Christopher A. Beadles

Trends in Emergent Hernia Repair in the United States

IMPORTANCE Abdominal wall hernia is one of the most common conditions encountered by general surgeons. Rising rates of abdominal wall hernia repair have been described; however, population-based evidence concerning incidence rates of emergent hernia repair and changes with time are unknown. OBJECTIVE To examine trends in rates of emergent abdominal hernia repair within the United States for inguinal, femoral, ventral, and umbilical hernias from January 1, 2001, to December 31, 2010. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of adults with emergent hernia repair using National Center for Health Statistics data, a nationally representative sample of inpatient hospitalizations in the United States that occurred from January 1, 2001, to December 31, 2010. All emergent hernia repairs were identified during the study period. MAIN OUTCOMES AND MEASURES Incidence rates per 100,000 person-years, age, and sex adjusted to the 2010 US census population estimates were calculated for selected subcategories of emergent hernia repairs and time trends were evaluated. RESULTS An estimated 2.3 million inpatient abdominal hernia repairs were performed from 2001 to 2010; of which an estimated 567,000 were performed emergently. A general increase in the rate of total emergent hernias was observed from 16.0 to 19.2 emergent hernia repairs per 100,000 person-years in 2001 and 2010, respectively. In 2010, emergent hernia rates were highest among adults 65 years and older, with 71.3 and 42.0 emergent hernia repairs per 100,000 person-years for men and women, respectively. As expected, femoral hernia rates were higher among women while emergent inguinal hernia rates were higher among men. Rates of emergent incisional hernia repair were high but relatively stable among older women, with 24.9 and 23.5 per 100,000 person-years in 2001 and 2010, respectively. However, rates of emergent incisional hernia repair among older men rose significantly, with 7.8 to 32.0 per 100,000 person-years from 2001 to 2010, respectively. CONCLUSIONS AND RELEVANCE These increasing rates of emergent incisional hernia repair are troublesome owing to the significantly increased risk morbidity and mortality associated with emergent hernia repair. While this increased mortality risk is multifactorial, it is likely associated with older age and the accompanying serious comorbidities.

Association between Initial Fluid Choice and Subsequent In-hospital Mortality during the Resuscitation of Adults with Septic Shock

Background:Currently, guidelines recommend initial resuscitation with intravenous (IV) crystalloids during severe sepsis/septic shock. Albumin is suggested as an alternative. However, fluid mixtures are often used in practice, and it is unclear whether the specific mixture of IV fluids used impacts outcomes. The objective of this study is to test the hypothesis that the specific mixture of IV fluids used during initial resuscitation, in severe sepsis, is associated with important in-hospital outcomes. Methods:Retrospective cohort study includes patients with severe sepsis who were resuscitated with at least 2 l of crystalloids and vasopressors by hospital day 2, patients who had not undergone any major surgical procedures, and patients who had a hospital length of stay (LOS) of at least 2 days. Inverse probability weighting, propensity score matching, and hierarchical regression methods were used for risk adjustment. Patients were grouped into four exposure categories: recipients of isotonic saline alone (“Sal” exclusively), saline in combination with balanced crystalloids (“Sal + Bal”), saline in combination with colloids (“Sal + Col”), or saline in combination with balanced crystalloids and colloids (“Sal + Bal + Col”). In-hospital mortality was the primary outcome, and hospital LOS and costs per day (among survivors) were secondary outcomes. Results:In risk-adjusted Inverse Probability Weighting analyses including 60,734 adults admitted to 360 intensive care units across the United States between January 2006 and December 2010, in-hospital mortality was intermediate in the Sal group (20.2%), lower in the Sal + Bal group (17.7%, P < 0.001), higher in the Sal + Col group (24.2%, P < 0.001), and similar in the Sal + Bal + Col group (19.2%, P = 0.401). In pairwise propensity score–matched comparisons, the administration of balanced crystalloids by hospital day 2 was consistently associated with lower mortality, whether colloids were used (relative risk, 0.84; 95% CI, 0.76 to 0.92) or not (relative risk, 0.79; 95% CI, 0.70 to 0.89). The association between colloid use and in-hospital mortality was inconsistent, and survival was not uniformly affected, whereas LOS and costs per day were uniformly increased. Results were robust in sensitivity analyses. Conclusions:During the initial resuscitation of adults with severe sepsis/septic shock, the types of IV fluids used may impact in-hospital mortality. When compared with the administration of isotonic saline exclusively during resuscitation, the coadministration of balanced crystalloids is associated with lower in-hospital mortality and no difference in LOS or costs per day. When colloids are coadministered, LOS and costs per day are increased without improved survival. A large randomized controlled trial evaluating crystalloid choice is warranted. Meanwhile, the use of balanced crystalloids seems reasonable. (Anesthesiology 2015; 123:1385-93)

Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury

OBJECT Disparities in access to inpatient rehabilitation services after traumatic brain injury (TBI) have been identified, but less well described is the likelihood of discharge to a higher level of rehabilitation for Hispanic or black patients compared with non-Hispanic white patients. The authors investigate racial disparities in discharge destination (inpatient rehabilitation vs skilled nursing facility vs home health vs home) following TBI by using a nationwide database and methods to address racial differences in prehospital characteristics. METHODS Analysis of discharge destination for adults with moderate to severe TBI was performed using National Trauma Data Bank data for the years 2007-2010. The authors performed propensity score weighting followed by ordered logistic regression in their analytical sample and in a subgroup analysis of older adults with Medicare. Likelihood of discharge to a higher level of rehabilitation based on race/ethnicity accounting for prehospital and in-hospital variables was determined. RESULTS The authors identified 299,205 TBI incidents: 232,392 non-Hispanic white, 29,611 Hispanic, and 37,202 black. Propensity weighting resulted in covariate balance among racial groups. Hispanic (adjusted OR 0.71, 95% CI 0.68-0.75) and black (adjusted OR 0.94, 95% CI 0.91-0.97) populations were less likely to be discharged to a higher level of rehabilitation than were non-Hispanic whites. The subgroup analysis indicated that Hispanic (adjusted OR 0.79, 95% CI 0.71-0.86) and black (OR 0.87, 95% CI 0.81-0.94) populations were still less likely to receive a higher level of rehabilitation, despite uniform insurance coverage (Medicare). CONCLUSIONS Adult Hispanic and black patients with TBI are significantly less likely to receive intensive rehabilitation than their non-Hispanic white counterparts; notably, this difference persists in the Medicare population (age ≥ 65 years), indicating that uniform insurance coverage alone does not account for the disparity. Given that insurance coverage and a wide range of prehospital characteristics do not eliminate racial disparities in discharge destination, it is crucial that additional unmeasured patient, physician, and institutional factors be explored to eliminate them.

Do medical homes increase medication adherence for persons with multiple chronic conditions

Background:Medications are an integral component of management for many chronic conditions, and suboptimal adherence limits medication effectiveness among persons with multiple chronic conditions (MCC). Medical homes may provide a mechanism for increasing adherence among persons with MCC, thereby enhancing management of chronic conditions. Objective:To examine the association between medical home enrollment and adherence to newly initiated medications among Medicaid enrollees with MCC. Research Design:Retrospective cohort study comparing Community Care of North Carolina medical home enrollees to nonenrollees using merged North Carolina Medicaid claims data (fiscal years 2008–2010). Subjects:Among North Carolina Medicaid-enrolled adults with MCC, we created separate longitudinal cohorts of new users of antidepressants (N=9303), antihypertensive agents (N=12,595), oral diabetic agents (N=6409), and statins (N=9263). Measures:Outcomes were the proportion of days covered (PDC) on treatment medication each month for 12 months and a dichotomous measure of adherence (PDC>0.80). Our primary analysis utilized person-level fixed effects models. Sensitivity analyses included propensity score and person-level random-effect models. Results:Compared with nonenrollees, medical home enrollees exhibited higher PDC by 4.7, 6.0, 4.8, and 5.1 percentage points for depression, hypertension, diabetes, and hyperlipidemia, respectively (P’s<0.001). The dichotomous adherence measure showed similar increases, with absolute differences of 4.1, 4.5, 3.5, and 4.6 percentage points, respectively (P’s<0.001). Conclusions:Among Medicaid enrollees with MCC, adherence to new medications is greater for those enrolled in medical homes.

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development

ABSTRACTBACKGROUNDPatient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.OBJECTIVEOur objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.DATA SOURCESWe searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.RESULTSFrom 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients’ preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.CONCLUSIONS/IMPLICATIONSThis model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.

Use of medical homes by patients with comorbid physical and severe mental illness.

Background:Patients with comorbid severe mental illness (SMI) may use primary care medical homes differently than other patients with multiple chronic conditions (MCC). Objective:To compare medical home use among patients with comorbid SMI to use among those with only chronic physical comorbidities. Research Design:We examined data on children and adults with MCC for fiscal years 2008–2010, using generalized estimating equations to assess associations between SMI (major depressive disorder or psychosis) and medical home use. Subjects:Medicaid and medical home enrolled children (age, 6–17 y) and adults (age, 18–64 y) in North Carolina with ≥2 of the following chronic health conditions: major depressive disorder, psychosis, hypertension, diabetes, hyperlipidemia, seizure disorder, asthma, and chronic obstructive pulmonary disease. Measures:We examined annual medical home participation (≥1 visit to the medical home) among enrollees and utilization (number of medical home visits) among participants. Results:Compared with patients without depression or psychosis, children and adults with psychosis had lower rates of medical home participation (−12.2 and −8.2 percentage points, respectively, P<0.01) and lower utilization (−0.92 and −1.02 visits, respectively, P<0.01). Children with depression had lower participation than children without depression or psychosis (−5.0 percentage points, P<0.05). Participation and utilization among adults with depression was comparable with use among adults without depression or psychosis (P>0.05). Conclusions:Overall, medical home use was relatively high for Medicaid enrollees with MCC, though it was somewhat lower among those with SMI. Targeted strategies may be required to increase medical home participation and utilization among SMI patients.

Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review

BACKGROUND Thromboprophylaxis regimens include pharmacologic and mechanical options such as intermittent pneumatic compression devices (IPCDs). There are a wide variety of IPCDs available, but it is uncertain if they vary in effectiveness or ease of use. This is a systematic review of the comparative effectiveness of IPCDs for selected outcomes (mortality, venous thromboembolism [VTE], symptomatic or asymptomatic deep vein thrombosis, major bleeding, ease of use, and adherence) in postoperative surgical patients. METHODS We searched MEDLINE (via PubMed), Embase, CINAHL, and Cochrane CENTRAL from January 1, 1995, to October 30, 2014, for randomized controlled trials, as well as relevant observational studies on ease of use and adherence. RESULTS We identified 14 eligible randomized controlled trials (2633 subjects) and 3 eligible observational studies (1724 subjects); most were conducted in joint arthroplasty patients. Intermittent pneumatic compression devices were comparable to anticoagulation for major clinical outcomes (VTE: risk ratio, 1.39; 95% confidence interval, 0.73-2.64). Limited data suggest that concurrent use of anticoagulation with IPCD may lower VTE risk compared with anticoagulation alone, and that IPCD compared with anticoagulation may lower major bleeding risk. Subgroup analyses did not show significant differences by device location, mode of inflation, or risk of bias elements. There were no consistent associations between IPCDs and ease of use or adherence. CONCLUSIONS Intermittent pneumatic compression devices are appropriate for VTE thromboprophylaxis when used in accordance with current clinical guidelines. The current evidence base to guide selection of a specific device or type of device is limited.

Heterogeneity in the quality of care for patients with multiple chronic conditions by psychiatric comorbidity

Background:Little is known about the quality of care received by Medicaid enrollees with multiple chronic conditions (MCCs) and whether quality is different for those with mental illness. Objectives:To examine cancer screening and single-disease quality of care measures in a Medicaid population with MCC and to compare quality measures among persons with MCC with varying medical comorbidities with and without depression or schizophrenia. Research Design:Secondary data analysis using a unique data source combining Medicaid claims with other administrative datasets from North Carolina’s mental health system. Subjects:Medicaid-enrolled adults aged 18 and older with ≥2 of 8 chronic conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, depression, or schizophrenia). Medicare/Medicaid dual enrollees were excluded due to incomplete data on their medical care utilization. Measures:We examined a number of quality measures, including cancer screening, disease-specific metrics, such as receipt of hemoglobin A1C tests for persons with diabetes, and receipt of psychosocial therapies for persons with depression or schizophrenia, and medication adherence. Results:Quality of care metrics was generally lower among those with depression or schizophrenia, and often higher among those with increasing levels of medical comorbidities. A number of exceptions to these trends were noted. Conclusions:Cancer screening and single-disease quality measures may provide a benchmark for overall quality of care for persons with MCC; these measures were generally lower among persons with MCC and mental illness. Further research on quality measures that better reflect the complex care received by persons with MCC is essential.

Strategic Planning to Reduce the Burden of Stroke Among Veterans Using Simulation Modeling to Inform Decision Making

Background and Purpose— Reducing the burden of stroke is a priority for the Veterans Affairs Health System, reflected by the creation of the Veterans Affairs Stroke Quality Enhancement Research Initiative. To inform the initiative’s strategic planning, we estimated the relative population-level impact and efficiency of distinct approaches to improving stroke care in the US Veteran population to inform policy and practice. Methods— A System Dynamics stroke model of the Veteran population was constructed to evaluate the relative impact of 15 intervention scenarios including both broad and targeted primary and secondary prevention and acute care/rehabilitation on cumulative (20 years) outcomes including quality-adjusted life years (QALYs) gained, strokes prevented, stroke fatalities prevented, and the number-needed-to-treat per QALY gained. Results— At the population level, a broad hypertension control effort yielded the largest increase in QALYs (35 517), followed by targeted prevention addressing hypertension and anticoagulation among Veterans with prior cardiovascular disease (27 856) and hypertension control among diabetics (23 100). Adjusting QALYs gained by the number of Veterans needed to treat, thrombolytic therapy with tissue-type plasminogen activator was most efficient, needing 3.1 Veterans to be treated per QALY gained. This was followed by rehabilitation (3.9) and targeted prevention addressing hypertension and anticoagulation among those with prior cardiovascular disease (5.1). Probabilistic sensitivity analysis showed that the ranking of interventions was robust to uncertainty in input parameter values. Conclusions— Prevention strategies tend to have larger population impacts, though interventions targeting specific high-risk groups tend to be more efficient in terms of number-needed-to-treat per QALY gained.

First Outpatient Follow-Up After Psychiatric Hospitalization: Does One Size Fit All?

OBJECTIVE Claims-based indicators of follow-up within seven and 30 days after psychiatric discharge have face validity as quality measures: early follow-up may improve disease management and guide appropriate service use. Yet these indicators are rarely examined empirically. This study assessed their association with subsequent health care utilization for adults with comorbid conditions. METHODS Postdischarge follow-up and subsequent utilization were examined among adults enrolled in North Carolina Medicaid who were discharged with claims-based diagnoses of depression or schizophrenia and not readmitted within 30 days. A total of 24,934 discharges (18,341 individuals) in fiscal years 2008-2010 were analyzed. Follow-up was categorized as occurring within 0-7 days, 8-30 days, or none in 30 days. Outcomes in the subsequent six months included psychotropic medication claims, adherence (proportion of days covered), number of hospital admissions, emergency department visits, and outpatient visits. RESULTS Follow-up within seven days was associated with greater medication adherence and outpatient utilization, compared with no follow-up in 30 days. This was observed for both follow-up with a mental health provider and with any provider. Adults receiving mental health follow-up within seven days had equivalent, or lower, subsequent inpatient and emergency department utilization as those without follow-up within 30 days. However, adults receiving follow-up with any provider within seven days were more likely than those with no follow-up to have an inpatient admission or emergency department visit in the subsequent six months. Few differences in subsequent utilization were observed between mental health follow-up within seven days versus eight to 30 days. CONCLUSIONS For patients not readmitted within 30 days, follow-up within 30 days appeared to be beneficial on the basis of subsequent service utilization.