Effective strategy for improving health care outcomes: Multidisciplinary care in cerebral infarction patients

A Multidisciplinary Algorithm for the Evaluation of Acute Neurologic Deficits Improves Management of Cryptogenic Stroke or Transient Ischemic Attack

The appropriate diagnosis and management of cryptogenic stroke and transient ischemic attack (TIA) is challenging and requires multidisciplinary involvement. Joint societal guidelines exist to guide the comprehensive evaluation of these entities. This study aimed to implement a standardized multidisciplinary diagnostic algorithm for cryptogenic stroke/TIA. We performed a retrospective analysis of patients admitted to the largest regional military healthcare center with stroke or TIA considered to be cryptogenic at the time of discharge. We abstracted baseline demographics and rates of extra- and intracranial imaging, transthoracic and transesophageal echocardiography, and event monitor orders at the time of discharge. The incidence of event monitor results at 30 days and six months were included. A diagnostic algorithm for evaluation of cryptogenic stroke/TIA was created and disseminated hospital-wide using increased compliance with neuroimaging, echocardiography, and cardiac rhythm monitoring as primary endpoints for our intervention. Post-intervention data abstraction revealed similar rates of extra- and intracranial imaging, but significantly greater rates of transthoracic echocardiography (70% vs. 87%, p 0.0073), inclusion of agitated saline study (41% vs. 65%, p 0.0024), and event monitors ordered at discharge (18% vs. 35%, p 0.0045). At six months there was a higher rate of event monitors obtained (24% vs. 45%, p 0.001). Our study showed implementation of an evidence-based diagnostic algorithm for evaluation of cryptogenic stroke/TIA increases appropriate use of echocardiography and event monitoring.

Multi-level models for heart failure patients' 30-day mortality and readmission rates: the relation between patient and hospital factors in administrative data

Background

This study aims at gathering evidence about the relation between 30-day mortality and 30-day unplanned readmission and patient and hospital factors. By definition, we refer to 30-day mortality and 30-day unplanned readmission as the number of deaths and non-programmed hospitalizations for any cause within 30 days after the incident heart failure (HF). In particular, the focus is on the role played by hospital-level factors.

Methods

A multi-level logistic model that combines patient- and hospital-level covariates has been developed to better disentangle the role played by the two groups of covariates. Later on, hospital outliers in term of better-than-expected/worst-than-expected performers have been identified by comparing expected cases vs. observed cases. Hospitals performance in terms of 30-day mortality and 30-day unplanned readmission rates have been visualized through the creation of funnel plots. Covariates have been selected coherently to past literature. Data comes from the hospital discharge forms for Heart Failure patients in the Lombardy Region (Northern Italy). Considering incident cases for HF in the timespan 2010–2012, 78,907 records for adult patients from 117 hospitals have been collected after quality checks.

Results

Our results show that 30-day mortality and 30-day unplanned readmissions are explained by hospital-level covariates, paving the way for the design and implementation of evidence-based improvement strategies. While the percentage of surgical DRG (OR = 1.001; CI (1.000–1.002)) and the hospital type of structure (Research hospitals vs. non-research public hospitals (OR = 0.62; CI (0.48–0.80)) and Non-research private hospitals vs. non-research hospitals OR = 0.75; CI (0.63–0.90)) are significant for mortality, the mean length of stay (OR = 0.96; CI (0.95–0.98)) is significant for unplanned readmission, showing that mortality and readmission rates might be improved through different strategies.

Conclusion

Our results confirm that hospital-level covariates do affect quality of care, and that 30-day mortality and 30-day unplanned readmission are affected by different managerial choices. This confirms that hospitals should be accountable for their “added value” to quality of care.

RBPJ polymorphisms associated with cerebral infarction diseases in Chinese Han population: A Clinical Trial/Experimental Study (CONSORT Compliant)

TRIAL DESIGN

Cerebral small vessel diseases (CSVDs) are a group of brain pathological processes involving cerebral small arteries, brain venules, and capillaries. The recombination signal-binding protein Jκ (RBPJ) is implicated in the pathogenesis of these diseases but its actual roles need confirmation. The aim of this work was to evaluate variations in RBPJ gene for their possible associations with the disease.

METHODS

The RBPJ gene was sequenced for 400 patients with cerebral infarction disease and 600 normal controls. The statistical analyses and Hardy-Weinberg equilibrium tests of the patients and control populations were conducted using the SPSS software (version 19.0) and Plink (version 1.9), Haploview software, and online software SNPSpD.

RESULTS

We characterized variants rs2871198, rs1397731, rs3822223, rs2077777, rs2270226, and rs2788861 within or near the RBPJ gene. The genetic heterozygosity of rs2871198, rs1397731, rs3822223, rs2077777, and rs2270226 was very high. Statistical analysis showed that the variants rs2270226 and rs2077777 in the gene were associated with the risk of cerebral infarction diseases in the Chinese Han population.

CONCLUSIONS

rs2270226 and rs2077777 in the RBPJ gene were associated with the risk of cerebral infarction diseases in the Chinese Han population.

Do Reduced Copayments Affect Mortality after Surgery due to Stroke? An Interrupted Time Series Analysis of a National Cohort Sampled in 2003-2012

BACKGROUND

The South Korean government introduced a policy in 2 phases, in September 2005 and in January 2010, for reducing copayments for patients with critical diseases, including stroke, to prevent excessive medical expenditures and to ease economic barriers. Previous studies of the effect of this policy were focused primarily on cancer. Therefore, we investigated the relationship between this policy and 1-year mortality after surgery among patients with stroke.

METHODS

We used data from the Korean National Health Insurance sampling cohort (n = 2173 in 2003-2012) and performed an interrupted time series analysis.

RESULTS

Approximately 26% of the patients died within 1 year after surgery. The time trends after reducing copayments from 10% to 5% (phase 2) were inversely associated with risk of 1-year mortality (relative risk = .855, 95% confidence interval: .749-.975; P = .0196). In addition, this inverse association was greater in patients with low incomes, of older ages, and with higher Charlson comorbidity indices.

CONCLUSIONS

The introduction of a policy for reducing copayments to ease excessive cost burdens for patients with stroke was positively associated with a reduced risk of 1-year mortality after surgical treatment due to stroke. On the basis of our results, health policy makers should make an effort to identify vulnerable populations and to overcome economic barriers for providing effective alternatives to ensure patients receive optimal health care.

The association between number of doctors per bed and readmission of elderly patients with pneumonia in South Korea

Background

There is an urgent need to reduce readmission of patients with pneumonia and improve quality of care. To assess the association between hospital resources and quality of care, we examined the effect of number of doctors per bed on 30-day readmission and investigated the combined effect of number of doctors per bed and number of beds.

Methods

We used nationwide cohort sample data of health insurance claims by the National Health Insurance Service (NHIS) from 2002 to 2013. Pneumonia admissions to acute care hospitals among 7446 inpatients older than 65 were examined. We conducted a multivariate Cox proportional hazard model to analyze the association between the number of doctors per bed and 30-day readmission, as well as that of pneumonia-specific 30-day readmission with the combined effects of number of doctors per bed and number of beds.

Results

Overall, 1421 (19.1%) patients were readmitted within 30 days and 756 (11.2%) patients were readmitted for pneumonia within 30 days. Patients with pneumonia treated by very low or low number of doctors per bed showed higher readmission (pneumonia-specific readmission: hazard ratio [HR] = 1. 406, 95% confidence interval [CI] = 1.072–1.843 for low number of doctors per bed; all-cause readmissions: HR = 1.276, 95% CI = 1.026–1.587 for very low number of doctors per bed, and HR = 1.280, 95% CI = 1.064–1.540 for low number of doctors per bed).

Conclusions

This empirical study showed that patients with pneumonia cared for in hospitals with more doctors were less likely to be readmitted. Pneumonia-specific 30-day readmission was also significantly associated with the combined effect of the number of doctors and the number of hospital beds.

Combined effects of age and polymorphisms in Notch3 in the pathogenesis of cerebral infarction disease

Cerebral infarction disease is a severe hypoxic ischemic tissue necrosis in the brain, often leading to long-term functional disability and residual impairments. The Notch signaling pathway plays key roles in proliferation and survival of the stem/progenitor cells of the central and peripheral nervous systems. Notch3 is an important member of the pathway, but the relationships between the genetic abnormalities and cerebral infarction disease still remain unclear. The aim of this work was to evaluate variations in Notch3 gene for their possible associations with the cerebral infarction disease. We sequenced the Notch3 gene for 260 patients with cerebral infarction disease, 300 normal controls with old ages and 300 normal controls with younger ages, and identified the variations. The statistical analyses were conducted using Chi-Square Tests as implemented in SPSS (version 19.0). The Hardy-Weinberg equilibrium test of the population was carried out using the online software OEGE. Six variations, including rs1044116, rs1044009, rs1044006, rs10408676, rs1043996 and rs16980398 within or near the Notch3 gene, were found. The genetic heterozygosity of rs1044116, rs1044009, rs1044006, and rs1043996 was very high, whereas that of rs10408676 and rs16980398 was very low. Statistical analyses showed that rs1044009 and rs1044006 were associated with the risk of cerebral infarction disease in the Chinese Han agedness population. The SNPs rs1044009 and rs1044006 in the Notch3 gene were associated with the risk of cerebral infarction diseases in the Chinese Han agedness population.

Readmission rates of South Korean psychiatric inpatients by inpatient volumes per psychiatrist

BACKGROUND

Readmission rates of psychiatric inpatients are higher in South Korea than other Organization for Economic Co-operation and Development (OECD) countries. In addition, the solution for readmission control is deficient based on the characteristics of the South Korean National Health Insurance (NHI) system. Therefore, it is necessary to identify ways to reduce psychiatric inpatient readmissions. This study investigated the relationship between inpatient volume per psychiatrist and the readmission rate of psychiatric inpatients in South Korea.

METHOD

We used NHI claim data (N = 37,796) from 53 hospitals to analyze readmission within 30 days for five diagnosis (organic mental disorders, mental and behavioral disorders due to psychoactive substance use, schizophrenia, mood disorders, neurotic disorders, and stress-related and somatoform disorders) between 2010 and 2013. We performed χ2 and analysis of variance tests to investigate associations between patient and hospital-level variables and readmission within 30 days. Finally, generalized estimating equation (GEE) models were analyzed to examine possible associations with readmission.

RESULTS

Readmissions within 30 days accounted for 1,598 (4.5 %) claims. Multilevel analysis demonstrated that inpatient volume per psychiatrist were inversely related with readmission within 30 days (low odds ratio [OR]: 0.38, 95 % confidence interval [CI]: 0.28-0.51; mid-low OR: 0.48, 95 % CI: 0.36-0.63; mid-high OR: 0.55, 95 % CI: 0.44-0.69; Q4 = ref). The subgroup analysis by diagnosis revealed that both "schizophrenia, schizotypal, and delusional disorders" and "mood disorders" had inverse relationships with readmission risk for all volume groups.

CONCLUSIONS

We observed an inverse association between inpatient volume per psychiatrist and the 30-day readmission rate of psychiatric inpatients, suggesting that it could be a useful quality indicator in mental health care.

Tocilizumab inhibits neuronal cell apoptosis and activates STAT3 in cerebral infarction rat model

Cerebral infarction is a severe hypoxic ischemic necrosis with accelerated neuronal cell apoptosis in the brain. As a monoclonal antibody against interleukin 6, tocilizumab (TCZ) is widely used in immune diseases, whose function in cerebral infarction has not been studied. This study aims to reveal the role of TCZ in regulating neuronal cell apoptosis in cerebral infarction. The cerebral infarction rat model was constructed by middle cerebral artery occlusion and treated with TCZ. Cell apoptosis in hippocampus and cortex of the brain was examined with TUNEL method. Rat neuronal cells cultured in oxygen-glucose deprivation (OGD) conditions and treated with TCZ were used to compare cell viability and apoptosis. Apoptosis-related factors including B-cell lymphoma extra large (Bcl-xL) and Caspase 3, as well as the phosphorylated signal transducer and activator of transcription 3 (p-STAT3) in brain cortex were analyzed from the protein level. Results indicated that TCZ treatment could significantly prevent the promoted cell apoptosis caused by cerebral infarction or OGD (P < 0.05 or P < 0.01). In brain cortex of the rat model, TCZ up-regulated Bcl-xL and down-regulated Caspase 3, consistent with the inhibited cell apoptosis. It also promoted tyrosine 705 phosphorylation of STAT3, which might be the potential regulatory mechanism of TCZ in neuronal cells. This study provided evidence for the protective role of TCZ against neuronal cell apoptosis in cerebral infarction. Based on these fundamental data, TCZ is a promising option for treating cerebral infarction, but further investigations on related mechanisms are still necessary.