Jove Graham

Increased traffic accident rates associated with shale gas drilling in Pennsylvania.

OBJECTIVES We examined the association between shale gas drilling and motor vehicle accident rates in Pennsylvania. METHODS Using publicly available data on all reported vehicle crashes in Pennsylvania, we compared accident rates in counties with and without shale gas drilling, in periods with and without intermittent drilling (using data from 2005 to 2012). Counties with drilling were matched to non-drilling counties with similar population and traffic in the pre-drilling period. RESULTS Heavily drilled counties in the north experienced 15-23% higher vehicle crash rates in 2010-2012 and 61-65% higher heavy truck crash rates in 2011-2012 than control counties. We estimated 5-23% increases in crash rates when comparing months with drilling and months without, but did not find significant effects on fatalities and major injury crashes. Heavily drilled counties in the southwest showed 45-47% higher rates of fatal and major injury crashes in 2012 than control counties, but monthly comparisons of drilling activity showed no significant differences associated with drilling. CONCLUSIONS Vehicle accidents have measurably increased in conjunction with shale gas drilling.

Readmission in the 30 days after percutaneous coronary intervention.

OBJECTIVES This study sought to identify the frequency and etiology of readmission within 30 days of percutaneous coronary intervention (PCI) in a large integrated healthcare system. BACKGROUND One-fifth of Medicare patients are readmitted within 30 days of hospitalization. Identifying the causes of readmission may help identify strategies to prevent readmission. METHODS All patients undergoing PCI (elective, urgent, and emergent) at our center between January 1, 2007, and April 12, 2010, were prospectively entered into the American College of Cardiology National Cardiovascular Data Registry. Patients readmitted to any hospital within 30 days of the index procedure were identified using an administrative database and telephone follow-up. Individual charts were reviewed independently by 2 investigators; disagreements regarding the cause for readmission were resolved by a third investigator. RESULTS During the study period, 3,255 PCI were performed, and 262 patients (8.0%) were readmitted within 30 days. Of these, 261 (99.6%) had medical records available for review. Reasons for readmission included: complications related to the PCI (n = 31, 11.9%); non-PCI cardiac causes related to index admission (n = 93, 35.6%); noncardiac causes related to index admission (n = 34, 13%); causes unrelated to the index admission (n = 103, 39.5%). Multivariable logistic regression modeling revealed that female sex, advanced age, peripheral arterial disease, prior valvular surgery, and PCI complications during the index procedure were associated with 30-day readmission. CONCLUSIONS Readmissions within 30 days due to complications related to PCI performed on index admission are rare (0.9% of all PCI) and are an infrequent cause of readmission (<12% of readmissions). Thirty-day readmission after PCI should not be used as a quality metric of PCI performance.

Postdischarge monitoring using interactive voice response system reduces 30-day readmission rates in a case-managed Medicare population.

Background:Automated home monitoring systems have been used to coordinate care to improve patient outcomes and reduce rehospitalizations, but with little formal study of efficacy. The Geisinger Monitoring Program (GMP) interactive voice response protocol is a post-hospital discharge telemonitoring system used as an adjunct to existing case management in a primary care Medicare population to reduce emergency department visits and hospital readmissions. Objectives:To determine if use of GMP reduced 30-day hospital readmission rates among case-managed patients. Research Design:A pre-post parallel quasi-experimental study. Methods:A total of 875 Medicare patients who were enrolled in the combined case-management and GMP program were compared with 2420 matched control patients who were only case managed. Claims data were used to document an acute care admission followed by a readmission within 30 days in the preintervention and postintervention periods (ie, before and during 2009). Regression modeling was used to estimate the within-patient effect of the intervention on readmission rates. Results:The use of GMP with case management was associated with a 44% reduction in 30-day readmissions in the study cohort (95% confidence interval, 23%−60%, P=0.0004), when using the control group to control for secular trends. Similar estimates were obtained when using different propensity score adjustment methods or different approaches to handling dropout observations. Conclusions:Investing in automated monitoring systems may reduce hospital readmission rates among primary care case-managed patients. Evidence from this quasi-experimental study demonstrates that the combination of telemonitoring and case management, as compared with case management alone, may significantly reduce readmissions in a Medicare Advantage population.

Impact of Chronic Kidney Disease Stage on Lower-extremity Arthroplasty

End-stage renal disease and dialysis is commonly associated with poor outcomes after joint replacement surgery. The goal of this study was to evaluate postoperative complications in patients with less advanced chronic kidney disease undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients who underwent THA or TKA between 2004 and 2011 with stage 1, 2, or 3 chronic kidney disease were retrospectively reviewed via an electronic medical record. The authors compared 377 patients who had stage 1 to 2 chronic kidney disease with 402 patients who had stage 3 chronic kidney disease. No significant differences in 90-day readmission or revision rates were found between the stage 1 to 2 and stage 3 patient groups. For patients with stage 3 chronic kidney disease, the overall mortality rate was greater than that in patients with stage 1 to 2 chronic kidney disease. However, when adjusted for comorbid disease, no significant increases were seen in joint infection, readmission, or early revision between patients with stage 1 to 2 chronic kidney disease vs patients with stage 3 chronic kidney disease. The overall incidence of infection was high (3.5%) but far less than reported for patients with end-stage renal disease, dialysis, and kidney transplant. In conclusion, patients with stage 1, 2, or 3 chronic kidney disease may have a higher than expected rate of prosthetic joint infection (3.5%) after total joint arthroplasty. Patients with stage 3 chronic kidney disease are at higher risk for postoperative mortality compared with those with lesser stages of kidney disease.

Pre- and postimplantation dynamic mechanical properties of silastic HP-100 finger joints

Dynamic mechanical properties of Silastic HP-100 finger joint implants were studied. Sixteen sections of unimplanted and 14 sections of retrieved implants were analyzed with standard thermal analysis techniques. Results show that implantation does not alter the viscoelastic properties of Silastic HP-100 elastomers. The authors conclude that fracture of Silastic HP-100 implants cannot be attributed to changes in rheologic properties of the implanted elastomer.

Reducing mortality in hip fracture patients using a perioperative approach and "Patient- Centered Medical Home" model: a prospective cohort study.

BackgroundHip fracture patients experience high morbidity and mortality rates in the first post-operative year after discharge. We compared mortality, utilization, costs, pain and function between two prospective cohorts of hip fracture patients, both managed with identical perioperative protocols and one group subsequently managed via a “Patient-Centered Medical Home” (PCMH) primary care management model.MethodsWe analyzed 6 and 12-month outcomes from two matched cohorts of patients who were surgically treated for hip fracture from January 1, 2010 to June 30, 2011 at two hospitals (n = 194). Controls did not receive PCMH and were matched to cases on surgery date, sex, age, and comorbidities. Mortality and healthcare utilization were the primary outcomes studied, with medical costs, quality of life, pain and function at 12 months assessed as secondary outcomes in a subgroup. Survival analysis, regression and Student-t testing were used with p < 0.05 considered significant.ResultsAt 6 months, PCMH patients had significantly lower mortality than patients receiving standard care (11% vs. 26%, p < 0.01). At 12 months, a difference persisted (23% vs. 30%, p = 0.12) but was no longer statistically significant. Mean quality of life scores were similar (0.73 vs. 0.76, p = 0.49) and Harris Hip score was slightly improved for PCMH (73 vs. 64, p = 0.04). Mean costs per patient per month were lower for PCMH but not significantly different (

What standards can (and can't) tell us about a spinal device.

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Levels of evidence have increased for musculoskeletal trauma questions on the orthopaedic in-training examination.

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The Use of Residual Collagenase for Single Digits With Multiple-Joint Dupuytren Contractures

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Role of Sonication for Detection of Infection in Explanted Orthopaedic Trauma Implants.

1452, p = 0.45 for non-pharmacy costs).ConclusionsPatients receiving aggressive post-discharge care from a PCMH program showed significant benefits in terms of reduced mortality at 6 months, with similar costs and functional outcomes at 12 months. PCMH was not shown to improve all outcomes studied, but these results suggest that ongoing Medical Home management can have some benefit for patients without negatively impacting function or cost.