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Background/objective: The Centers for Medicare & Medicaid Services (CMS) Overall Hospital Quality Star Rating, established in 2016, is a summary of publicly available quality information for acute care hospitals. In July 2023, Veterans Health Administration (VHA) hospitals became eligible to receive a CMS Overall Hospital Quality Star Rating for the first time. Our objective was to compare performance in quality ratings among VHA and non-VHA hospitals., Methods: We used the hospital quality measure scores posted to Care Compare on Medicare.gov as of January 2023 as our primary data set. We conducted a pair of analyses to characterize the performance of VHA hospitals compared to non-VHA hospitals: an overall analysis including all rated hospitals, and a matched analysis in which only a single nearby hospital was included for each VHA hospital., Results: Of the 4518 non-VHA hospitals, 2962 (65.6%) received a Star Rating, compared to 114 (84%) of 136 VHA hospitals. VHA hospitals tended to receive higher ratings overall (one-star: 8%; two-star: 11%; three-star: 14%; four-star: 35%; five-star: 32%) than non-VHA (one-star: 8%; two-star: 22%; three-star: 29%; four-star: 26%; five-star: 15%). A similar pattern was observed in the matched analysis., Conclusions: VHA hospitals tended to perform better on the Overall Star Rating compared to non-VHA hospitals, as evidenced by being more likely to receive a four- or five-star rating. The eligibility of VHA hospitals to receive an Overall Star Rating signifies an important addition to the program that will allow Veterans to make more informed healthcare decisions., (© 2024 The Author(s). Journal of Hospital Medicine published by Wiley Periodicals LLC on behalf of Society of Hospital Medicine.)

Pediatric liver masses are rare and difficult to treat. Common liver masses in children include hepatoblastoma, hemangiomas, liver abscesses, and hydatid disease. Isolated liver tuberculosis (TB) is rare in children and can have variable clinical presentations. We report a child with isolated liver TB masquerading as a liver tumor., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Indian Association of Pediatric Surgeons.)

Background: US hospitals have reported compliance with the SEP-1 quality measure to Medicare since 2015. Finding an association between compliance and outcomes is essential to gauge measure effectiveness., Research Question: What is the association between compliance with SEP-1 and 30-day mortality among Medicare beneficiaries?, Study Design and Methods: Studying patient-level data reported to Medicare by 3,241 hospitals from October 1, 2015, to March 31, 2017, we used propensity score matching and a hierarchical general linear model (HGLM) to estimate the treatment effects associated with compliance with SEP-1. Compliance was defined as completion of all qualifying SEP-1 elements including lactate measurements, blood culture collection, broad-spectrum antibiotic administration, 30 mL/kg crystalloid fluid administration, application of vasopressors, and patient reassessment. The primary outcome was a change in 30-day mortality. Secondary outcomes included changes in length of stay., Results: We completed two matches to evaluate population-level treatment effects. In standard match, 122,870 patients whose care was compliant were matched with the same number whose care was noncompliant. Compliance was associated with a reduction in 30-day mortality (21.81% vs 27.48%, respectively), yielding an absolute risk reduction (ARR) of 5.67% (95% CI, 5.33-6.00; P < .001). In stringent match, 107,016 patients whose care was compliant were matched with the same number whose care was noncompliant. Compliance was associated with a reduction in 30-day mortality (22.22% vs 26.28%, respectively), yielding an ARR of 4.06% (95% CI, 3.70-4.41; P < .001). At the subject level, our HGLM found compliance associated with lower 30-day risk-adjusted mortality (adjusted conditional OR, 0.829; 95% CI, 0.812-0.846; P < .001). Multiple elements correlated with lower mortality. Median length of stay was shorter among cases whose care was compliant (5 vs 6 days; interquartile range, 3-9 vs 4-10, respectively; P < .001)., Interpretation: Compliance with SEP-1 was associated with lower 30-day mortality. Rendering SEP-1 compliant care may reduce the incidence of avoidable deaths., (Copyright © 2021 American College of Chest Physicians. All rights reserved.)

Background: The Merit-based Incentive Payment System (MIPS) incorporates financial incentives and penalties intended to drive clinicians towards value-based purchasing, including alternative payment models (APMs). Newly available Medicare-approved qualified clinical data registries (QCDRs) offer specialty-specific quality measures for clinician reporting, yet their impact on clinician performance and payment adjustments remains unknown., Objectives: We sought to characterize clinician participation, performance, and payment adjustments in the MIPS program across specialties, with a focus on clinician use of QCDRs., Research Design: We performed a cross-sectional analysis of the 2018 MIPS program., Results: During the 2018 performance year, 558,296 clinicians participated in the MIPS program across the 35 specialties assessed. Clinicians reporting as individuals had lower overall MIPS performance scores (median [interquartile range (IQR)], 80.0 [39.4-98.4] points) than those reporting as groups (median [IQR], 96.3 [76.9-100.0] points), who in turn had lower adjustments than clinicians reporting within MIPS APMs (median [IQR], 100.0 [100.0-100.0] points) (P<0.001). Clinicians reporting as individuals had lower payment adjustments (median [IQR], +0.7% [0.1%-1.6%]) than those reporting as groups (median [IQR], +1.5% [0.6%-1.7%]), who in turn had lower adjustments than clinicians reporting within MIPS APMs (median [IQR], +1.7% [1.7%-1.7%]) (P<0.001). Within a subpopulation of 202,685 clinicians across 12 specialties commonly using QCDRs, clinicians had overall MIPS performance scores and payment adjustments that were significantly greater if reporting at least 1 QCDR measure compared with those not reporting any QCDR measures., Conclusions: Collectively, these findings highlight that performance score and payment adjustments varied by reporting affiliation and QCDR use in the 2018 MIPS., Competing Interests: A.K.V. serves on the Clinical Emergency Data Registry (CEDR) Committee and within several other quality measurement related roles in the American College of Emergency Physicians. A.K.V. is also supported by the Moore Foundation, the American College of Emergency Physicians, the American College of Radiology, and the Foundation for Opioid Response Efforts for work developing quality measures or programs such as the Emergency Quality Network intended to be used for CMS MIPS Program participation. A.K.V., S.M.B., and E.E.D. also receive support for contracted work from the Centers for Medicare and Medicaid Services to develop hospital and health care outcome and efficiency quality measures and rating systems. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: The Merit-based Incentive Payment System (MIPS), established as part of the Quality Payment Program, is a Medicare value-based payment program that evaluates clinicians' performance across 4 categories: quality, cost, promoting interoperability, and improvement activities. The cost category includes novel episode-based measures designed for targeted evaluation of the resource use of specific conditions. This report describes the development of episode-based cost measures and their role in the shift from volume-based to value-based purchasing., Objectives: Episode-based cost measures focus on resource use related to the treatment of a specific condition or procedure. The measures exclude health care costs unrelated to the condition or procedure of focus. The episode-based cost measures provide a nuanced examination of resource use that can be used alongside quality metrics to identify opportunities to improve the value by capturing costs that are clinically related to the care being delivered within a given patient-clinician relationship of care delivered to patients. These measures were developed with the input of clinical committees composed of over 320 clinicians from 127 specialty societies and stakeholder organizations. The MIPS program currently evaluates clinician cost category performance based on 2 population-based cost measures (Medicare spending per beneficiary and total per capita costs) in addition to 18 episode-based cost measures. Additional episode-based cost measures are currently under development., Conclusions and Relevance: The transition to value-based payment requires an accurate assessment of clinician effect on health care quality and cost. The use of episode-based cost measures to assess clinician influence on health care costs for high-priority conditions and procedures is an important step. The Centers for Medicare & Medicaid Services is introducing MIPS Value Pathways that will align episode-based cost measures with related quality measures to further incentivize the transition from fee-for-service to value-based care.

Objective: The objective of this study was to develop and test a measure that estimates unplanned, 30-day, all-cause risk-standardized readmission rates (RSRRs) after inpatient psychiatric facility (IPF) discharge., Participants: We established a retrospective cohort of adults with a principal diagnosis of psychiatric illness or dementia discharged from IPFs to nonacute care settings, using 2012-2013 Medicare fee-for-service claims data., Measures: All-cause unplanned readmissions within 3-30 days post-IPF discharge were assessed by constructing then validating a parsimonious logistic regression model of 56 risk factors (selected via empirical data, systematic literature review, clinical expert opinion) for readmission using bootstrapping. RSRRs were calculated from the ratio of predicted versus expected readmission rates for each IPF using hierarchical regression. Measure reliability and validity were assessed via multiple strategies., Results: The measure development cohort included 716,174 admissions to 1679 IPFs and 149,475 (20.9%) readmissions. Most readmissions (>80%) had principal diagnoses of mood, schizoaffective or substance use disorders, delirium/dementia, infections or drug/substance poisoning. Facility RSRRs ranged from 11.0% to 35.4%. The risk adjustment model showed good calibration and moderate discrimination similar to other readmission risk models (c statistic 0.66). Sensitivity analyses solidified the risk modeling approach. The intraclass correlation coefficient of estimated IPF RSRRs was 0.78, indicating good reliability. The measure identified 8.3% of hospitals as having better and 13.4% as having worse RSRRs than the national readmission rate., Conclusions: The measure provides an assessment of facility-level quality and insight into risk factors useful for informing preventive interventions. The measure will be included in the Centers for Medicare and Medicaid Services (CMS) Inpatient Psychiatric Quality Reporting program in 2019.

Chronic lymphocytic leukemia is a B-cell neoplasm with an indolent clinical course. Most patients are asymptomatic and are diagnosed incidentally on a routine blood count. The malignant cells of this low-grade neoplasm infiltrate various organs and tissues. However, the resultant end organ damage is a rare phenomenon. Here we describe a case of chronic lymphocytic leukemia that presented with an unusual cause of acute renal dysfunction. The patient had deranged renal parameters with a nephrotic range proteinuria. The uncommon cause for his renal problem was membranoproliferative glomerulonephritis diagnosed by performing a kidney biopsy. Moreover, the acute renal dysfunction in this patient mandated an appropriate treatment and as of now there are no well-established treatment protocols for chronic lymphocytic leukemia with nephrotic syndrome. The patient was successfully treated with rituximab and bendamustine based on the expertise and judgement of the clinician., Competing Interests: Compliance with Ethical Standards Conflicts of interest None of the authors of this manuscript has conflict of interest is publishing it. Human and Animal Rights This research does not involve human or animal subject, its merely presentation of a rare entity. Informed Consent Obtained.

Importance: Commercial virtual visits are an increasingly popular model of health care for the management of common acute illnesses. In commercial virtual visits, patients access a website to be connected synchronously-via videoconference, telephone, or webchat-to a physician with whom they have no prior relationship. To date, whether the care delivered through those websites is similar or quality varies among the sites has not been assessed., Objective: To assess the variation in the quality of urgent health care among virtual visit companies., Design, Setting, and Participants: This audit study used 67 trained standardized patients who presented to commercial virtual visit companies with the following 6 common acute illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection. The 8 commercial virtual visit websites with the highest web traffic were selected for audit, for a total of 599 visits. Data were collected from May 1, 2013, to July 30, 2014, and analyzed from July 1, 2014, to September 1, 2015., Main Outcomes and Measures: Completeness of histories and physical examinations, the correct diagnosis (vs an incorrect or no diagnosis), and adherence to guidelines of key management decisions., Results: Sixty-seven standardized patients completed 599 commercial virtual visits during the study period. Histories and physical examinations were complete in 417 visits (69.6%; 95% CI, 67.7%-71.6%); diagnoses were correctly named in 458 visits (76.5%; 95% CI, 72.9%-79.9%), and key management decisions were adherent to guidelines in 325 visits (54.3%; 95% CI, 50.2%-58.3%). Rates of guideline-adherent care ranged from 206 visits (34.4%) to 396 visits (66.1%) across the 8 websites. Variation across websites was significantly greater for viral pharyngitis and acute rhinosinusitis (adjusted rates, 12.8% to 82.1%) than for streptococcal pharyngitis and low back pain (adjusted rates, 74.6% to 96.5%) or ankle pain and recurrent urinary tract infection (adjusted rates, 3.4% to 40.4%). No statistically significant variation in guideline adherence by mode of communication (videoconference vs telephone vs webchat) was found., Conclusions and Relevance: Significant variation in quality was found among companies providing virtual visits for management of common acute illnesses. More variation was found in performance for some conditions than for others, but no variation by mode of communication.

Background: Return visits to the emergency department (ED) or hospital after an index ED visit strain the health system, but information about rates and determinants of revisits is limited., Objective: To describe revisit rates, variation in revisit rates by diagnosis and state, and associated costs., Design: Observational study using the Healthcare Cost and Utilization Project databases., Setting: 6 U.S. states., Patients: Adults with ED visits between 2006 and 2010., Measurements: Revisit rates and costs., Results: Within 3 days of an index ED visit, 8.2% of patients had a revisit; 32% of those revisits occurred at a different institution. Revisit rates varied by diagnosis, with skin infections having the highest rate (23.1% [95% CI, 22.3% to 23.9%]). Revisit rates also varied by state. For skin infections, Florida had higher risk-adjusted revisit rates (24.8% [CI, 23.5% to 26.2%]) than Nebraska (10.6% [CI, 9.2% to 12.1%]). In Florida, the only state with complete cost data, total revisit costs for the 19.8% of patients with a revisit within 30 days were 118% of total index ED visit costs for all patients (including those with and without a revisit)., Limitation: Whether a revisit reflects inadequate access to primary care, a planned revisit, the patient's nonadherence to ED recommendations, or poor-quality care at the initial ED visit remains unknown., Conclusion: Revisits after an index ED encounter are more frequent than previously reported, in part because many occur outside the index institution. Among ED patients in Florida, more resources are spent on revisits than on index ED visits., Primary Funding Source: Agency for Healthcare Research and Quality.

Recent studies have suggested that cytokines, and in particular tumor necrosis factor alpha (TNFα), have a role in modulating antidepressant efficacy. To directly test this idea, we compared the response of TNFα(-/-) mice and astrocyte-specific TNFα(-/-) mice to the antidepressants fluoxetine and desipramine. Using standard behavior models for measuring antidepressant efficacy, the forced swim test (FST) and tail suspension test (TST), we determined that TNFα(-/-) mice were essentially normal in basal behavior in the FST and TST. However, TNFα(-/-) mice showed no behavioral response to a standard dose of chronic antidepressant treatment, in sharp contrast to wildtype mice. Similar results were seen with acute antidepressant treatment, but TNFα(-/-) mice did respond to a very high-dose acute antidepressant treatment. We also assessed in vitro and in vivo effects of fluoxetine on TNFα expression. Glia responded to serotonin in vitro and fluoxetine in vivo by upregulating TNFα mRNA. Consistent with this source of TNFα, mice with an astrocyte-specific deletion of TNFα also did not respond to standard chronic antidepressant treatment. These data suggest that astrocytic TNFα is important to the sensitivity of the behavioral response to administration of antidepressants., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Systemic lupus erythematosus (SLE) has one of the highest hospital readmission rates among chronic conditions. This study was undertaken to identify patient-level, hospital-level, and geographic predictors of 30-day hospital readmissions associated with SLE., Methods: Using hospital discharge databases from 5 geographically dispersed states, we studied all-cause readmission of SLE patients between 2008 and 2009. We evaluated each hospitalization as a possible index event leading up to a readmission, our primary outcome. We accounted for clustering of hospitalizations within patients and within hospitals and adjusted for hospital case mix. Using multilevel mixed-effects logistic regression, we examined factors associated with 30-day readmission and calculated risk-standardized hospital-level and state-level readmission rates., Results: We examined 55,936 hospitalizations among 31,903 patients with SLE. Of these hospitalizations, 9,244 (16.5%) resulted in readmission within 30 days. In adjusted analyses, age was inversely related to risk of readmission. African American and Hispanic patients were more likely to be readmitted than white patients, as were those with Medicare or Medicaid insurance (versus private insurance). Several clinical characteristics of lupus, including nephritis, serositis, and thrombocytopenia, were associated with readmission. Readmission rates varied significantly between hospitals after accounting for patient-level clustering and hospital case mix. We also found geographic variation, with risk-adjusted readmission rates lower in New York and higher in Florida as compared to California., Conclusion: We found that ~1 in 6 hospitalized patients with SLE were readmitted within 30 days of discharge, with higher rates among historically underserved populations. Significant geographic and hospital-level variation in risk-adjusted readmission rates suggests potential for quality improvement., (Copyright © 2014 by the American College of Rheumatology.)

Minocycline is neuroprotective in animal models of a number of acute CNS injuries, neurodegenerative diseases and CNS infection. While anti-inflammatory and anti-apoptotic effects of Minocycline have been characterized, the molecular basis for the neuroprotective effects of Minocycline remains unclear. We report here that Minocycline and two classical antioxidant compounds inhibit the Japanese Encephalitis Virus (JEV)-induced free radical generation in mouse neuroblastoma. In cultures of Neuro2a (N2a) cells infected with JEV for up to 24h, the number of cells undergoing cell death was also reduced by Minocycline (20 microM). JEV infection resulted in increased oxidative stress, as revealed by an increase in the fluorescence intensity for 5-(and-6)-chloromethyl-2',7'-dichlorodihydrofluorescein diacetate (CM-H2DCFDA), a reactive oxygen species (ROS) indicator. Minocycline at 20 microM inhibited this ROS production. Cells were moderately protected from JEV-induced death by diphenyleneiodonium (DPI), an inhibitor of flavon-containing enzyme inhibitor, whereas common antioxidants such as N-acetyl-cysteine (NAC) turned out to be ineffective. Direct antioxidant property of Minocycline and reference antioxidant compounds is evaluated by LDH assay, ROS measurement and mitochondrial membrane potential measurement. Our findings suggest that Minocycline reduces the neuronal damage seen in JEV infection in neuronal cell culture models at least in part through inhibition of oxidative stress.

Background: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated., Objectives: The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs)., Methods: We reviewed the English-language literature for the years 1989-2007 for case series, cohort studies, and clinical trials addressing crowding's effects on COOs. Keywords searched included "ED crowding,""ED overcrowding,""mortality,""time to treatment,""patient satisfaction,""quality of care," and others., Results: A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding's effects on patient satisfaction and other quality endpoints., Conclusions: A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.

Objectives: The prehospital management of trauma patients remains controversial. Little is known about the time each procedure contributes to the on-scene duration, and this information would be helpful in prioritizing which procedures to perform in the prehospital setting. We sought to estimate the contribution of procedures to on-scene duration focusing on intubation and establishment of intravenous (IV) access., Methods: Data were provided by the Office of Emergency Planning and Response at the Mississippi Department of Health. Real-time prehospital patient-level data are collected by emergency medical services (EMS) providers for all 9-1-1 calls statewide. Linear regression was performed to determine the overall additional time for an average procedure and to calculate marginal increases in on-scene time associated with the establishment of IV access and with endotracheal intubation. Analyses were performed using Stata 9., Results: During 2001-2005, 192,055 prehospital runs were made for trauma patients. 121,495 (63%) included prehospital procedures. Average on-scene duration for those runs was 15:24 (minutes:seconds). On average, each procedure was associated with an addition of 1 minute to the on-scene duration (95% confidence interval [CI]: 58-62 seconds). A scene involving the establishment of IV access was 5:04 longer, while one involving tracheal intubation was 2:36 longer., Conclusions: We estimate the marginal increase in on-scene duration associated with the performance of an average procedure, establishment of IV access, and endotracheal intubation. There are policy and planning implications for the time trade-off of prehospital procedures, especially discretionary ones.

The anti-inflammatory cytokine interleukin (IL)-10 is synthesized in the central nervous system (CNS) and acts to limit clinical symptoms of stroke, multiple sclerosis, Alzheimer's disease, meningitis, and the behavioral changes that occur during bacterial infections. Expression of IL-10 is critical during the course of most major diseases in the CNS and promotes survival of neurons and all glial cells in the brain by blocking the effects of proinflammatory cytokines and by promoting expression of cell survival signals. In order to assess functional importance of this cytokine in viral encephalitis we have exploited an experimental model of Japanese encephalitis (JE). We report for the first time that in Japanese encephalitis, there is a progressive decline in level of IL-10. The extent of progressive decrease in IL-10 level following viral infection is inversely proportional to the increase in the level of proinflammatory cytokines as well as negative consequences that follows viral infection.

Chemokines and their receptors are important elements for the selective attraction and activation of various subsets of leukocytes. Interferon-gamma inducible protein (IP-10 or CXCL-10) is a potent chemoattractant and has been suggested to enhance the severity of virus infection and neuronal injury. In order to assess functional importance of this chemokine in viral encephalitis, we have exploited an experimental model of Japanese encephalitis. We report for the first time that in Japanese encephalitis, astrocytes are the predominant source of IP-10. A progressive increase in IP-10 induction following viral infection is concomitant with the increase in IFN-gamma a known inducer of IP-10. However, this increase in IFN-gamma level is not sufficient to confer protection as animals eventually succumb to the infection.

Correctly identifying and appropriately triaging patients who present to the ED with the broad range of symptoms suggestive of acute cardiac ischemia (ACI: unstable angina pectoris [UAP] and acute myocardial infarction [AMI]) remains one of the greatest challenges in EM. Although a number of diagnostic technologies have been described to aid in this triage process, each of these tests or technologies has limitations. We report a case series in which either the use of adjuncts with unknown performance or tests with known but not considered limitations could have contributed to the failure to appropriately triage and treat patients with ACI. Each case illustrates different aspects of this clinical challenge. One case illustrates the hazards of reliance on a single set of negative cardiac biomarkers. The limitations of a negative exercise electrocardiographic stress test (ETT) are illustrated in the second case. Finally, the limitations of a negative coronary angiogram, the "gold standard" test for symptomatic coronary artery disease, are discussed. We review the literature on technologies to aid in the evaluation of patients who present to the ED with symptoms suggestive of ACI.