Failure of vital sign normalization is more strongly associated than single measures with mortality and outcomes.

BACKGROUND: Modified Early Warning Systems (MEWS) scores offer proxies for morbidity and mortality that are easily acquired, but there are limited data on what changing MEWS scores within the ED indicate. We examined the correlation of changing MEWS scores during resuscitation in the ED and in-hospital morbidity and mortality. METHODS: We conducted a retrospective analysis on medical ED patients with simplified MEWS scores (without urine output or mental status) admitted to a single academic tertiary care center over one year. Triage-to-Last delta MEWS score and Triage-to-Max delta MEWS scores were calculated and correlated to in-hospital mortality, ICU admission, length of stay (LOS) and diagnosis of sepsis. RESULTS: Our analysis included 8322 ED patients with an ICU admission rate of 17% and a mortality rate of 2%. Every point of worsened MEWS after triage was more strongly associated with all-cause mortality (OR 2.41, 95% CI 1.96-2.97) than triage MEWS alone (OR 1.33, 95% CI 1.23-1.44; p < 0.001). Likewise, each point of worsened MEWS was associated with increased odds of ICU admission (Triage-to-Last: OR 2.12, 95% CI 1.92-2.33 and Triage-to-Max: OR 1.52, 95% CI 1.45-1.60, respectively). Among patients with suspected infection, similar associations are found. CONCLUSIONS: Dynamic vital signs in the emergency department, as categorized by delta MEWS, and failure to normalize abnormalities, were associated with increased mortality, ICU admission, LOS, and the diagnosis of sepsis. Our results suggest that MEWS scores that do not normalize, from triage onward, are more strongly associated with outcome than any single score.

Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality.

IMPORTANCE: Transformation of US health care from volume to value requires meaningful quantification of costs and outcomes at the level of individual patients. OBJECTIVE: To measure the association of a value-driven outcomes tool that allocates costs of care and quality measures to individual patient encounters with cost reduction and health outcome optimization. DESIGN, SETTING, AND PARTICIPANTS: Uncontrolled, pre-post, longitudinal, observational study measuring quality and outcomes relative to cost from 2012 to 2016 at University of Utah Health Care. Clinical improvement projects included total hip and knee joint replacement, hospitalist laboratory utilization, and management of sepsis. EXPOSURES: Physicians were given access to a tool with information about outcomes, costs (not charges), and variation and partnered with process improvement experts. MAIN OUTCOMES AND MEASURES: Total and component inpatient and outpatient direct costs across departments; cost variability for Medicare severity diagnosis related groups measured as coefficient of variation (CV); and care costs and composite quality indexes. RESULTS: From July 1, 2014, to June 30, 2015, there were 1.7 million total patient visits, including 34 000 inpatient discharges. Professional costs accounted for 24.3% of total costs for inpatient episodes ($114.4 million of $470.4 million) and 41.9% of total costs for outpatient visits ($231.7 million of $553.1 million). For Medicare severity diagnosis related groups with the highest total direct costs, cost variability was highest for postoperative infection (CV = 1.71) and sepsis (CV = 1.37) and among the lowest for organ transplantation (CV ≤ 0.43). For total joint replacement, a composite quality index was 54% at baseline (n = 233 encounters) and 80% 1 year into the implementation (n = 188 encounters) (absolute change, 26%; 95% CI, 18%-35%; P < .001). Compared with the baseline year, mean direct costs were 7% lower in the implementation year (95% CI, 3%-11%; P < .001) and 11% lower in the postimplementation year (95% CI, 7%-14%; P < .001). The hospitalist laboratory testing mean cost per day was $138 (median [IQR], $113 [$79-160]; n = 2034 encounters) at baseline and $123 (median [IQR], $99 [$66-147]; n = 4276 encounters) in the evaluation period (mean difference, -$15; 95% CI, -$19 to -$11; P < .001), with no significant change in mean length of stay. For a pilot sepsis intervention, the mean time to anti-infective administration following fulfillment of systemic inflammatory response syndrome criteria in patients with infection was 7.8 hours (median [IQR], 3.4 [0.8-7.8] hours; n = 29 encounters) at baseline and 3.6 hours (median [IQR], 2.2 [1.0-4.5] hours; n = 76 encounters) in the evaluation period (mean difference, -4.1 hours; 95% CI, -9.9 to -1.0 hours; P = .02). CONCLUSIONS AND RELEVANCE: Implementation of a multifaceted value-driven outcomes tool to identify high variability in costs and outcomes in a large single health care system was associated with reduced costs and improved quality for 3 selected clinical projects. There may be benefit for individual physicians to understand actual care costs (not charges) and outcomes achieved for individual patients with defined clinical conditions.

Rivaroxaban for the Long-term Treatment of Spontaneous Ovarian Vein Thrombosis Caused by Factor V Leiden Homozygosity.

OBJECTIVE: To report a case where rivaroxaban was used in the management of an ovarian vein thrombosis and to briefly review the literature, pathophysiology, and clinical implications therein. CASE SUMMARY: A 30-year-old previously healthy woman was diagnosed with acute, spontaneous, left-ovarian vein thrombosis (OVT) with proximal extension into the renal vein. After initial catheter-directed thrombolysis with tPA, angioplasty of the left renal vein, and heparinoid treatment, rivaroxaban was begun for long-term anticoagulation. Three months after her index event she was symptom free, with complete resolution of her thrombosis and no adverse effects or bleeding complications from rivaroxaban. To our knowledge, this is the first report of OVT successfully treated with rivaroxaban. DISCUSSION: OVT is a rare but potentially fatal cause of abdominal pain that may pose diagnostic and therapeutic dilemmas. Factor V Leiden (FVL) homozygosity, an uncommon but severe inherited thrombophilia, increases the risk of thrombosis by approximately 50- to 80-fold. This case report and accompanying literature review highlight important clinical pearls related to the diagnosis and management of OVT and inherited thrombophilias. CONCLUSIONS: This clinical vignette adds to the published literature suggesting that novel oral anticoagulants, such as rivaroxaban, may eventually emerge as an alternative to vitamin K antagonists for the treatment of extra-axial thromboses. Reporting these cases is important because their prevalence is low outside of specialized referral centers, and thus, dissemination of these experiences may help other providers in treating their patients.

Hospital-Level Care at Home for Acutely Ill Adults in Rural Settings: Proof of Concept.

Residents in rural areas face barriers to accessing acute care. Rural home hospital (RHH) or delivery of acute care at home could represent an important clinical care model. This study assessed the feasibility and acceptability of RHH as a substitute to traditional hospital care. Patients were cared for by a remote RHH attending physician and an RHH registered nurse deployed to the home. The study team conducted daily check-ins with RHH clinicians to assess workflows for completion. Surveys assessed patient experience and qualitative interviews assessed perceived acceptability, safety, and quality of care. We completed qualitative analysis of the interviews and coded qualitative data into domains and subdomains through an iterative process. RHH was successfully deployed to three acutely ill patients in rural Utah. RHH admission, daily care, and discharge processes were accomplished for each patient. From qualitative analysis, we identified four domains: (1) Perceived comfort level during RHH admission, (2) Perceived safety during RHH admission, (3) Perceived quality of care during RHH admission, and (4) Perception of RHH workflows. We found acute care was delivered to rural homes with satisfactory patient and clinician experience. Team dynamics, technology build, robust clinical and operational workflows, and care coordination were important to a successful admission. Learnings from this study can inform program design and training for RHH teams and startup for larger RHH evaluation. Home hospital care is expanding rapidly in the United States and RHH could represent an important clinical care model.

A Retrospective Cohort Study Evaluating the Use of the Modified Early Warning Score to Improve Outcome Prediction in Neurosurgical Patients.

Introduction The modified early warning score (mEWS) has been used to identify decompensating patients in critical care settings, potentially leading to better outcomes and safer, more cost-effective patient care. We examined whether the admission or maximum mEWS of neurosurgical patients was associated with outcomes and total patient costs across neurosurgical procedures. Methods This retrospective cohort study included all patients hospitalized at a quaternary care hospital for neurosurgery procedures during 2019. mEWS were automatically generated during a patient's hospitalization from data available in the electronic medical record. Primary and secondary outcome measures were the first mEWS at admission, maximum mEWS during hospitalization, length of stay (LOS), discharge disposition, mortality, cost of hospitalization, and patient biomarkers (i.e., white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin). Results In 1,408 patients evaluated, a mean first mEWS of 0.5 ± 0.9 (median: 0) and maximum mEWS of 2.6 ± 1.4 (median: 2) were observed. The maximum mEWS was achieved on average one day (median = 0 days) after admission and correlated with other biomarkers (p < 0.0001). Scores correlated with continuous outcomes (i.e., LOS and cost) distinctly based on disease types. Multivariate analysis showed that the maximum mEWS was associated with longer stay (OR = 1.8; 95% CI = 1.6-1.96, p = 0.0001), worse disposition (OR = 0.82, 95% CI = 0.71-0.95, p = 0.0001), higher mortality (OR = 1.7; 95% CI = 1.3-2.1, p = 0.0001), and greater cost (OR = 1.2, 95% CI = 1.1-1.3, p = 0.001). Machine learning algorithms suggested that logistic regression, naïve Bayes, and neural networks were most predictive of outcomes. Conclusion mEWS was associated with outcomes in neurosurgical patients and may be clinically useful. The composite score could be integrated with other clinical factors and was associated with LOS, discharge disposition, mortality, and patient cost. mEWS also could be used early during a patient's admission to stratify risk. Increase in mEWS scores correlated with the outcome to a different degree in distinct patient/disease types. These results show the potential of the mEWS to predict outcomes in neurosurgical patients and suggest that it could be incorporated into clinical decision-making and/or monitoring of neurosurgical patients during admission. However, further studies and refinement of mEWS are needed to better integrate it into patient care.

Using CDS Hooks to increase SMART on FHIR app utilization: a cluster-randomized trial.

OBJECTIVE: HL7 SMART on FHIR apps have the potential to improve healthcare delivery and EHR usability, but providers must be aware of the apps and use them for these potential benefits to be realized. The HL7 CDS Hooks standard was developed in part for this purpose. The objective of this study was to determine if contextually relevant CDS Hooks prompts can increase utilization of a SMART on FHIR medical reference app (MDCalc for EHR). MATERIALS AND METHODS: We conducted a 7-month, provider-randomized trial with 70 providers in a single emergency department. The intervention was a collection of CDS Hooks prompts suggesting the use of 6 medical calculators in a SMART on FHIR medical reference app. The primary outcome was the percentage of provider-patient interactions in which the app was used to view a recommended calculator. Secondary outcomes were app usage stratified by individual calculators. RESULTS: Intervention group providers viewed a study calculator in the app in 6.0% of interactions compared to 2.6% in the control group (odds ratio = 2.45, 95% CI, 1.2-5.2, P value .02), an increase of 130%. App use was significantly greater for 2 of 6 calculators. DISCUSSION AND CONCLUSION: Contextually relevant CDS Hooks prompts led to a significant increase in SMART on FHIR app utilization. This demonstrates the potential of using CDS Hooks to guide appropriate use of SMART on FHIR apps and was a primary motivation for the development of the standard. Future research may evaluate potential impacts on clinical care decisions and outcomes.

Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis.

OBJECTIVE: The objective of this study was to assess the clinical and financial impact of a quality improvement project that utilized a modified Early Warning Score (mEWS)-based clinical decision support intervention targeting early recognition of sepsis decompensation. MATERIALS AND METHODS: We conducted a retrospective, interrupted time series study on all adult patients who received a diagnosis of sepsis and were exposed to an acute care floor with the intervention. Primary outcomes (total direct cost, length of stay [LOS], and mortality) were aggregated for each study month for the post-intervention period (March 1, 2016-February 28, 2017, n = 2118 visits) and compared to the pre-intervention period (November 1, 2014-October 31, 2015, n = 1546 visits). RESULTS: The intervention was associated with a decrease in median total direct cost and hospital LOS by 23% (P = .047) and .63 days (P = .059), respectively. There was no significant change in mortality. DISCUSSION: The implementation of an mEWS-based clinical decision support system in eight acute care floors at an academic medical center was associated with reduced total direct cost and LOS for patients hospitalized with sepsis. This was seen without an associated increase in intensive care unit utilization or broad-spectrum antibiotic use. CONCLUSION: An automated sepsis decompensation detection system has the potential to improve clinical and financial outcomes such as LOS and total direct cost. Further evaluation is needed to validate generalizability and to understand the relative importance of individual elements of the intervention.

Improving Physician Communication With Patients as Measured by HCAHPS Using a Standardized Communication Model.

Physicians often fail to communicate well with patients. The objective of this retrospective controlled interrupted time series study was to evaluate the impact of a standardized communication intervention to improve physician communication. All patients ages 18 years or older (N = 7739 visits) admitted to University of Utah Health Care in Salt Lake City, Utah, from July 1, 2012, to June 31, 2014, were included. Obstetrics, rehabilitation, and psychiatric patients were excluded. The primary outcome was the percentage of patients who answered "Always" to all HCAHPS questions regarding physician-patient communication. Among the intervention group, the primary outcome increased from 56% to 63% ( P = .014, N = 1021) while remaining stable for the control group (65% to 66%, P = .6, N = 6718). The downward trend reversed after the intervention (-0.6% to +1.7% per month, P < .001). Standardized communication was associated with improvement in physician communication HCAHPS scores.

Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs.

BACKGROUND: Inappropriate laboratory testing is a contributor to waste in healthcare. OBJECTIVE: To evaluate the impact of a multifaceted laboratory reduction intervention on laboratory costs. DESIGN: A retrospective, controlled, interrupted time series (ITS) study. SETTING: University of Utah Health Care, a 500-bed academic medical center in Salt Lake City, Utah. POPULATION: All patients 18 years or older admitted to the hospital to a service other than obstetrics, rehabilitation, or psychiatry. INTERVENTION: Multifaceted quality-improvement initiative in a hospitalist service including education, process change, cost feedback, and financial incentive. MEASUREMENTS: Primary outcomes of lab cost per day and per visit. Secondary outcomes of number of basic metabolic panel (BMP), comprehensive metabolic panel (CMP), complete blood count (CBC), and prothrombin time/international normalized ratio tests per day; length of stay (LOS); and 30-day readmissions. RESULTS: A total of 6310 hospitalist patient visits (intervention group) were compared to 25,586 nonhospitalist visits (control group). Among the intervention group, the unadjusted mean cost per day was reduced from $138 before the intervention to $123 after the intervention (P < 0.001), and the unadjusted mean cost per visit decreased from $618 to $558 (P = 0.005). The ITS analysis showed significant reductions in cost per day, cost per visit, and the number of BMP, CMP, and CBC tests per day (P = 0.034, 0.02, <0.001, 0.004, and <0.001). LOS was unchanged and 30-day readmissions decreased in the intervention group. CONCLUSION: A multifaceted approach to laboratory reduction demonstrated a significant reduction in laboratory cost per day and per visit, as well as common tests per day at a major academic medical center. Journal of Hospital Medicine 2016;11:348-354. © 2016 Society of Hospital Medicine.

Delayed addition of glucocorticoids selectively suppresses cytokine production in stimulated human whole blood.

Glucocorticoids (GC) are potent drugs proven to effectively treat inflammatory diseases, although patients typically begin therapy after the onset of symptoms. Clinical studies with cytokine inhibitors prove that these mediators drive inflammatory responses in diseases such as rheumatoid arthritis and Crohn's disease. Despite the clear sequence of cytokine-induced inflammation followed by effective GC treatment, most basic science investigations have examined the ability of GC to prevent an inflammatory response rather than halt its progression. The current studies used the Toll-like receptor 2 (TLR2) agonist palmitoyl(3)-cysteine-serine-lysine(4) (PAM) or the TLR4 agonist lipopolysaccharide (LPS) to stimulate human whole blood and determine whether postponing the addition of the GC dexamethasone (DEX) limits its ability to decrease cytokine production. Twenty-four hours after stimulation, tumor necrosis factor (TNF), interleukin-1beta (IL-1beta), IL-6, and IL-8 levels were measured, in addition to the cytokine inhibitors IL-1 soluble receptor II (SRII), IL-1 receptor antagonist, and TNF SRII. LPS rapidly induced all of the proinflammatory mediators over 24 h while failing to induce any of the cytokine inhibitors. PAM stimulation also induced IL-1beta, IL-6, and IL-8. Concomitant addition of DEX plus LPS or PAM significantly suppressed all cytokine levels. Delaying the addition of DEX until 6 h after LPS stimulation failed to decrease TNF or IL-6. In contrast, delayed DEX addition significantly suppressed PAM-induced IL-1beta, IL-6, or IL-8 and also suppressed LPS-induced IL-1beta and IL-8. Our results show that cytokines which typically increase in concentration between 6 and 24 h after stimulation were significantly suppressed by the addition of DEX 6 h after stimulation.