Valentin Prieto-Centurion

Interventions to Reduce Rehospitalizations after Chronic Obstructive Pulmonary Disease Exacerbations. A Systematic Review

RATIONALE Approximately 20% of patients hospitalized for COPD exacerbations in the United States will be readmitted within 30 days. The Centers for Medicare and Medicaid Services has recently proposed to revise the Hospital Readmissions Reduction Program to financially penalize hospitals with high all-cause 30-day rehospitalization rates after a hospitalization for COPD exacerbation on or after October 1, 2014. OBJECTIVES To report the results of a systematic review of randomized clinical trials evaluating interventions to reduce the rehospitalizations after COPD exacerbations. METHODS Multiple electronic databases were systematically searched to identify relevant studies published between January 1966 and June 2013. Titles, abstracts, and, subsequently, full-text articles were assessed for eligibility. Each study was appraised using predefined criteria. MEASUREMENTS AND MAIN RESULTS Among 913 titles and abstracts screened, 5 studies (1,393 participants) met eligibility criteria. All studies had a primary outcome of rehospitalization at 6 or 12 months. No study examined 30-day rehospitalization as the primary outcome. Each study tested a different set of interventions. Two studies (one conducted in Canada and one conducted in Spain and Belgium) showed a decrease in all-cause rehospitalization over 12 months in the intervention group versus comparator group (mean number of hospitalizations per patient, 1.0 vs. 1.8; P = 0.01; percent hospitalized, 45 vs. 67%; P = 0.028; respectively). The only study conducted in the United States found a greater than twofold higher risk of mortality in the intervention group (17 vs. 7%, P = 0.003) but no significant difference in rehospitalizations. It was unclear which set of interventions was effective or harmful. CONCLUSIONS The evidence base is inadequate to recommend specific interventions to reduce rehospitalizations in this population and does not justify penalizing hospitals for high 30-day rehospitalization rates after COPD exacerbations.

Health Monitors for Chronic Disease by Gait Analysis with Mobile Phones

We have developed GaitTrack, a phone application to detect health status while the smartphone is carried normally. GaitTrack software monitors walking patterns, using only accelerometers embedded in phones to record spatiotemporal motion, without the need for sensors external to the phone. Our software transforms smartphones into health monitors, using eight parameters of phone motion transformed into body motion by the gait model. GaitTrack is designed to detect health status while the smartphone is carried during normal activities, namely, free-living walking. The current method for assessing free-living walking is medical accelerometers, so we present evidence that mobile phones running our software are more accurate. We then show our gait model is more accurate than medical pedometers for counting steps of patients with chronic disease. Our gait model was evaluated in a pilot study involving 30 patients with chronic lung disease. The six-minute walk test (6 MWT) is a major assessment for chronic heart and lung disease, including congestive heart failure and especially chronic obstructive pulmonary disease (COPD), affecting millions of persons. The 6 MWT consists of walking back and forth along a measured distance for 6 minutes. The gait model using linear regression performed with 94.13% accuracy in measuring walk distance, compared with the established standard of direct observation. We also evaluated a different statistical model using the same gait parameters to predict health status through lung function. This gait model has high accuracy when applied to demographic cohorts, for example, 89.22% accuracy testing the cohort of 12 female patients with ages 50-64 years.

Multicenter Study Comparing Case Definitions Used to Identify Patients with Chronic Obstructive Pulmonary Disease

RATIONALE Clinical trials in chronic obstructive pulmonary disease (COPD) usually require evidence of airflow obstruction and clinical risk factors. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes or patient-reported physician diagnoses are often used for epidemiologic studies and performance improvement programs. OBJECTIVES To evaluate agreement between these case definitions for COPD and to assess the comparability of study populations identified as having COPD not using the clinical trial reference standard. METHODS We recruited patients from the COPD Outcomes-based Network for Clinical Effectiveness and Research Translation multicenter clinical registry in a cross-sectional study. Demographics, clinical, and post-bronchodilator spirometry data were collected at an in-person study visit. The kappa statistic (κ) was used to evaluate agreement. A multivariable logistic regression model was used to identify patient characteristics associated with meeting the trial reference standard. MEASUREMENTS AND MAIN RESULTS A total of 998 (82.8%) of 1,206 study participants met at least one case definition for COPD (of the 998: 91% using ICD-9 codes, 73% using patient-reported physician diagnosis, 56% using trial reference standard); agreement between case definitions was poor (κ = 0.20-0.26). Lack of airflow obstruction was the principal (89%) reason patients identified as having COPD did not meet the trial reference standard. Patients who were black (vs. white), obese (vs. normal weight), or had depression (vs. not) were less likely to meet the trial reference standard (odds ratio [95% CI], 0.37 [0.26-0.53], 0.51 [0.34-0.75], 0.53 [0.40-0.71], respectively). CONCLUSIONS Findings highlight concerns about the applicability of findings in clinical trials to patients meeting other case definitions for COPD.

GaitTrack: Health Monitoring of Body Motion from Spatio-Temporal Parameters of Simple Smart Phones

Detecting abnormal health is an important issue for mobile health, especially for chronic diseases. We present a free-living health monitoring system based on simple standalone smart phones, which can accurately compute walking speed. This phone app can be used to validate status of the major chronic condition, Chronic Obstructive Pulmonary Disease (COPD), by estimating gait speed of actual patients. We first show that smart phone sensors are as accurate for monitoring gait as expensive medical accelerometers. We then propose a new method of computing human body motion to estimate gait speed from the spatio-temporal gait parameters generated by regular phone sensors. The raw sensor data is processed in both time and frequency domain and pruned by a smoothing algorithm to eliminate noise. After that, eight gait parameters are selected as the input vector of a support vector regression model to estimate gait speed. For trained subjects, the overall root mean square error of absolute gait speed is <0.088 m/s, and the error rate is <6.11%. We design GaitTrack, a free living health monitor which runs on Android smart phones and integrates known activity recognition and position adjustment technology. The GaitTrack system enables the phone to be carried normally for health monitoring by transforming carried spatio-temporal motion into stable human body motion with energy saving sensor control for continuous tracking. We present validation by monitoring COPD patients during timed walk tests and healthy subjects during free-living walking. We show that COPD patients can be detected by spatio-temporal motion and abnormal health status of healthy subjects can be detected by personalized trained models with accuracy >84%.

Chronic Obstructive Pulmonary Disease Readmissions at Minority-serving Institutions

About 20% of patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations are readmitted within 30 days. High 30-day risk-standardized readmission rates after COPD exacerbations will likely place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services starting in fiscal year 2015. Factors contributing to hospital readmissions include healthcare quality, access to care, coordination of care between hospital and ambulatory settings, and factors linked to socioeconomic resources (e.g., social support, stable housing, transportation, and food). These concerns are exacerbated at minority-serving institutions, which provide a disproportionate share of care to patients with low socioeconomic resources. Solutions tailored to the needs of minority-serving institutions are urgently needed. We recommend research that will provide the evidence base for strategies to reduce readmissions at minority-serving institutions. Promising innovative approaches include using a nontraditional healthcare workforce, such as community health workers and peer-coaches, and telemedicine. These strategies have been successfully used in other conditions and need to be studied in patients with COPD.

Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution

Limited socioeconomic resources contribute to high readmission rates at minority serving institutions (MSIs). A better understanding of patient-level factors and need for patient navigators could inform approaches to enhance care transitions tailored to these vulnerable patient populations. We sought to understand the perspectives of patients and their caregivers about hospital to home transitions from an MSI, as well as their attitudes about patient navigators to facilitate care transitions. We conducted qualitative research using focus groups (FGs)—five disease-specific patient FGs and two caregiver FGs, including 23 patients and 10 caregivers. Findings support the need for additional services to address: (1) gaps in the hospital discharge; (2) socioeconomic resources; (3) access to post-discharge care; (4) patient’s health care seeking behaviors; (5) patient anxiety; (6) self-management education; and (7) social supports for patients and caregivers. While caregivers uniformly expressed interest in patient navigators, support for navigators among patients was more variable.

Thoracic splenosis: History is the key

Splenosis is an acquired ectopic autotransplantation of splenic tissue; that occurs after traumatic splenic rupture and splenectomy [1]. Splenosis is a rare but benign disease, and the diagnosis can be challenging as the multiple incidentally found nodules could mimic malignancy [2]. Abdominopelvic Splenosis is thought to occur in as many as 65% of cases of splenic rupture [1]. However, Thoracic Splenosis is rare and usually involve the left parietal and visceral pleura [1,2]. Intraparenchymal lesions are less common but have been reported in cases of parenchymal and diaphragm laceration [1,2]. Taking a thorough history is of utmost importance, as these patients usually present more than two decades after the splenic traumatic rupture. The use of commonly available nuclear studies will further confirm the diagnosis [3]. This will help to avoid unnecessary procedures, like biopsies; and prevent the potential complications. We present a case of Thoracic Splenosis that highlights the importance of taking a detailed history; and the importance of using nuclear studies for the diagnosis. Further adding to its uniqueness, this case showed with multiple intraparenchymal nodules which is a less common presentation of Splenosis.

COPD Bundle to Prevent Hospital Readmissions and ED Visits

Th e search for interventions to reduce avoidable readmissions aft er an exacerbation of COPD has attracted substantial attention aft er the Centers for Medicare & Medicaid Services included COPD exacerbations in its Hospital Readmissions Reduction Program. 1 We read with great interest the study by Jennings et al 2 in a recent issue of CHEST (May 2015) and applaud the authors for conducting a randomized clinical trial to test the eff ects of a predischarge care bundle. Th e study demonstrated a numerically lower but not statistically signifi cant risk of 30-day readmissions or visits to the ED in the intervention group (risk diff erence, 2 3.4%; 95% CI, 2 15.7% to 8.8%). Th e authors acknowledged several potential limitations in the study design, including relying on the primary team to implement interventions directed at risk factors identifi ed by the researchers and the selective eligibility criteria.