ranged from 277 discharges in 2003 to 473 discharges in 2012. We estimated the incidence of hospitalization due to debility in children and adolescents with CCCs at 421 discharges during the sample period, which ranged from 39 discharges in 2003 to 217 discharges in 2012. Cachexia was associated with a 60% increase in the risk of inpatient mortality, whereas debility was associated with a 40% decrease in the risk of mortality. Cachexia and debility increased duration of stay in hospital (17% and 39% longer stays, respectively). Median cost of hospitalization was $15,441.59 and $23,796.16 for children and adolescents with cachexia and debility, respectively. CONCLUSIONS: Incidence of hospitalization for cachexia in children and adolescents with CCCs is less than that for adults but the frequency of cachexia diagnoses increased over time. Estimates of the incidence of hospitalization with debility in children and adolescents with CCCs have not been reported, but our study demonstrates that the frequency of these discharges is also increasing.

Identification of a major QTL that alters flowering time at elevated [CO(2)] in Arabidopsis thaliana.

BACKGROUND: The transition from vegetative to reproductive stages marks a major milestone in plant development. It is clear that global change factors (e.g., increasing [CO(2)] and temperature) have already had and will continue to have a large impact on plant flowering times in the future. Increasing atmospheric [CO(2)] has recently been shown to affect flowering time, and may produce even greater responses than increasing temperature. Much is known about the genes influencing flowering time, although their relevance to changing [CO(2)] is not well understood. Thus, we present the first study to identify QTL (Quantitative Trait Loci) that affect flowering time at elevated [CO(2)] in Arabidopsis thaliana. METHODOLOGY/PRINCIPAL FINDINGS: We developed our mapping population by crossing a genotype previously selected for high fitness at elevated [CO(2)] (SG, Selection Genotype) to a Cape Verde genotype (Cvi-0). SG exhibits delayed flowering at elevated [CO(2)], whereas Cvi-0 is non-responsive to elevated [CO(2)] for flowering time. We mapped one major QTL to the upper portion of chromosome 1 that explains 1/3 of the difference in flowering time between current and elevated [CO(2)] between the SG and Cvi-0 parents. This QTL also alters the stage at which flowering occurs, as determined from higher rosette leaf number at flowering in RILs (Recombinant Inbred Lines) harboring the SG allele. A follow-up study using Arabidopsis mutants for flowering time genes within the significant QTL suggests MOTHER OF FT AND TFL1 (MFT) as a potential candidate gene for altered flowering time at elevated [CO(2)]. CONCLUSION/SIGNIFICANCE: This work sheds light on the underlying genetic architecture that controls flowering time at elevated [CO(2)]. Prior to this work, very little to nothing was known about these mechanisms at the genomic level. Such a broader understanding will be key for better predicting shifts in plant phenology and for developing successful crops for future environments.