Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database

BACKGROUND

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid.

METHODS

All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits.

RESULTS

For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of "unnecessary" transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits.

CONCLUSION

A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.

Data Sharing Between Providers and Quality Initiatives Eliminate Unnecessary Nursing Home Admissions

BACKGROUND

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) has monitored discharge disposition, after total hip and knee arthroplasties, since inception in 2012 and found the standardized risk of extended care facility (ECF) placement to be highly variable between hospitals.

METHODS

The variation in standardized risks of ECF placement among MARCQI member sites was reported to the collaborative. At the May 2, 2014 quarterly meeting, a quality initiative was started, emphasizing the wide variability between hospitals, the contribution of hospital and surgeon to that variability using median odds ratios, and the need for outlier hospitals to initiate quality improvement (QI) processes. Patients from 29 hospitals that were members of MARCQI before the intervention were included in this analysis. We compared standardized risks before and after the intervention in the entire cohort, and for 3 hospitals that implemented institution-specific QI projects. We report changes in ECF placement, length of stay, emergency room visits, and readmissions over time.

RESULTS

This study includes 31,347 patients before and 20,879 patients after the implementation of the quality initiative. The range in standardized risk dropped from 9.4%-46.1% to 9.4%-32.4% and the average dropped from 23.0% to 19.6%. Three outlier hospitals decreased their absolute risk of ECF placement by 12.2%, 8.9%, and 12.4% after QI, without increases in adverse outcomes.

CONCLUSION

Discharge to ECF after primary hip and knee arthroplasties is highly variable and influenced by hospital and surgeon practices. Hospital-level QI measures can decrease ECF admissions.

Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children

OBJECTIVES

We describe children's postconcussive symptoms (PCSs), neurocognitive function, and recovery during 4 to 5 weeks after mild traumatic brain injury (MTBI) and compare performance and recovery with those of injured control group participants without MTBIs.

METHODS

A prospective, longitudinal, observational study was performed with a convenience sample from a tertiary care, pediatric emergency department. Participants were children 10 to 17 years of age who were treated in the emergency department and discharged. The MTBI group included patients with blunt head trauma, Glasgow Coma Scale scores of 13 to 15, loss of consciousness for < or = 30 minutes, posttraumatic amnesia of < or = 24 hours, altered mental status, or focal neurologic deficits, and no intracranial abnormalities. The control group included patients with injuries excluding the head. The Post-Concussion Symptom Questionnaire and domain-specific neurocognitive tests were completed at baseline and at 1 and 4 to 5 weeks after injury.

RESULTS

Twenty-eight MTBI group participants and 45 control group participants were compared. There were no significant differences in demographic features. Control group participants reported some PCSs; however, MTBI group participants reported significantly more PCSs at all times. Among MTBI group participants, PCSs persisted for 5 weeks after injury, decreasing significantly between 1 and 4 to 5 weeks. Patterns of recovery on the Trail-Making Test Part B differed significantly between groups; performance on other neurocognitive measures did not differ.

CONCLUSIONS

In children 10 to 17 years of age, self-reported PCSs were not exclusive to patients with MTBIs. However, PCSs and recovery patterns for the Trail-Making Test Part B differed significantly between the groups.

Methylphenidate and cocaine: A placebo-controlled drug interaction study

Up to thirty percent of cocaine addicted individuals may meet diagnostic criteria for Attention-Deficit/Hyperactivity Disorder (ADHD). Methylphenidate (MPH) is a highly effective and commonly used treatment for ADHD but, like cocaine, is a cardiovascular and central nervous system stimulant with the potential to cause toxicity at high doses. The present study was undertaken to investigate the likelihood of a toxic reaction in individuals who use cocaine while concurrently taking MPH. Seven non-treatment seeking cocaine-dependent individuals completed this placebo-controlled, crossover study with two factors: Medication (placebo, 60 mg MPH, 90 mg MPH) and Infusion (saline, 20 mg cocaine, 40 mg cocaine). Physiological measures included vital signs, adverse events, and electrocardiogram. Subjective response was measured with visual analog scale (VAS) ratings of craving and drug effect. Cocaine pharmacokinetic parameters were calculated for each participant at each drug combination, using a non-compartmental model. MPH was well tolerated, did not have a clinically significant impact on cocaine's physiological effects, and decreased some of the positive subjective effects of cocaine. MPH did not significantly alter the pharmacokinetics of cocaine. The study results suggest that MPH at the doses studied can likely be used safely in an outpatient setting with active cocaine users.

A placebo-controlled screening trial of tiagabine, sertraline and donepezil as cocaine dependence treatments

AIMS

To conduct a preliminary evaluation of the safety and efficacy of tiagabine, sertraline or donepezil versus an unmatched placebo control as a treatment for cocaine dependence.

DESIGN

A 10-week out-patient study was conducted using the Cocaine Rapid Efficacy and Safety Trial (CREST) study design.

SETTING

This study was conducted at the Cincinnati Medication Development Research Unit (MDRU) and at an affiliated site in Dayton, Ohio.

PARTICIPANTS

Participants met Diagnostic and Statistical Manual version IV (DSM-IV) criteria for cocaine dependence. Sixty-seven participants were enrolled with 55 completing final study measures.

INTERVENTION

The targeted daily doses of medication were tiagabine 20 mg, sertraline 100 mg and donepezil 10 mg. All participants received 1 hour of manualized individual cognitive behavioral therapy on a weekly basis.

MEASUREMENTS

Primary outcome measures of efficacy included urine benzoylecgonine (BE) level, Cocaine Clinical Global Impression Scale-Observer and self-report of cocaine use. Safety measures included adverse events, ECGs, vital signs and laboratory tests.

FINDINGS

Subjective measures of cocaine dependence indicated significant improvement for all study groups. Generalized estimating equations analysis indicated that the tiagabine group showed a trend toward a significant decrease in urine BE level from baseline to weeks 5-8 (P = 0.10) and non-significant changes for the other study groups. No pattern of physical or laboratory abnormalities attributable to treatment with any of the medications was identified. There were three serious adverse events reported, none of which were related to study procedures.

CONCLUSIONS

The present findings suggest that tiagabine may be worthy of further study as a cocaine dependence treatment.

A medication screening trial evaluation of reserpine, gabapentin and lamotrigine pharmacotherapy of cocaine dependence

AIMS

To conduct a preliminary evaluation of the safety and efficacy of reserpine, gabapentin or lamotrigine versus an unmatched placebo control as a treatment for cocaine dependence.

DESIGN

A 10-week out-patient study using the Cocaine Rapid Efficacy and Safety Trial (CREST) study design.

SETTING

The study was conducted at the Cincinnati Medication Development Research Unit (MDRU).

PARTICIPANTS

Participants met Diagnostic and Statistical Manual version IV (DSM-IV) criteria for cocaine dependence. Sixty participants were enrolled, with 50 participants completing the final study measures.

INTERVENTION

The targeted daily doses of medication were reserpine 0.5 mg, gabapentin 1800 mg and lamotrigine 150 mg. All participants received 1 hour of manualized individual cognitive behavioral therapy on a weekly basis.

MEASUREMENTS

Primary outcome measures of efficacy included urine benzoylecgonine (BE) level, Cocaine Clinical Global Impression scale--observer and self-report of cocaine use. Safety measures included adverse events, electrocardiograms (ECGs), vital signs and laboratory tests.

FINDINGS

Subjective measures of cocaine dependence indicated significant improvement for all study groups. Urine BE results indicated a significant improvement for the reserpine group (P < 0.05) and non-significant changes for the other study groups. No pattern of physical or laboratory abnormalities attributable to treatment with any of the medications was identified. There were three serious adverse events reported, none of which were related to study procedures. The medications appeared to be tolerated well.

CONCLUSIONS

The present findings suggest that reserpine may be worthy of further study as a cocaine dependence treatment.

Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review

OBJECTIVE

The objectives of this study were to systematically review the recent studies of the contribution of depression to the onset of coronary disease and to estimate the magnitude of the risk posed by depression for onset of coronary disease.

METHOD

We searched MEDLINE (1966-2000), PsychInfo (1967-2000), and cross references and conducted informal searches for all community studies of depression symptoms in samples with no clinically apparent heart disease at baseline. From these studies we selected all published cohort studies of 4 years or more follow-up that controlled for other major coronary disease risk factors and reported relative risks (or a comparable measure) of baseline depression for the onset of coronary disease. Following methods for the meta-analysis of epidemiologic studies, we used a random-effects model to estimate the combined overall relative risk.

RESULTS

Ten studies met our inclusion criteria. Relative risks ranged from 0.98 to 3.5. Nine studies reported significantly increased risk, including two with mixed results; one study reported no increased risk. The combined overall relative risk of depression for the onset of coronary disease was 1.64 (95% CI = 1.41-1.90).

CONCLUSIONS

This quantitative review suggests that depressive symptoms contribute a significant independent risk for the onset of coronary disease, a risk (1.64) that is greater than the risk conferred by passive smoking (1.25) but less than the risk conferred by active smoking (2.5). Future prospective community studies should examine the effect of severity and duration of depressive symptoms and disorders on the risk for the onset of coronary disease.

Geriatric patient emergency visits. Part II: Perceptions of visits by geriatric and younger patients

OBJECTIVES

To compare group perceptions of reasons for emergency department care, ED use patterns, and the effect of illness on self-care ability for elderly and younger adult patients.

DESIGN

Patient survey.

SETTING

Six geographically distinct US hospital EDs.

PARTICIPANTS

From each site, a stratified sample (approximately 7:3) of elderly (65 years and older) and nonelderly (21 to 64 years old) control ED patients treated during the same time period was contacted.

METHODS

Three hundred ninety-nine elderly patients and 172 adult controls were interviewed using a structured survey instrument. Groups were compared using chi 2 analysis and the Mann-Whitney U test.

RESULTS

Both the elderly and the control patients (49% versus 38%) commonly stated that the most important reason for coming to the ED was because they were "too sick to wait for an office visit." Of patients with a regular physician, both groups often were referred to the ED by their primary care provider (35% versus 26%). While the elderly had more visits to their primary care provider (3.3 versus 2.9 visits; P less than .00001), there was no difference in the number of ED visits (1.5 versus 1.6 visits) during the preceding six months. Of those released from the ED, more elderly noted deterioration in their ability to care for themselves as a result of their illness (21% versus 11%; P less than .03).

CONCLUSION

The elderly use the ED for reasons similar to those for younger adults. Often they feel too ill to wait for an office visit or are referred in by their primary care provider. Elderly patients more commonly have difficulty with self care after release home, and emergency physicians must plan accordingly.

Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients

OBJECTIVES

To describe emergency department use by the elderly, to define problems associated with emergency care of the elderly, and to compare these results with those for younger adult patients.

DESIGN

Retrospective, controlled chart review.

SETTING

Six geographically distinct US hospital EDs.

PARTICIPANTS

From each site, a stratified sample (approximately 7:3) of elderly (65 years or older) and nonelderly (21 to 64 years old) control patients treated during the same time period was used.

METHODS

Standardized review of ED records and billing charges. Comparisons of elderly and control patient groups using chi 2 analysis and Mann-Whitney U test (alpha = 0.05).

RESULTS

Four hundred eighteen elderly patients and 175 nonelderly controls were entered into the study. The elderly were more likely to arrive by ambulance (35% versus 11%; P less than .00001). More elderly than controls presented with conditions of either high or intermediate urgency (78% versus 61%; P less than .0003). The elderly more frequently presented with comorbid diseases (94% versus 63%; P less than .00001). Other findings for the elderly included a longer mean stay in the ED (185 versus 155 minutes; P less than .003), higher laboratory (78% versus 53%; P less than .00001) and radiology (77% versus 52%; P less than .00001) test rates, higher mean overall care charges ($471 versus $344; P less than .00001), and an admission rate (47% versus 19%; P less than .00001) twice that of younger adults.

CONCLUSION

Resource use and charges associated with emergency care are higher for the elderly than for younger patients. Increases in emergency resources and personnel or improvement in efficiency will be needed to maintain emergency care at present levels as the US population continues to grow and age.

Efficacy of the stat serum electrolyte panel in the management of older emergency patients

The serum electrolyte panel (SEP) is commonly ordered in the workup of the emergency department (ED) patient. This study was done: 1) to evaluate the efficacy of the SEP in terms of the identification of clinically significant abnormals (yield) and the impact on therapeutic plan (impact); 2) to evaluate the reasons that the test was ordered; and 3) to compare the expected and realized contributions of the test to patient care. Pretest and posttest questionnaires were administered to physicians managing 800 ED patients greater than or equal to 55 years old for whom SEPs were ordered. The yield of significant abnormals was 16%. Fluid and electrolyte treatment plans were modified after the SEP results became known in 35% of cases. This modification was associated with a normal SEP 48% of the time. Both the yield and the impact of the SEP were related to the reason that the test was ordered. The most common reason given was "to look for an unexpected abnormality" (50%). Physicians' expectations for the contribution of the SEP to patient care decisions were greater than the contributions realized after the results were known. However, in 115 cases, the test contributed more than expected. Physicians predicted that 13% of the tests would contribute nothing to patient care. After the results were known, they felt that 38% had made no contribution. Physicians tend to overestimate the potential impact of the SEP but are occasionally surprised by a result that contributes more than expected. Thus, there is considerable pretest uncertainty about treatment decisions and normal results appear to have a substantial impact.

Prediction of electrolyte abnormalities in elderly emergency patients

STUDY OBJECTIVES

To evaluate the operating characteristics of a previously published decision rule (Lowe's criteria) for the ordering of the stat serum electrolyte panel (SEP) and to identify features from the history and physical examination that are predictive for clinically significant electrolyte abnormalities (CSEA) in older emergency patients.

DESIGN

A cross-sectional study using a physician questionnaire, record review, and telephone follow-up.

SETTING

An urban, university hospital emergency department with approximately 70,000 patient visits a year.

TYPE OF PARTICIPANTS

A convenience sample of patients 55 years of age or older who presented for care for any reason were identified by a research associate stationed in the ED.

INTERVENTIONS

Physicians managing 1,766 patients were interviewed to determine the presence or absence of 20 dichotomous clinical variables, ten of which constitute Lowe's criteria set. All patients were followed by chart review and/or telephone interview.

MEASUREMENTS AND MAIN RESULTS

The determination of clinical significance was made on record review using pre-established guidelines. The SEP was ordered on 800 of the patients on the index visit. The yield of CSEA in this group was 16%. Lowe's criteria operated with a sensitivity of 0.95 (95% confidence intervals, 0.89-0.98) and a specificity of 0.10 (95% confidence intervals, 0.07-0.12) for predicting CSEAs in this population. Logistic regression analysis showed that impaired ability to communicate, acute seizures, vomiting, and prior abnormal electrolytes were independent predictors for CSEA.

CONCLUSION

Lowe's criteria showed useful sensitivity but poor specificity in this population. The criteria may be used to encourage selective test ordering by physicians when a low pretest probability for CSEA exists and as part of an algorithm for emergency nurses who order tests to expedite patient care.

The impact of a rapid screen for streptococcal pharyngitis on clinical decision making in the emergency department

The impact of a rapid streptococcal screening test (RSS) on clinical decision making in the management of patients with acute pharyngitis was evaluated. Physicians managing 95 ambulatory patients with the complaint of sore throat were asked to estimate the probability of group A beta-hemolytic streptococcal pharyngitis (GRABS) in each patient and whether they intended to treat with antibiotics both before and after the results of the RSS were known. Simultaneous throat cultures were obtained for 80 patients at the discretion of the treating physicians. Regression analysis revealed that the RSS result was an important independent predictor for the posttest decision to treat with antibiotics and for the estimated probability of disease. The mean absolute log-likelihood ratio was used to quantify the effect of the RSS on diagnostic certainty; a greater contribution to diagnostic certainty occurred when the RSS was positive. Physicians would have prescribed an antibiotic 49 times without the benefit of the RSS and prescribed an antibiotic 48 times given the RSS result. Without the RSS, the treatment decision contradicted the throat culture result in 25 cases. With the RSS, this occurred in 26 cases. The RSS, while influencing decision making, especially when positive, did not decrease the use of antibiotics.

Decision rules and clinical prediction of pneumonia: evaluation of low-yield criteria

Prediction rules have been recommended for guiding the ordering of diagnostic tests. Such rules can be used to define low-yield criteria (LYC) for the purpose of identifying patients with an extremely low probability of disease and hence discouraging test ordering by the physician on patients meeting LYC. In this study, community hospital emergency department populations of adults (n = 255) and children (n = 78) were evaluated prospectively for the presence of predictive clinical parameters and the physician's estimate of pneumonia prior to obtaining a chest film. We developed LYC and analyzed published LYC for obtaining chest films on patients considered at risk for pneumonia by means of logistic regression, receiver operating characteristics curve, and negative predictive value analyses. We were unable to derive or validate clinically useful LYC to improve on the seasoned clinician's probability estimate of pneumonia. We discuss the inherent limitations in the development and application of LYC that must be understood by those who seek to limit the ordering of chest films by the application of guidelines developed from decision rules.