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Helicopter transport can allow trauma patients to reach definitive treatment rapidly, but its appropriate utilization for interfacility transfer to a pediatric trauma center (PTC) has not been well evaluated. This study evaluated differences in variables associated with transport type and intervention at a PTC between helicopter and ground transport for interfacility trauma transfers.This retrospective study evaluated pediatric (18 years old) trauma patients transferred to a rural PTC over a 5-year period. Records (n = 423) were evaluated for transport type, injuries, mechanism, interventions (eg, operations, transfusions, intubation), and treatment time points. Multiple logistic regression and Cox regression survival analyses were performed to evaluate associations with type of transport and interventions.Thirty-five percent of patients received intervention at the PTC, with no significant difference between transport types. Helicopter transport was associated with transport distance, respiratory rate greater than 30 breaths/min, pedestrian struck by auto, subdural hematoma, epidural hematoma, pneumothorax, solid organ injury, and vascular compromise/open fracture. Intervention was associated with epidural hematoma, extremity and pelvic fractures, vascular compromise/open fracture, penetrating neck/trunk injury, and complex laceration. Cox regression at less than 6, less than 4, and less than 2 hours after arrival at the PTC demonstrated similar intervention associations. Helicopter transport also correlated with intervention at these time points.Most pediatric trauma patients transferred by helicopter did not require interventions. Epidural hematoma, vascular compromise/open fracture, and penetrating neck/trunk injuries predicted prompt interventions (2 hours) and may have benefited from helicopter transport. There was a disparity between the perceived need for rapid transport and the need for urgent interventions.

Physician consultation in the Emergency Department (ED) can account for a significant portion of ED length of stay, which can lead to poor clinical outcomes.The purpose of this study was to determine whether an institutional guideline could lead to a reduction in time between consult request and admission decision. This guideline codified a 90-min expected time interval to arrive and complete an admission disposition where the consulting and admitting service were the same in an academic ED with weekly audits and reports to departmental chairs and hospital administrators.This was a study of consultation times of patients who presented to an academic ED 6 months before the adoption of an institutional guideline and 6 months after the adoption of the guideline. Data measurement in both periods included the length of time from ED consult order to admission disposition, time of ED discharge, number of ED consultations (single and multiple), ED admissions, and the hospital discharge time of admitted patients.Physician consult response time decreased from 121 min to 100 min (p0.0001), and patients left the ED 18 min earlier (p = 0.0221) after implementation of the consultation guideline despite more ED visits, consultations, and admissions in the post-implementation time period. Patients were discharged from the inpatient setting 50 min later (p0.0001) after implementation of the guideline.An institutional guideline codifying timely ED consultations led to a significant reduction in the time from ED consultation to admission disposition while also allowing patients to leave the ED earlier in a high-occupancy academic medical center. However, the discharge time of admitted hospital patients was later after implementation of the guideline.

ObjectiveData from the Surveillance Epidemiology and End Results Medicare-linked database were used to estimate the incidence of and risk factors associated with recurrent thyroid cancer, and to assess the impact of recurrence on mortality following diagnosis, controlling for mortality as a competing risk.DesignWe identified 2883 patients over 65 years of age diagnosed with a single, primary well-differentiated thyroid cancer between 1995 and 2007. A recurrence was considered if the patient had evidence of I-131 therapy, imaging for metastatic thyroid carcinoma, or complete thyroidectomy beyond 6 months of diagnosis. Competing risk regressions were performed using Cox proportional hazards models with 1- and 2-year landmarks.ResultsRecurrence was observed in 1117 (39%) of the 2883 patients in the cohort. Age, stage, and treatment status were significant risk factors for developing recurrent disease (PP=0.03) than patients with no recurrence.ConclusionsThe rate of recurrence of well-differentiated thyroid carcinomas in this sample of elderly patients was 39%. Extent of disease and older age negatively impacted the risk of recurrence from differentiated thyroid cancer. In these data, patients with follicular histology and a recurrence were less likely to die, suggesting that mortality and recurrence are competing risks. These data should be taken into account with individualized treatment strategies for elderly patients with recurrent malignant thyroid disease.

A relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003.Data from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125-299], and low [125]) and surgeon volume categories (high [≥50] and low [50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity.High-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year.In Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.

For rectal cancer, it is unknown how use of radiation, treatment cost, and survival differ based on hospital teaching designation.Private insurance claims data linked with the Pennsylvania Cancer Registry were used to identify rectal cancer patients undergoing surgery from 2004 to 2006. Patients with missing data of interest were excluded. Hospitals were characterized as follows: large (≥200 beds) versus small size (200 beds), teaching versus nonteaching, and urban versus rural. Logistic regression was used to model the use of neoadjuvant radiotherapy, and Cox proportional hazards models were used to compare cancer-specific survival between hospital types.A total of 432 patients were analyzed. There was no difference in the distribution of cancer stages among the various hospital types (all p 0.20). Teaching hospitals were associated with significantly higher utilization of neoadjuvant radiotherapy for stage II and III cancers compared with nonteaching facilities (57 vs. 28 %; p 0.0001). On multivariate analysis, teaching status was the only hospital designation associated with use of neoadjuvant radiation (p 0.001); hospital size and rural/urban designation were not significant. Nonteaching hospitals were more likely to use adjuvant radiotherapy for stage II and III disease (13 vs. 30 %; p 0.01). Teaching hospitals had lower odds of death from rectal cancer when evaluating all stages [hazard ratio (HR) = 0.35; p 0.0001] with similar costs of inpatient treatment (teaching: US $30,769 versus nonteaching: US $26,892; p = 0.22).Teaching designation was associated with higher incidence of neoadjuvant radiotherapy for stage II and III disease, with improved cancer-specific survival compared with nonteaching hospitals, and with similar treatment costs.

After neoadjuvant chemoradiotherapy for rectal cancer, the interpretation of surgical pathology poses difficulties in deciding the need for adjuvant chemotherapy (AC). The aim of this study was to determine whether there is a survival benefit to providing AC in patients with node-negative disease on surgical pathology. Patients with clinical stage II and III rectal adenocarcinoma who received neoadjuvant chemoradiation and definitive surgical resection from 2006 to 2012 were identified in the National Cancer Data Base. Patients were stratified by both receipt of AC and nodal status on surgical pathology. Propensity score matching was used to form two cohorts (AC vs. no AC) with otherwise balanced characteristics. Overall survival was compared by Kaplan–Meier analysis, and multivariable survival analysis was performed by a Weibull model. After propensity score matching, 4172 patients who received adjuvant therapy (2645 node negative and 1527 node positive) and 4172 patients who did not receive adjuvant therapy (3063 node negative and 1109 node positive) were identified. Among patients with either node-negative or node-positive disease, the use of AC was associated with a significant improvement in overall survival. These results were also observed after using a multivariable survival model to control for clinical stage as well as patient- and facility-related characteristics. In both patients with node-negative and node-positive disease on surgical pathology, the use of AC is associated with a survival benefit. In the absence of contraindications, AC should continue to be routinely recommended to patients after neoadjuvant chemoradiotherapy for locally advanced rectal cancers.

Chronic insomnia is associated with disabling symptoms and decrements in functional performance. It may contribute to the development of heart failure (HF) and incident mortality. In our previous work, cognitive-behavioral therapy for insomnia (CBT-I), compared to HF self-management education, provided as an attention control condition, was feasible, acceptable, and had large effects on insomnia and fatigue among HF patients.The purpose of this randomized controlled trial (RCT) is to evaluate the sustained effects of group CBT-I compared with HF self-management education (attention control) on insomnia severity, sleep characteristics, daytime symptoms, symptom clusters, functional performance, and health care utilization among patients with stable HF. We will estimate the cost-effectiveness of CBT-I and explore the effects of CBT-I on event-free survival (EFS).Two hundred participants will be randomized in clusters to a single center parallel group (CBT-I vs. attention control) RCT. Wrist actigraphy and self-report will elicit insomnia, sleep characteristics, symptoms, and functional performance. We will use the psychomotor vigilance test to evaluate sleep loss effects and the Six Minute Walk Test to evaluate effects on daytime function. Medical record review and interviews will elicit health care utilization and EFS. Statistical methods will include general linear mixed models and latent transition analysis. Stochastic cost-effectiveness analysis with a competing risk approach will be employed to conduct the cost-effectiveness analysis.The results will be generalizable to HF patients with chronic comorbid insomnia and pave the way for future research focused on the dissemination and translation of CBT-I into HF settings.

BACKGROUND Patients admitted with Clostridium difficile infection are managed in a variety of settings. If their care is inadequate, these patients can rapidly deteriorate. OBJECTIVE The purpose of this study was to evaluate whether mortality for patients admitted with C difficile differed between medical and general/colorectal surgery services. DESIGN This was a retrospective cohort study with multivariable logistic regression used to evaluate the effect of admitting service on in-hospital mortality rates, with propensity score matching used to validate this relationship. SETTINGS The study was conducted at a single, tertiary care center. PATIENTS Inpatients with a positive C difficile stool test within 24 hours of admission to medical or surgical services were identified (2005-2015) using institutional electronic data sources. MAIN OUTCOME MEASURE We measured inpatient mortality rate. RESULTS Of 1175 patients, 985 (83%) were admitted to medical services, whereas 190 (17%) were admitted by surgeons. Medical patients were older (63.9 vs 58.9 years; p = 0.001) and had a mean of 0.6 additional comorbidities (p < 0.001); cohorts were similar regarding vasopressors, peak white blood cell counts, and rate of intensive care unit admissions. Mortality was lower among surgery patients (2.6% vs 6.8%; p = 0.028), and logistic regression demonstrated lower odds of mortality for this group OR = 0.18 (95% CI, 0.05-0.58)). After propensity score matching for age, comorbidities, and severity of disease, this difference was confirmed (2.6% vs. 9.5%). A higher incidence of total colectomy for surgery patients (14.2% vs 0.4%) was a causal factor in their longer lengths of stay and higher total hospital costs. The time between orders for stool testing and metronidazole therapy was shorter in the surgery group (1.8 vs 3.8 hours; p = 0.002), although this trend was not observed with vancomycin therapy. LIMITATIONS This was a retrospective study from a single institution, thereby limiting generalizability, with a lack of information regarding premorbid creatinine levels, ileus, or megacolon. CONCLUSIONS In-hospital mortality rates for patients admitted with C difficile were lower on surgery services, perhaps in part related to higher colectomy rates.

Background Surgical resection and chemotherapy offer the only chance of long-term survival for pancreatic cancer. Neoadjuvant therapy (NAT) is increasingly used to optimize outcomes. Trends in NAT utilization and short-term outcomes in resected pancreatic cancer were evaluated. Methods The National Cancer Database (2003 to 2011) was analyzed for pancreatic cancer patients who underwent surgery ± NAT, evaluating utilization, 30- and 90-day mortality, hospital readmissions, and length of stay (LOS). Results About 16,007 underwent initial surgery and 1,736 received NAT. Over the past decade, initial surgery and multimodality NAT have steadily decreased, whereas the use of neoadjuvant radiation has remained low and the use of neoadjuvant chemotherapy (neoCT) has steadily increased. Thirty- and 90-day mortality rates and hospital readmissions were significantly higher for NAT vs initial surgery on univariate analysis. There was no significant difference in LOS or readmission rate. On multivariate analysis, neoCT had no significant impact on odds of mortality at 30 and 90 days (hazard ratio = .68, P = .285, hazard ratio = 1.32, P = .161, respectively). Advanced age, greater comorbidities, greater clinical stage disease, and resection with pancreaticoduodenectomy or total pancreatectomy negatively impacted 30- and 90-day mortality. Conclusion The use of neoCT has increased over the past decade and does not appear to adversely affect short-term outcomes, including 30- and 90-day mortality, LOS, and readmission rates.

Pancreatic cancer carries a dismal prognosis, with surgical resection and adjuvant therapy offering the only hope for long-term survival. Recently, neoadjuvant therapy (NAT) has been employed to optimize outcomes. This study evaluates the impact of NAT in resected pancreatic cancer.Patients with clinically staged I-III resected carcinoma of the pancreas who underwent at least NAT or surgery first in the 2003-2011 National Cancer Data Base were included. Univariate statistics were used to compare characteristics between treatment groups. Kaplan-Meier and multivariate survival analyses using Cox proportional hazards models were also performed.1736 patients who underwent NAT, 6706 patients who underwent surgical resection alone, and 9890 patients who underwent surgical resection followed by adjuvant therapy were studied. In patients with clinical stage I disease, adjuvant therapy was associated with similar median survival to NAT, which was greater than surgery alone (24.9, 24.8, and 18.3 months, respectively, p 0.0001). However, in stage II, NAT offered improved median survival over adjuvant therapy, which was greater than surgery alone (21.78, 20.63, and 12.1 months, respectively, p 0.0001). In stage III disease, NAT had better median survival relative to other groups (22.6, 14.6, and 8.7 months, respectively, p 0.0001). In multivariate survival analysis, patients who received NAT had a 33% lower hazard of mortality up to 5 years as compared to surgical resection alone (p 0.0001).Neoadjuvant therapy in advanced stage pancreatic cancer is associated with a survival benefit, perhaps related to a selection bias. In early stage pancreatic cancer, NAT is associated with similar survival.

Patients with type 2 diabetes mellitus (type 2 DM) are at greater risk of poor hospital outcomes. The purpose of this study was to determine the impact of type 2 DM on 30-day hospital readmission and length of stay (LOS).We studied all inpatient admissions in Pennsylvania during 2011 using data from the Pennsylvania Health Care Cost Containment Council. Outcomes included 30-day readmission and inpatient LOS. We estimated the impact of type 2 DM on readmission and LOS, and identified risk factors for readmission and prolonged LOS.Among inpatient admissions, patients with diabetes were more likely to be readmitted (AOR=1.17, P0.001) and have longer LOS (0.19days, P0.001) compared to patients without diabetes. Among those with diabetes, several factors were associated with readmission, including demographics, source of admission, and comorbidities. Patients with diabetes were more likely to be readmitted for infectious complications (9.4% vs. 7.7%), heart failure (6.0% vs. 3.1%), and chest pain/MI (5.5% vs. 3.3%) than patients without diabetes.Diabetes is associated with risk of 30-day readmission and LOS, and several patient-specific factors are associated with outcomes for patients with diabetes. Future studies may target risk factors to develop strategies to reduce readmissions and LOS.

While hospital charges related to neonatal abstinence syndrome (NAS) have increased recently, there are no data available regarding costs. Therefore, we sought to describe the NAS population and compare with the non-NAS population, determine the incidence of NAS in the United States and estimate the total annual costs and hospital days of NAS admissions, and estimate the incremental costs and length of stay of an NAS admission compared with a non-NAS admission.Retrospective, observational study. Data were obtained from the Kids' Inpatient Database (2003-12). Survey-weighting was used to obtain national counts of NAS births. The incremental burden of costs and length of stay were estimated for NAS admissions and compared to non-NAS admissions.United States hospitals from states participating in the Kids' Inpatient Database (KID), a nationally representative sample of all-payer in-patient pediatric discharges.Infants with a diagnosis of NAS (27 943) were identified from the KID using ICD-9-CM codes and compared with non-NAS infants (3 783 629).Primary outcome measures were provider costs and length of stay for NAS and non-NAS admissions. Costs were calculated using cost-to-charge ratios and were adjusted for inflation to 2014 US dollars.Between 2003 and 2012, NAS admissions increased more than fourfold, resulting in a surge in annual costs from US$61 million and 67 869 hospital days in 2003 to nearly US$316 million and 291 168 hospital days in 2012. For an infant affected by NAS, the hospital stay was nearly 3.5 times as long (16.57 hospital days compared with 4.98 for a non-NAS patient, P 0.001) and the costs more than three times greater (US$16 893 compared to US$5610 for a non-affected infant, P 0.001).The incidence of neonatal abstinence syndrome is increasing in the United States, and carries an enormous burden in terms of hospital days and costs. The number of US hospital admissions involving neonatal abstinence syndrome increased more than fourfold between the years 2003 and 2012. In 2012, neonatal abstinence syndrome cost nearly $316 million in the United States.

Learner mistreatment has been a long-standing example of unprofessional behavior in medical training. Alignment of perceptions of professional behavior is a critical component of developing a defined organizational culture. Clinical vignettes addressing learner mistreatment can help to achieve this goal. Our aim was to determine whether using clinical vignettes to address learner mistreatment during onboarding can reduce variability in the perceptions of mistreatment.External experts in the field of labor and employment relations embedded in the clinical learning environment identified six thematic areas of potential mistreatment. Corresponding clinical case vignettes were developed and presented to incoming trainees during the onboarding process, followed by facilitated discussion. Perceptions of mistreatment before and after discussion were assessed on a Likert scale, with results compared using F-test and t-test.There were 145 participants. Most participants reported previously witnessing or experiencing episodes of mistreatment before matriculation (84%), with the majority reporting multiple events. The most common offenders were faculty (57%), residents/fellows (49%), and nurses (33%). Only 10% of incoming trainees reported a previous incident of mistreatment. Postintervention scores demonstrated decreased variability (P 0.05) in perceptions of mistreatment in all but one vignette (withholding learning opportunities). Two vignettes demonstrated higher perception of mistreatment after intervention (noneducational tasks and gender or racial discrimination, P 0.05).Mistreatment remains a prevalent phenomenon in medical training involving a wide cross-section of healthcare providers. Trainees arrive with discordant definitions of mistreatment. Alignment of individuals' definitions can be achieved through the use of carefully crafted clinical vignettes and facilitated discussion.

Low selenium levels have been linked to a higher incidence of cancer and other diseases, including Keshan, Chagas, and Kashin-Beck, and insulin resistance. Additionally, muscle and cardiovascular disorders, immune dysfunction, cancer, neurological disorders, and endocrine function have been associated with mutations in genes encoding for selenoproteins. Selenium biology is complex, and a systems biology approach to study global metabolomics, genomics, and/or proteomics may provide important clues to examining selenium-responsive markers in circulation. In the current investigation, we applied a global proteomics approach on plasma samples collected from a previously conducted, double-blinded placebo controlled clinical study, where men were supplemented with selenized-yeast (Se-Yeast; 300 μg/day, 3.8 μmol/day) or placebo-yeast for 48 weeks. Proteomic analysis was performed by iTRAQ on 8 plasma samples from each arm at baseline and 48 weeks. A total of 161 plasma proteins were identified in both arms. Twenty-two proteins were significantly altered following Se-Yeast supplementation and thirteen proteins were significantly changed after placebo-yeast supplementation in healthy men. The differentially expressed proteins were involved in complement and coagulation pathways, immune functions, lipid metabolism, and insulin resistance. Reconstruction and analysis of protein-protein interaction network around selected proteins revealed several hub proteins. One of the interactions suggested by our analysis, PHLD-APOA4, which is involved in insulin resistance, was subsequently validated by Western blot analysis. Our systems approach illustrates a viable platform for investigating responsive proteomic profile in 'before and after' condition following Se-Yeast supplementation. The nature of proteins identified suggests that selenium may play an important role in complement and coagulation pathways, and insulin resistance.

Background The Support, Health Information, Nutrition, and Exercise (SHINE) trial recently showed that a telephone adaptation of the Diabetes Prevention Program (DPP) lifestyle intervention was effective in reducing weight among patients with metabolic syndrome. The aim of this study is to determine whether a conference call (CC) adaptation was cost effective relative to an individual call (IC) adaptation of the DPP lifestyle intervention in the primary care setting. Methods We performed a stochastic cost-effectiveness analysis alongside a clinical trial comparing two telephone adaptations of the DPP lifestyle intervention. The primary outcomes were incremental cost-effectiveness ratios estimated for weight loss, body mass index (BMI), waist circumference, and quality-adjusted life years (QALYs). Costs were estimated from the perspective of society and included direct medical costs, indirect costs, and intervention costs. Results After one year, participants receiving the CC intervention accumulated fewer costs ($2,831 vs. $2,933) than the IC group, lost more weight (6.2 kg vs. 5.1 kg), had greater reduction in BMI (2.1 vs. 1.9), and had greater reduction in waist circumference (6.5 cm vs. 5.9 cm). However, participants in the CC group had fewer QALYs than those in the IC group (0.635 vs. 0.646). The incremental cost-effectiveness ratio for CC vs. IC was $9,250/QALY, with a 48% probability of being cost-effective at a willingness-to-pay of $100,000/QALY. Conclusions CC delivery of the DPP was cost effective relative to IC delivery in the first year in terms of cost per clinical measure (weight lost, BMI, and waist circumference) but not in terms of cost per QALY, most likely because of the short time horizon.

Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure.A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension.Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease.Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months.At baseline, the 136 intervention and 144 control subjects' mean 4-year coronary heart disease risk did not differ (intervention=5.8 % and control=6.4 %, P=0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p=0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference -0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p=0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a5 mmHg reduction (61 % versus 45 %, respectively, p=0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference -6.47 mmHg, 95 % confidence interval: -10.69 to -2.25, P=0.003). One patient died in each study arm.Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure.

Objectives The objectives of this analysis were to assess health and economic consequences of targeting hemoglobin (Hb) levels around 10-11 g/dL relative to 9-10 g/dL using an economic model and to explore the impact of different assumptions on cost-effectiveness. Study Design Clinical and economic impact of treating anemia in the US hemodialysis population to target Hb levels of 10-11 g/dL and 9-10 g/dL was assessed using a Markov model. A sensitivity analysis assessed the effects of varying assumptions on the model. Results Our cost-effectiveness analysis suggests that maintaining Hb 10-11 g/dL would result in average reductions of 0.51 hospitalizations and increases of 0.09 quality-adjusted life years per patient, with hospitalization cost offsets of $15,340 over 5 years when compared with Hb of 9-10 g/dL. Over the lifetime of the patient, cost-effectiveness improved with hospitalization cost offsets of $21,450 and increases of 0.12 quality-adjusted life years. Sensitivity analysis of individual parameters showed that mortality, hospitalization, health preference, and time horizon of the model had the most influence on cost-effectiveness. Conclusions Our analysis suggests that epoetin alfa use targeting Hb levels of 10-11 g/dL relative to 9-10 g/dL may result in better patient outcomes and lower costs. The sensitivity analysis highlighted how assumptions affected cost-effectiveness conclusions; the appropriateness of these assumptions will remain uncertain until new research in today’s dialysis population examining the effects of targeting to lower Hb levels is conducted.

Background Excess supply of blood is required to ensure availability to patients requiring transfusions at the time of need. End-stage renal disease (ESRD) patients undergoing dialysis account for a substantial portion of the demand for transfusions. Objective The purpose of this analysis was to explore the impact of ESRD transfusion demand on the US blood supply and its margin. Methods A mathematical model was developed to evaluate the impact on the overall US demand for blood transfusions associated with changes in the mean hemoglobin (Hb) among ESRD patients at Hb levels ranging from 9 to 12 g/dL. Results Our results suggested that, based on ESRD prevalence and blood supply estimates and a mean population Hb of 12 g/dL, 27,845 dialysis patients would receive an estimated total of 17,384 units of blood, compared with an estimated 123,503 dialysis patients receiving a total of 288,590 units of blood at a mean population Hb level of 9 g/dL. Based on an assumed supply margin of 10%, our model estimated that approximately 21.9% of this margin would be utilized by ESRD patients with a mean population Hb of 9 g/dL, compared with 8.7% for mean Hb of 10 g/dL, 3.0% for mean Hb of 11 g/dL, and 1.3% for mean Hb of 12 g/dL. Conclusions Potential changes in treatment practices for ESRD may shrink the blood margin and limit availability of blood products for other uses, such as for acute injuries and surgical procedures.

Summary Advanced age donors have inferior outcomes of liver transplantation for Hepatitis C (HCV). Aged donors grafts may be transplanted into young or low model for end stage liver disease (MELD) patients in order to offset the effect of donor age. However, it is not well understood how to utilize liver grafts from advanced aged donors for HCV patients. Using the UNOS database, we retrospectively studied 7508 HCV patients who underwent primary liver transplantation. Risk factors for graft failure and graft survival using advanced aged grafts (donor age ≥ 60 years) were analyzed by Cox hazards models, donor risk index (DRI) and organ patient index (OPI). Recipient’s age did not affect on graft survival regardless of donor age. Advanced aged grafts had significant inferior survival compared to younger aged grafts regardless of MELD score (P

Corticosteroid use after kidney transplantation results in severe bone loss and high fracture risk. Although corticosteroid withdrawal in the early posttransplant period has been associated with bone mass preservation, there are no published data regarding corticosteroid withdrawal and risk of fracture. We hypothesized lower fracture incidence in patients discharged from the hospital without than with corticosteroids after transplantation. From the United States Renal Data System (USRDS), 77, 430 patients were identified who received their first kidney transplant from 2000 to 2006. Fracture incidence leading to hospitalization was determined from 2000 to 2007; discharge immunosuppression was determined from United Networks for Organ Sharing forms. Time-to-event analyses were used to evaluate fracture risk. Median (interquartile range) follow-up was 1448 (808-2061) days. There were 2395 fractures during follow-up; fracture incidence rates were 0.008 and 0.0058 per patient-year for recipients discharged with and without corticosteroid, respectively. Corticosteroid withdrawal was associated with a 31% fracture risk reduction (HR 0.69; 95% CI 0.59-0.81). Fractures associated with hospitalization are significantly lower with regimens that withdraw corticosteroid. As this study likely underestimates overall fracture incidence, prospective studies are needed to determine differences in overall fracture risk in patients managed with and without corticosteroids after kidney transplantation.

Background Surgical site infections (SSIs) are an important end point and measure of quality of care. Surgical site infections can be identified using clinical registries, electronic surveillance, and administrative claims data. This study compared measurements of SSIs using these 3 different methods and estimated their implication for health care costs. Study Design Data were obtained from 5,476 surgical patients treated at a single academic children's hospital (January 1, 2010 through August 31, 2014). Surgical site infections within 30 days were identified using a clinical registry in the NSQIP Pediatric, an electronic surveillance method (Nosocomial Infection Marker; MedMined), and billing claims. Infection rates, diagnostic characteristics, and attributable costs were estimated for each of the 3 measures of SSI. Results Surgical site infections were observed in 2.24% of patients per NSQIP Pediatric definitions, 0.99% of patients per the Nosocomial Infection Marker, and 2.34% per billing claims definitions. Using NSQIP Pediatric as the clinical reference, Nosocomial Infection Marker had a sensitivity of 31.7% and positive predictive value of 72.2%, and billing claims had a sensitivity of 48.0% and positive predictive value of 46.1% for detection of an SSI. Nosocomial Infection Marker and billing claims overestimated the costs of SSIs by 108% and 41%, respectively. Conclusions There is poor correlation among SSIs measured using electronic surveillance, administrative claims, and clinically derived measures of SSI in the pediatric surgical population. Although these measures might be more convenient, clinically derived data, such as NSQIP Pediatric, may provide a more appropriate quality metric to estimate the postoperative burden of SSIs in children.

Renal cell carcinoma (RCC) is the third most common genitourinary cancer and the most common primary renal neoplasm. Estimates of the economic burden of RCC in the United States range from approximately $400 million (in year 2000 dollars) to $4.4 billion (in year 2005 dollars). Actual costs associated with RCC, particularly for elderly Medicare patients who account for 46% of U.S. patients hospitalized for RCC, are poorly understood.To estimate all-cause health care costs associated with RCC using the combined Surveillance Epidemiology and End Results (SEER)-Medicare database.The sample was limited to non-HMO patients aged 65 years or older who were diagnosed with a first primary RCC (SEER site recode 59, kidney and renal pelvis) between 1995 and 2002. Our final sample included 4,938 patients with RCC and 9,876 non-HMO noncancer comparison group cases without chronic renal disease drawn from the SEER 5% Medicare sample and matched by a propensity score calculated from age, gender, race/ethnicity, and comorbidities. Costs were defined as payments made by Medicare for all-cause medical treatments including inpatient stays, emergency room visits, outpatient procedures, office visits, home health visits, durable medical equipment, and hospice care, but excluding out-patient prescription drugs. Using the method of Bang and Tsiatis (2000), we estimated cumulative costs at 1 and 5 years by estimating average costs for each patient in each month up to 60 months following diagnosis. Total costs were weighted sums of monthly costs, where weights were the inverse probability that the patient was not censored, and inverse probabilities were estimated by Kaplan-Meier estimates of time to censoring. Using the method of Lin (2000), we performed multivariate analyses of costs by fitting each of the 60 monthly costs to linear models that controlled for demographic characteristics and comorbidities. Marginal effects of covariates on 1- and 5-year costs were obtained by summing the coefficients for months 1 through 12 and months 1 through 60, respectively. Confidence intervals were obtained by bootstrapping.Patients with RCC and matched comparison group cases had similar demographic characteristics, comorbidities, and chronic conditions. At the start of the fifth year post-diagnosis, there were 1,208 Medicare RCC cases of the original 4,938 (20.8%). Mean costs per patient per month (PPPM) in the first year were $3,673 for patients with RCC and $793 for comparison group patients. PPPM costs were higher for RCC patients with more advanced stage (i.e., regional or distant) disease. Average cumulative total costs for RCC patients were $33,605 per patient in the first year following diagnosis and $59,397 per patient in the first 5 years following diagnosis. Several patient-specific factors were associated with 1- and 5-year costs in multivariate analyses, including age, race/ethnicity, and comorbidities. Among RCC patients, treatment with surgery and radiation was associated with higher costs per patient than treatment with surgery alone at 1 year ($24,556, 95% CI = $16,673-$32,940) and 5 years ($30,540, 95% CI = $17,853-$43,648). RCC patients who received chemotherapy as part of their treatment regimen also had significantly higher costs per patient than those who received surgery alone at 1 year ($15,144, 95% CI = $ 9,979-$20,344) and 5 years ($13,440, 95% CI = $1,257-$27,572).Newly diagnosed RCC is associated with a significant economic burden, which is largely determined by several patient characteristics, disease stage, and treatment choice.

Predictive modeling can be used to identify persons who are at increased risk for adverse health outcomes. We used demographic, medical, and pharmacy claims data to create a gender-specific model for fee-for-service Medicaid based on 2 states' data that can assist with the identification of persons with an elevated future risk of hospitalization, elevated claims expense, or death. Depending on age and the outcome of interest, the area under the receiver operating characteristic curve for this predictive modeling tool across 2 states' diabetes populations ranged from 0.608 to 0.834. We conclude that this analysis yielded a level of accuracy comparable to other predictive models that can be used to target patient enrollment in population-based care management. (Population Health Management 2011;14:239–242)

OBJECTIVE The purpose of this study was to compare the cost-effectiveness of the National Surgical Quality Improvement Program (NSQIP) at an academic medical center between the first 6 months and through the first and second years of implementation. BACKGROUND The NSQIP has been extended to private-sector hospitals since 1999, but little is known about its cost-effectiveness. METHODS Data included 2229 general or vascular surgeries, 699 of which were conducted after NSQIP was in place for 6 months. We estimated an incremental cost-effectiveness ratio (ICER) comparing costs and benefits before and after the adoption of NSQIP. Costs were estimated from the perspective of the hospital and included hospital costs for each admission plus the total annual cost of program adoption and maintenance, including administrator salary, training, and information technology costs. Effectiveness was defined as events avoided. Confidence intervals and a cost-effectiveness acceptability curve were computed by using a set of 10,000 bootstrap replicates. The time periods we compared were (1) July 2007 to December 2007 to July 2008 to December 2008 and (2) July 2007 to June 2008 to July 2008 to June 2009. RESULTS The incremental costs of the NSQIP program were $832 and $266 for time periods 1 and 2, respectively, yielding ICERs of $25,471 and $7319 per event avoided. The cost-effectiveness acceptability curves suggested a high probability that NSQIP was cost-effective at reasonable levels of willingness to pay. CONCLUSIONS In these data, not only did NSQIP appear cost-effective, but also its cost-effectiveness improved with greater duration of participation in the program, resulting in a decline to 28.7% of the initial cost.

The number of female inmates is growing, and their average age is increasing. As a result, end-of-life care is situated in a highly restrictive environment with a focus on security rather than comfort. We describe the need for and potential barriers to humane care and provide care strategies that can be useful in a complex organizational system. Frontline workers such as nurses who understand the balance between care and control must promote change in the women’s prison system.

Objectives:To determine whether the cost of a statewide smoking cessation program in Pennsylvania could be justified by the benefits.Methods:A cost-benefit analysis of statewide access to smoking cessation programs. We compared three treatment alternatives, both with and without counselling: nicotine replacement therapy, bupropion and varenicline.Results:While the retail price of a pack of cigarettes in Pennsylvania is on average US$4.72, the combined medical costs and productivity losses in Pennsylvania attributable to each pack of cigarettes sold are approximately US$23.78 per pack of cigarettes. The ratio of benefits to cost varied from US$0.97 to US$2.76 saved per dollar spent on smoking cessation programs, depending upon the type of intervention.Conclusions:For most smoking cessation treatments, the benefits of a statewide smoking cessation program in Pennsylvania would greatly outweigh its costs.

We compare employment and usual hours of work for prime-age cancer survivors from the Penn State Cancer Survivor Survey to a comparison group drawn from the Panel Study of Income Dynamics using cross-sectional and difference-in-differences regression and matching estimators. Because earlier research has emphasized workers diagnosed at older ages, we focus on employment effects for younger workers. We find that as long as two to six years after diagnosis, cancer survivors have lower employment rates and work fewer hours than other similarly aged adults.

Long-term ethanol exposure leads to a sexually dimorphic response in both the susceptibility to cardiac pathology (protective effect of the female heart) and the expression of selected myocardial proteins. The purpose of the present study was to use proteomics to examine the effect of chronic alcohol consumption on a broader array of cardiac proteins and how these were affected between the sexes. Male and female rats were maintained for 18 wk on a 40% ethanol-containing diet in which alcohol was provided in drinking water and agar blocks. Differences in the content of specific cardiac proteins in isopycnic centrifugal fractions were determined using mass spectrometry on iTRAQ-labeled tryptic fragments. A random effects model of meta-analysis was developed to combine the results from multiple iTRAQ experiments. Analysis of a network of proteins involved in cardiovascular system development and function showed that troponins were oppositely regulated by alcohol exposure in females (upregulated) vs. males (downregulated), and this effect was validated by Western blot analysis. Pathway analysis also revealed that alcohol-consuming males showed increased expression of proteins involved in various steps of oxidative phosphorylation including complexes I, III, IV, and V, whereas females showed no change or decreased content. One implication from these findings is that females may be protected from the toxic effects of alcohol due to their ability to maintain contractile function, maintain efficiency of force generation, and minimize oxidative stress. However, the alcohol-induced insult may lead to increased production of reactive oxygen species and structural abnormalities in male myocardium.

Summary In addition to standard corticosteroid induction, anti-thymocyte globulin (ATG) or daclizumab as induction immunosuppression has been reported for liver transplantation. However, the effects and long-term outcomes of antibody induction therapy are not well known, especially for hepatitis C (HCV). The United Network for Organ Sharing (UNOS) database was utilized to analyze 16 898 adult primary liver transplant patients who received ATG alone (n = 452), ATG and steroids (ATG + S) (n = 1758), daclizumab alone (n = 683), or steroid alone (n = 14 005), listed as induction immunosuppression. Graft and patient survival, and donor and recipient factors for survival were analyzed for HCV and all liver diseases. For patients with HCV, ATG + S had significantly inferior graft survival compared with daclizumab (P = 0.01) and steroids (P = 0.03). The Cox proportional hazards model also showed that ATG + S was a marginal risk factor for graft failure (P = 0.05). On the other hand, for patients with all the liver diseases, graft and patient survival were not significantly different between induction regimens. ATG induction appeared to be preferentially used in patients with renal dysfunction, with improvement in renal function after liver transplantation. Thus, ATG induction can be used for patients with renal dysfunction in non-HCV diseases. Daclizumab induction achieved satisfactory short-term and long-term outcomes of liver transplantation in all the liver diseases including HCV disease.

The purpose of this research was to estimate employment effects for spouses of cancer survivors who were working at the time of the cancer diagnosis.Spouses of cancer survivors were drawn from the Penn State Cancer Survivor Survey. Comparable spouses of individuals without cancer were drawn from the Panel Survey of Income Dynamics. The final sample included 827 spouses of cancer survivors (542 husbands, 285 wives) and 2,766 spouses of individuals without cancer (1,459 husbands, 1,307 wives). Three employment outcomes were studied 2-6 years after diagnosis: whether working, whether working full time (35+ hours per week), and usual hours per week. We used propensity scores to match cases to controls 3:1.Wives of cancer survivors had a lower probability (-7.5 percentage points) of being employed 2-6 years after diagnosis (p = 0.036). They were slightly more likely to be working full time, while averaging 1.1 fewer hours per week overall, but these effects were not statistically significant. Cancer's effect on husbands was not significant for any of the employment outcomes. However, if survivor wives and husbands were working at follow-up, they had more than twice the odds of working full-time (wives OR = 2.18, p = 0.0004; husbands OR = 2.65, p = 0.012) and worked more hours per week than other spouses (wives 1.9, p = 0.041; husbands 1.5, p = 0.04).The implications to cancer survivors and their spouses of these results is that the employment of survivor spouses, especially of wives, is somewhat reshaped by cancer in the medium to long run. However, there is little or no effect on aggregate hours worked by spouses who were employed at diagnosis.

Uemura T, Riley TR, Khan A, Hollenbeak C, Schreibman I, Ghahramani N, Reeves B, Domen RE, Zander DS, Kadry Z. Immune functional assay for immunosuppressive management in post-transplant malignancy. Clin Transplant 2011: 25: E32–E37. © 2010 John Wiley & Sons A/S. Abstract: Immunosuppression management in post-transplant malignancy is challenging because of a lack of objective immunologic assessment tools. The ImmuKnow assay measures the ATP level from CD4 T cells, quantifying cell-mediated immunity and providing an insight into the immune status of transplant recipients. Its potential use in patients with post-transplant de novo malignancy was evaluated. Thirteen adult transplant patients with de novo malignancy were divided into survivors (n = 9) and non-survivors (n = 4) after malignancy treatment. Tacrolimus and the ImmuKnow levels were monitored before, during, and after malignancy treatment. The ImmuKnow level in non-survivors group was significantly lower before and after malignancy treatment compared to survivors group (p = 0.013 and 0.0014 respectively). In survivor group, the ImmuKnow level was significantly decreased during malignancy treatment (p = 0.019) but recovered to the initial level after the treatment. However, in non-survivor group, the ImmuKnow level remained suppressed throughout the observed period despite a reduction in immunosuppressive drug levels. The ImmuKnow assay can be an objective means evaluating immune status of patients with de novo malignancy. The ImmuKnow assay can express the degree of immune suppression induced by chemotherapeutic or radiation therapy and may be a useful tool in optimizing the timing of re-introduction of immunosuppression after malignancy treatment.

Study Type – Prognosis (retrospective cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Upper-tract urothelial carcinoma (UTUC) is a relatively uncommon urological malignancy with survival and outcomes data largely determined from single-centre series which can be limited by relatively small case numbers. Through review of a large population based cohort, this study provides valuable information regarding epidemiological and survival patterns for over 13,000 patients with UTUC diagnosed over the past three decades. OBJECTIVE • To evaluate epidemiological and survival patterns of upper-tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population-based database. PATIENTS AND METHODS • Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10-year increments to evaluate disease trends. • Univariate and multivariate survival analyses identified prognostic variables for outcomes. RESULTS • In total, 13 800 SEER-registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100 000 person-years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). • The proportion of in situ tumours increased from 7.2% to 31.0% (P < 0.001), whereas local tumours declined from 50.4% to 23.6% (P < 0.001). • There was no change in the proportion of patients presenting with distant disease. • In multivariate analysis, increasing patient age (P < 0.001), male gender (P < 0.001), black non-Hispanic race (P < 0.001), bilateral UTUC (P= 0.001) and regional/distant disease (P < 0.001) were all associated with poorer survival outcomes. CONCLUSIONS • The incidence of UTUC has slowly risen over the past 30 years. • Increased use of bladder cancer surveillance regimens and improved abdominal cross-sectional imaging may contribute to the observed stage migration towards more in situ lesions. • Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.

The effect on cancer-specific survival (CSS) from the number of resected nodes (node yield) and the number of nodes involved with colon cancer has not been studied with respect to age. Data from 1992 to 2006 from the Surveillance, Epidemiology and End Results (SEER) registry were analyzed for colon cancer patients undergoing curative resection, comparing younger (

Objective To determine whether racial disparities exist with regard to the age at which patients with systemic lupus erythematosus (SLE) experience cardiovascular disease (CVD) and CVD-associated death. Methods Using the 2003–2006 Nationwide Inpatient Sample, we calculated the age difference between patients with SLE and their race- and sex-matched controls at the time of hospitalization for a cardiovascular event and for CVD-associated death. In addition, we calculated the age difference between white patients with SLE and sex-matched controls for each minority group for the same outcomes. Results The mean age difference between women with and those without SLE at the time of admission for a CVD event was 10.5 years. All age differences between women with SLE (n = 3,627) and women without SLE admitted for CVD were significant (P < 0.0001). Among different racial groups with SLE, black women were the youngest to be admitted with CVD (53.9 years) and to have a CVD-associated in-hospital death (52.8 years; n = 218). Black women with SLE were 19.8 years younger than race- and sex-matched controls at the time of CVD-associated death. Admission trends for CVD were reversed for black women, such that the highest proportions of these patients were admitted before age 55 years, and then the proportions steadily decreased across age categories. Among the 805 men with SLE who were admitted with a CVD event, those who were black or Hispanic were youngest. Conclusion There are significant racial disparities with regard to age at the time of hospital admission for CVD events and CVD-related hospitalization resulting in death in patients with SLE.

Purpose To examine the effect of antihypertensive adherence on blood pressure and barriers to adherence in racially diverse elderly patients. Methods Telephone survey of a representative sample of 300 of all 3416 hypertensive patients aged >70 from four urban primary care practices. From electronic records, we calculated subjects' annual mean systolic blood pressure. We asked about the last missed antihypertensive dose in six time intervals. Based on association with blood pressure control, non-adherence was defined as missing any dose in the past 3 months. Subjects were also asked about six domains of adherence barriers: health, personal support, drug coverage, medication filling and use, doctor–patient interaction and knowledge. All models adjust for demographics, treatment regimen and sampling weights. Results The 202 subjects (67% response rate) were: female (65.9%), black (64.8%), mean age 77.4 years (5.49) and on mean 2.4 (SD 1.3) antihypertensive drugs. Mean annual systolic pressure for non-adherent subjects (22% of the cohort) was higher than adherent subjects (137.7 vs.133.4 mmHg, p = 0.065). After adjustment, the association between adherence and blood pressure was stronger in black than white patients (p = 0.007). In an initial model, being unaware of Medicare Part D had a lower adjusted odds ratio (AOR) of adherence (p

To determine whether survival outcomes of younger patients with oral cavity squamous cell cancer (OSCC) differs from older patients in the US. A retrospective cohort study using data from the Surveillance, Epidemiology and End Results (SEER) registry. We studied cases (n=19681) of OSCC diagnosed from 1973 to 1999 and used age cutoffs at 40, 45, 50, and 55 years. Control groups of older patients were retrospectively matched on gender, race, cancer subsite, and stage of disease. Survival was estimated using the Kaplan-Meier method. A propensity score matching produced groups with similar distributions of patient and disease characteristics. Between these matched groups, younger patients had a significantly better five-year survival (age 40: 63.4% vs. 80.6%, p

Background. Technetium 99m sestamibi scans have become a principal means of localizing parathyroid adenomas. Its accuracy and reliability has allowed for the proliferation of minimal access parathyroidectomy. Localizing interpretation of these scans often drives referral of hyperparathyroid patients for surgery. Interpretation of these scans may differ between nuclear medicine physicians and surgeons. Methods. We reviewed patients (N = 65) with digital images from an academic medical center with the diagnosis of primary hyperparathyroidism. We assessed the willingness to define an adenoma's location, the interrater reliability, and the accuracy of technetium (Tc-99m) sestamibi read by a surgeon and a nuclear medicine physician. Results. There was poor correlation between both readers for assessment of quality of images (k = 0.54, 0.07) but very good correlation for adenoma location (k = 0.81). Conclusion. Both readers had good accuracy in predicting the location of the parathyroid adenoma. The surgeon was more likely to call a scan positive. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

SUMMARY: Background: Acute renal failure (ARF) still bears a poor prognosis with mortality rates up to 70% and the ideal form of renal replacement therapy (RRT) remains controversial. The purpose of this study was to conduct a systematic review and meta-analysis of all randomized controlled trials (RCT) to examine the effect of dialysis modality (IHD: Intermittent haemodialysis; CRRT: continuous renal replacement therapy) on survival of patients with ARF and to also study the effect of each modality on dialysis dependence (DD). Methods: Using and combining two comprehensive search themes (ARF and RRT), we searched electronic databases from 1969 through September of 2007, supplemented by a manual review of abstracts from nephrology meetings and reference lists of review articles. All RCT comparing IHD with CRRT in adult patients with ARF and with explicit reporting of mortality were included. The primary outcome was the pooled estimate of the odds ratio (OR) of mortality for patients with ARF treated with CRRT versus IHD. The secondary outcome was OR of DD at time of discharge for surviving patients. Results: A total of 587 studies were identified, 554 of which were excluded on initial screening. Analysis of the nine RCT (1635 patients) showed an OR of 0.89 (0.63–1.24) for survival in patients on CRRT. Limiting the analysis to the seven RCT published after the year 2000, revealed an OR of 0.72 (0.58–0.90). The OR of all the studies before 2000 was 1.06 (95% CI 0.67–1.68), as compared with OR of 0.61 (95% CI 0.50–0.74) for studies post-2000. Four studies showed a significantly lower risk of DD among the CRRT group and none showed higher OR for DD. When analysis was limited to the RCT, the OR for DD was 1.07 (0.47–2.39), suggesting no difference in DD between the modalities. Conclusions: Similar to previously reported meta-analyses, we did not find a significant effect of CRRT on the OR of survival. The progressive reduction in the OR of survival with CRRT relative to IHD might reflect progressive improvements in IHD. The OR of DD was not affected by mode of RRT. In conclusion, compared with IHD, CRRT does not offer an advantage with regards to survival or DD in ARF. Considering its cost and potential disadvantages, it is imperative to identify the subset of patients with ARF that would potentially derive maximum benefit from CRRT. This will require large, adequately powered studies with sufficient follow-up.

It is unclear whether public reporting of hospital and physician performance has improved outcomes for the conditions being reported. We studied the effect of intensive public reporting on hospital mortality for 6 high-frequency, high-mortality medical conditions. Patients in Pennsylvania were matched to patients in other states with varying public reporting environments using propensity score methods. The effect of public reporting was estimated using a difference in differences approach. Patients treated at hospitals subjected to intensive public reporting had significantly lower odds of in-hospital mortality when compared with similar patients treated at hospitals in environments with no public reporting or only limited reporting. Overall, the 2000-2003 in-hospital mortality odds ratio for Pennsylvania patients versus non-Pennsylvania patients ranged from 0.59 to 0.79 across 6 clinical conditions (all P.0001). For the same comparison using the 1997-1999 period, odds ratios ranged from 0.72 to 0.90, suggesting improvement when intensive public reporting occurred.

Physician treatment of cardiovascular risk factors may be affected by specific types of patient comorbidities.To examine the relationship between discordant comorbidities and LDL-cholesterol management in hypertensive patients not previously treated with lipid-lowering therapy; to determine whether the presence of cardiovascular (concordant) conditions mediates this relationship.We performed a retrospective cohort study of 1,935 hypertensive primary care patients (men45 years of age, women55 years of age) with documented elevated low-density lipoprotein (LDL) cholesterol and no lipid-lowering therapy at baseline. The outcome was guideline-consistent hyperlipidemia management defined as optimal value on repeat LDL cholesterol testing or initiation of lipid-lowering therapy. Using generalized estimating equations (GEE), we examined the association of concordant and discordant comorbidities with guideline-consistent hyperlipidemia management over a 2-year follow-up period, adjusting for patient characteristics.Guideline-consistent hyperlipidemia management was achieved in 1,236 patients (64%). In the fully adjusted model, each additional discordant condition resulted in a 19% lower adjusted odds ratio of guideline-consistent hyperlipidemia management (p0.001) when compared with no discordant conditions. The dampening effect of discordant conditions on guideline-consistent management persisted even in the presence of concordant conditions, but each additional concordant condition was associated with a 37% increase in the adjusted odds of guideline-consistent hyperlipidemia management (p0.001).In this cohort of hypertensive primary care patients, the number of conditions discordant with cardiovascular risk was strongly negatively associated with guideline-consistent hyperlipidemia management even in patients at the highest risk for cardiovascular events and cardiac death.

OBJECTIVE—The purpose of this study was to determine whether multidisciplinary team-based care guided by the chronic care model can reduce medical payments and improve quality for Medicaid enrollees with diabetes. RESEARCH DESIGN AND METHODS—This study was a difference-in-differences analysis comparing Medicaid patients with diabetes who received team-based care versus those who did not. Team-based care was provided to patients treated at CareSouth, a multisite rural federally qualified community health center located in South Carolina. Control patients were matched to team care patients using propensity score techniques. Financial outcomes compared Medicaid (and Medicare for dually eligible patients) payments 1 year before and after intervention. Trends over time in levels of A1C, BMI, and systolic blood pressure (SBP) were analyzed for intervention patients during the postintervention period. RESULTS—Although average claims payments increased for both the CareSouth patients and control patients, there were no statistically significant differences in total payments between the two groups. In the intervention group, patients with A1C >9 at baseline experienced an average reduction of 0.75 mg/dl per year (95% CI 0.50–0.99), patients with BMI >30 at baseline had an average reduction of 2.3 points per year (95% CI 0.99–3.58), and patients with SBP >140 mmHg at baseline had an average reduction of 2.2 mmHg per year (95% CI 0.44–3.88). CONCLUSIONS—Team-based care following the chronic care model has the potential to improve quality without increasing payments. Short-term savings were not evident and should not be assumed when designing programs.

Among patients unlikely to attend a scheduled colonoscopy, we examined the impact of peer coach versus educational brochure support and compared these with concurrent patients who did not receive support.From health system data, we identified 275 consecutive patients aged50 who kept75% of visits to 4 primary care practices and scheduled for a first colonoscopy from February 1, 2005 to August 31, 2006. Using block randomization, we assigned consenting patients to a phone call by a peer coach trained to address barriers to attendance or to a mailed colonoscopy brochure. Study data came from electronic medical records. Odds ratios of colonoscopy attendance were adjusted for demographic, clinical, and health care factors.Colonoscopy attendance by the peer coach group (N = 70) and brochure group (N = 66) differed by 11% (68.6% vs 57.6%, respectively). Compared with the brochure group, the peer coach group had over twofold greater adjusted odds ratio (AOR) of attendance (2.14, 95% confidence interval [CI] = 0.99-4.63) as did 49 patients who met the prespecified criteria for needing no support (2.68, 95% CI = 1.05-6.82) but the AORs did not differ significantly for 41 patients who declined support (0.61, 95% CI = 0.25-1.45) and 49 patients who could not be contacted (0.85, 95% CI = 0.36-2.02). Attendance was less likely for black versus white race (AOR = 0.37, 95% CI = 0.19-0.72) but more likely for patients with high versus low primary care visit adherence (AOR = 2.30, 95% CI = 1.04-5.07).For patients who often fail to keep appointments, peer coach support appears to promote colonoscopy attendance more than an educational brochure.