Nancy Neil

Optimum percutaneous transluminal coronary angioplasty compared with routine stent strategy trial (OPUS-1): a randomised trial

BACKGROUND Whether routine implantation of coronary stents is the best strategy to treat flow-limiting coronary stenoses is unclear. An alternative approach is to do balloon angioplasty and provisionally use stents only to treat suboptimum results. We did a multicentre trial to compare the outcomes of patients treated with these strategies. METHODS We randomly assigned 479 patients undergoing single-vessel coronary angioplasty routine stent implantation or initial balloon angioplasty and provisional stenting. We followed up patients for 6 months to determine the composite rate of death, myocardial infarction, cardiac surgery, and target-vessel revascularisation. RESULTS Stents were implanted in 227 (98.7%) of the patients assigned routine stenting. 93 (37%) patients assigned balloon angioplasty had at least one stent placed because of suboptimum angioplasty results. At 6 months the composite endpoint was significantly lower in the routine stent strategy (14 events, 6.1%) than with the strategy of balloon angioplasty with provisional stenting (37 events, 14.9%, p=0.003). The cost of the initial revascularisation procedure was higher than when a routine stent strategy was used (US

Frequency and characteristics of cognitive services provided in response to a financial incentive.

389 vs

Epidemiology and healthcare costs of incident Clostridium difficile infections identified in the outpatient healthcare setting.

339, p<0.001) but at 6 months, average per-patient hospital costs did not differ (

Clostridium difficile infection, Colorado and the northwestern United States, 2007.

10,206 vs

Bladder Sensation Measures and Overactive Bladder

10,490). Bootstrap replication of 6-month cost data showed continued economic benefit of the routine stent strategy. INTERPRETATION Routine stent implantation leads to better acute and long-term clinical outcomes at a cost similar to that of initial balloon angioplasty with provisional stenting.

Learning to leverage existing information systems: Part 1. Principles.

OBJECTIVE To determine the effects of a financial incentive on the number and types of cognitive services (CS) provided by community pharmacies to Medicaid recipients in the State of Washington. DESIGN Prospective randomized trial. CS were reported using a problem-intervention-result coding system over a 20-month period. SETTING AND SUBJECTS Pharmacists practicing in 110 study (financial incentive) and 90 control community pharmacies. RESULTS Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period, significantly more than controls, who documented an average of 0.67 interventions (P < .05) per 100 prescriptions. One-half (48.4%) of all CS were for patient-related problems, 32.6% were for drug-related problems, 17.6% were for prescription-related problems, and 1.4% were for other problems that did not involve drug therapy. A change in drug therapy occurred as a result of 28% of all CS documented in this demonstration. Changes were rarely (2.4%) due to generic or therapeutic substitution and almost always (90%) followed communication with the prescriber. The average self-reported time to perform CS was 7.5 minutes; 75% of interventions were < or = 6 minutes. Considerable differences existed between study and control groups in the types of problems identified, intervention activities performed, and results of interventions. CONCLUSION A financial incentive was associated with significantly more, and different types of, CS performed by pharmacists.

PS1-23: The Incidence and Epidemiology of Inpatient and Outpatient Clostridium difficile Infections at Kaiser Permanente.

OBJECTIVE To describe the epidemiology and healthcare costs of Clostridium difficile infection (CDI) identified in the outpatient setting. DESIGN Population-based, retrospective cohort study. PATIENTS Kaiser Permanente Colorado and Kaiser Permanente Northwest members between June 1, 2005, and September 30, 2008. METHODS We identified persons with incident CDI and classified CDI by whether it was identified in the outpatient or inpatient healthcare setting. We collected information about baseline variables and follow-up healthcare utilization, costs, and outcomes among patients with CDI. We compared characteristics of patients with CDI identified in the outpatient versus inpatient setting. RESULTS We identified 3,067 incident CDIs; 56% were identified in the outpatient setting. Few strong, independent predictors of diagnostic setting were identified, although a previous stay in a nonacute healthcare institution (odds ratio [OR], 1.45 [95% confidence interval (CI), 1.13-1.86]) was statistically associated with outpatient-identified CDI, as was age from 50 to 59 years (OR, 1.64 [95% CI, 1.18-2.29]), 60 to 69 years (OR, 1.37 [95% CI, 1.03-1.82]), and 70 to 79 years (OR, 1.36 [95% CI, 1.06-1.74]), when compared with persons aged 80-89 years. CONCLUSIONS We found that more than one-half of incident CDIs in this population were identified in the outpatient setting. Patients with outpatient-identified CDI were younger with fewer comorbidities, although they frequently had previous exposure to healthcare. These data suggest that practitioners should be aware of CDI and obtain appropriate diagnostic testing on outpatients with CDI symptoms.

IDENTIFICATION OF MEASURES OF BLADDER SENSATION IN PATIENTS WITH OVERACTIVE BLADDER

To determine the incidence of Clostridium difficile infection during 2007, we examined infection in adult inpatient and outpatient members of a managed-care organization. Incidence was 14.9 C. difficile infections per 10,000 patient-years. Extrapolating this rate to US adults, we estimate that 284,875 C. difficile infections occurred during 2007.

Surgical treatment of hyperparathyroidism improves health-related quality of life.

PURPOSE We performed a prospective multicomponent study to determine whether subjective and objective bladder sensation instruments may provide data on sensory dysfunction in patients with overactive bladder. MATERIALS AND METHODS We evaluated 70 prospectively enrolled patients with urodynamics and questionnaires on validated urgency (Urgency Perception Score), general overactive bladder (Urogenital Distress Inventory) and quality of life (Incontinence Impact Questionnaire). We first sought a correlation between sensory specific (Urgency Perception Score) and quality of life questionnaire scores. We then assessed a correlation between sensory questionnaire scores and urodynamic variables, exploring the hypothesis that certain urodynamic parameters may be bladder sensation measures. We evaluated 2 urodynamic derivatives (first sensation ratio and bladder urgency velocity) to increase sensory finding discrimination. RESULTS We noted a moderate correlation between the Urgency Perception Score (0.56) and the Urogenital Distress Inventory (0.74) vs the Incontinence Impact Questionnaire (each p <0.01). A weak negative correlation was seen between Urgency Perception Score and bladder capacity (-0.25, p <0.05). No correlation was noted for the other urodynamics parameters. First sensation ratio and bladder urgency velocity statistically significantly correlated with the Urgency Perception Score despite the lesser or absent correlation associated with the individual components of these derivatives. CONCLUSIONS Bladder sensation questionnaires may be valuable to identify patients with sensory dysfunction and provide additional data not obtained in generalized symptom questionnaires. Urodynamic variables correlated with bladder sensation questionnaire scores and may be an objective method to assess sensory dysfunction.

Influence of a Financial Incentive on Cognitive Services: CARE Project Design/Implementation

BACKGROUND The success of performance improvement efforts depends on effective measurement and feedback regarding clinical processes and outcomes. Yet most health care organizations have fragmented rather than integrated data systems. Methods and practical guidance are provided for leveraging available information sources to obtain and create valid performance improvement-related information for use by clinicians and administrators. CASE VIGNETTE At Virginia Mason Health System (VMHS; Seattle), a vertically integrated hospital and multispecialty group practice, patient records are paper based and are supplemented with electronic reporting for laboratory and radiology services. Despite growth in the resources and interest devoted to organization-wide performance measurement, quality improvement, and evidence-based tools, VMHSs information systems consist of largely stand-alone, legacy systems organized around the ability to retrieve information on patients, one at a time. By 2002, without any investment in technology, VMHS had developed standardized, clinic-wide key indicators of performance updated and reported regularly at the patient, provider, site, and organizational levels. LEVERAGING EXISTING SYSTEMS On the basis of VHMSs experience, principles can be suggested to guide other organizations to explore solutions using their own information systems: for example, start simply, but start; identify information needs; tap multiple data streams; and improve incrementally.