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Mauck MC, Aylward AF, Barton CE, Birckhead B, Carey T, Dalton DM, Fields AJ, Fritz J, Hassett AL, Hoffmeyer A, Jones SB, McLean SA, Mehling WE, O'Neill CW, Schneider MJ, Williams DA, Zheng P, Wasan AD. [Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]. Schmerz 2024:10.1007/s00482-024-00798-x. [PMID: 38381187 DOI: 10.1007/s00482-024-00798-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP. OBJECTIVE The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial. METHODS A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered. CONCLUSION The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.
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Affiliation(s)
- Matthew C Mauck
- Department of Anesthesiology, University of North Carolina at Chapel Hill, CB#7011, 27599-7010, Chapel Hill, NC, USA.
| | - Aileen F Aylward
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chloe E Barton
- Department of Anesthesiology, University of North Carolina at Chapel Hill, CB#7011, 27599-7010, Chapel Hill, NC, USA
| | - Brandon Birckhead
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Timothy Carey
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diane M Dalton
- Department of Physical Therapy, Boston University, College of Health and Rehabilitation Sciences, Sargent, Boston, MA, USA
| | - Aaron J Fields
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, Kalifornien, USA
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Afton L Hassett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Anna Hoffmeyer
- University of North Carolina at Chapel Hill, Collaborative Studies Coordinating Center, Chapel Hill, NC, USA
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel A McLean
- Department of Anesthesiology, University of North Carolina at Chapel Hill, CB#7011, 27599-7010, Chapel Hill, NC, USA
| | - Wolf E Mehling
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, Kalifornien, USA
| | - Conor W O'Neill
- Section of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, Kalifornien, USA
| | - Michael J Schneider
- Department of Physical Therapy and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David A Williams
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Patricia Zheng
- Section of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, Kalifornien, USA
| | - Ajay D Wasan
- Departments of Anesthesiology and Perioperative Medicine and Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Jones SB, Johnson AM, Mormer ER, Ressel KE, Pastva AM, Wen M, Patterson CG, Duncan PW, Bushnell CD, Freburger JK. Abstract P471: Predictors of Referral to Community-Based Rehabilitation Following Stroke. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Background:
While several studies have examined care transitions following stroke, few have assessed use of rehabilitation. We explored factors predictive of referral to community-based rehabilitation following stroke.
Setting:
40 NC acute care hospitals that participated in the COMprehensive Post-Acute Stroke Services study from 2016-2019.
Participants:
Adults discharged home following stroke or TIA (N=11,195)
Methods:
Guided by an a priori conceptual framework, 41 predictors of referral to community-based rehabilitation were grouped into 3 patient-level domains: demographics, stroke severity, and medical history (e.g., prior stroke); 2 hospital-level domains: structural characteristics (e.g., bed size) and stroke-specific characteristics (e.g., stroke center status); and 1 community-level domain (county-level therapist supply). We estimated predictors of referral using a logistic mixed model with a hospital-specific random effect. We used a hierarchical backward selection approach, first performing domain-specific model selection, then entering retained variables into a complete model.
Results:
The cohort was 49% female, 72% white, with a mean age of 66.8 (SD=14.0) years and overall low stroke severity [mean [SD] NIHSS 2.4 [3.8]). Thirty-six percent of patients were referred to rehabilitation. Referral varied across hospitals, ranging from 3-78%, with a median of 35%. In the final model, older age, female sex, non-white race, higher stroke severity, longer length of stay, previous stroke, current smoking, and heart failure were associated with higher odds of referral as was hospital-employed vs. external-contracted OT services (Table).
Discussion:
Approximately one-third of stroke survivors discharged home were referred to community-based rehabilitation. Women and non-white patients had higher odds of referral. Hospital and community factors were largely not independent predictors of referral. Unmeasured process measures may play a role in unexplained hospital variation.
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Affiliation(s)
| | | | | | | | | | - Molly Wen
- Univ of North Carolina, Chapel Hill, NC
| | | | - Pamela W Duncan
- Atrium Health Wake Forest Baptist Med Cntr, Winston Salem, NC
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Lutz BJ, Kucharska-Newton AM, Jones SB, Psioda MA, Gesell SB, Coleman SW, Johnson AM, Radman MD, Levy S, Bettger JP, Freburger JK, Chou A, Celestino J, Rosamond WD, Bushnell CD, Duncan PW. Familial caregiving following stroke: findings from the comprehensive post-acute stroke services (COMPASS) pragmatic cluster-randomized transitional care study. Top Stroke Rehabil 2022; 30:436-447. [PMID: 35603644 DOI: 10.1080/10749357.2022.2077520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Stroke patients discharged home often require prolonged assistance from caregivers. Little is known about the real-world effectiveness of a comprehensive stroke transitional care intervention on relieving caregiver strain. OBJECTIVES To describe the effect of the COMPASS transitional care (COMPASS-TC) intervention on caregiver strain and characterize the types, duration, and intensity of caregiving. METHODS The cluster-randomized COMPASS pragmatic trial evaluated the effectiveness of COMPASS-TC versus usual care with patients with mild stroke and TIA at 40 hospitals in North Carolina, USA. Of 5882 patients enrolled, 4208 (71%) identified a familial caregiver. A follow-up Caregiver Questionnaire, including the Modified Caregiver Strain Index, was administered at approximately three months post-discharge. Demographics and frequency, duration, and intensity of caregiving were compared between groups. RESULTS 1228 caregivers (29%) completed the questionnaire. Completion was positively associated with older patient age, white race, and spousal relationship. One-third of the caregivers provided ≥30 hours of care per week and 889 (79%) provided care ≥9 weeks. Average standardized caregiver strain was 21.9 (0-100), increasing with stroke severity and comorbidity burden. Women caregivers reported higher strain than men. Treatment allocation was not associated with caregiver strain. CONCLUSIONS This sample of mild stroke and TIA survivors received significant assistance from familial caregivers. However, caregiver strain was relatively low. Findings support the importance of familial caregiving in stroke, the continued disproportionate burden on women within the family, and the need for future research on caregiver support.
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Affiliation(s)
- Barbara J. Lutz
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, North Carolina, USA
| | - Anna M. Kucharska-Newton
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sara B. Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew A. Psioda
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sabina B. Gesell
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sylvia W. Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna M. Johnson
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Samantha Levy
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Janet K Freburger
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, USA
| | - Aileen Chou
- Department of Physical Therapy, School of Health and Rehabilitation Science, University of Pittsburgh, Pittsburgh, USA
| | - Joan Celestino
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Wayne D. Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cheryl D. Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Pamela W. Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Bushnell CD, Kucharska-Newton AM, Jones SB, Psioda MA, Johnson AM, Daras LC, Halladay JR, Prvu Bettger J, Freburger JK, Gesell SB, Coleman SW, Sissine ME, Wen F, Hunt GP, Rosamond WD, Duncan PW. Hospital Readmissions and Mortality Among Fee-for-Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster-Randomized Pragmatic Trial. J Am Heart Assoc 2021; 10:e023394. [PMID: 34730000 PMCID: PMC9075395 DOI: 10.1161/jaha.121.023394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS-TC (Comprehensive Post-Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all-cause and stroke-specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee-for-service claims linked with COMPASS cluster-randomized trial data, we performed intention-to-treat analyses for 30-day, 90-day, and 1-year unplanned all-cause and stroke-specific readmissions and all-cause mortality between INV and UC groups, with 90-day unplanned all-cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all-cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1-year all-cause readmissions, stroke-specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS-TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
| | - Anna M Kucharska-Newton
- Department of Epidemiology College of Public Health University of Kentucky Lexington KY.,Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Sara B Jones
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Matthew A Psioda
- Department of Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Anna M Johnson
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | | | - Jacqueline R Halladay
- Department of Family Medicine University of North Carolina School of Medicine Chapel Hill NC
| | | | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Sciences University of Pittsburgh PA
| | - Sabina B Gesell
- Division of Public Health Sciences Department of Social Sciences and Health Policy Wake Forest School of Medicine Winston-Salem NC
| | - Sylvia W Coleman
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Mysha E Sissine
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Fang Wen
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Gary P Hunt
- Cecil G Sheps Center for Health Services Research University of North Carolina at Chapel Hill NC
| | - Wayne D Rosamond
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Pamela W Duncan
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
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Freburger JK, Pastva AM, Coleman SW, Peter KM, Kucharska-Newton AM, Johnson AM, Psioda MA, Duncan PW, Bushnell CD, Rosamond WD, Jones SB. Skilled Nursing and Inpatient Rehabilitation Facility Use by Medicare Fee-for-Service Beneficiaries s Discharged Home following a Stroke: Findings from the COMPASS Trial. Arch Phys Med Rehabil 2021; 103:882-890.e2. [PMID: 34740596 DOI: 10.1016/j.apmr.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVES To examine the effect of a comprehensive transitional care model on the utilization of skilled nursing facility (SNF) and inpatient rehabilitation facility (IRF) care in the 12 months after acute care discharge home following stroke; and to identify predictors of experiencing a SNF or IRF admission following discharge home after stroke. DESIGN Cluster randomized pragmatic trial Setting: 41 acute care hospitals in North Carolina. PARTICIPANTS 2,262 Medicare fee-for-service beneficiaries with transient ischemic attack or stroke discharged home. The sample was 80.3% White and 52.1% female, with a mean (standard deviation [SD]) age of 74.9 (10.2) years and a mean (SD) NIH stroke scale score of 2.3 (3.7). INTERVENTION Comprehensive transitional care model (COMPASS-TC) which consisted of a 2-day follow-up phone call from the post-acute care coordinator (PAC) and 14-day in-person visit with the PAC and advanced practice provider. MAIN OUTCOME MEASURES Time to first SNF or IRF and SNF or IRF admission (yes/no) in the 12 months following discharge home. All analyses utilized multivariable mixed models including a hospital-specific random effect to account for the non-independence of measures within hospital. Intent to treat analyses using Cox proportional hazards regression assessed the effect of COMPASS-TC on time to SNF/IRF admission. Logistic regression was used to identify clinical and non-clinical predictors of SNF/IRF admission. RESULTS Only 34% of patients in the intervention arm received COMPASS-TC per protocol. COMPASS-TC was not associated with a reduced hazard of a SNF/ IRF admission in the 12 months post-discharge (HR=1.20 [0.95 - 1.52]) compared to usual care. This estimate was robust to additional covariate adjustment (HR=1.23 [0.93-1.64]). Both clinical and non-clinical factors (i.e., insurance, geography) were predictors of SNF/IRF use. CONCLUSIONS COMPASS-TC was not consistently incorporated into real-world clinical practice. The use of a comprehensive transitional care model for patients discharged home after stroke was not associated with SNF or IRF admissions in a 12-month follow-up period. Non-clinical factors predictive of SNF/IRF use suggest potential issues with access to this type of care.
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Affiliation(s)
- Janet K Freburger
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Bridgeside Point 1, Suite 210, 100 Technology Dr, Pittsburgh, PA 15219-3130.
| | - Amy M Pastva
- Duke University School of Medicine, DUMC Box 104002, 311 Trent Drive, Durham, NC, 27710
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Kennedy M Peter
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599; Department of Epidemiology, College of Public Health, University of Kentucky, 111 Washington Ave, Lexington, KY, 40536
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Matthew A Psioda
- Department of Biostatistics, Gillings School of Global Public Health, 135 University of North Carolina at Chapel Hill, Dauer Dr, Chapel Hill, NC 27599
| | - Pamela W Duncan
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC, 27157
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27599
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Rosamond WD, Kucharska‐Newton AM, Jones SB, Psioda MA, Lutz BJ, Johnson AM, Coleman SW, Schilsky SR, Patel MD, Duncan PW. Emergency department utilization after hospitalization discharge for acute stroke: The COMprehensive Post-Acute Stroke Services (COMPASS) study. Acad Emerg Med 2021; 29:369-371. [PMID: 34657341 DOI: 10.1111/acem.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Wayne D. Rosamond
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Anna M. Kucharska‐Newton
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
- Department of Epidemiology College of Public Health University of Kentucky Lexington Kentucky USA
| | - Sara B. Jones
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Matthew A. Psioda
- Department of Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Barbara J. Lutz
- School of Nursing University of North Carolina Wilmington Wilmington North Carolina USA
| | - Anna M. Johnson
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Sylvia W. Coleman
- Department of Neurology Wake Forest Baptist Health Winston‐Salem North Carolina USA
| | - Samantha R. Schilsky
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Mehul D. Patel
- Department of Emergency Medicine School of Medicine The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Pamela W. Duncan
- Department of Neurology Wake Forest Baptist Health Winston‐Salem North Carolina USA
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Abstract
BACKGROUND The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention. OBJECTIVE The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial. METHODS We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses. DISCUSSION Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.
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Affiliation(s)
- Matthew A. Psioda
- Department of Biostatistics, Collaborative Studies Coordinating Center
| | - Sara B. Jones
- Department of Epidemiology, Gillings School of Global Public Health
| | - James G. Xenakis
- Department of Genetics, University of North Carolina, Chapel Hill
| | - Ralph B. D’Agostino
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
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Pastva AM, Coyle PC, Coleman SW, Radman MD, Taylor KM, Jones SB, Bushnell CD, Rosamond WD, Johnson AM, Duncan PW, Freburger JK. Movement Matters, and So Does Context: Lessons Learned From Multisite Implementation of the Movement Matters Activity Program for Stroke in the Comprehensive Postacute Stroke Services Study. Arch Phys Med Rehabil 2020; 102:532-542. [PMID: 33263286 DOI: 10.1016/j.apmr.2020.09.386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/16/2022]
Abstract
The purpose of this Special Communication is to discuss the rationale and design of the Movement Matters Activity Program for Stroke (MMAP) and explore implementation successes and challenges in home health and outpatient therapy practices across the stroke belt state of North Carolina. MMAP is an interventional component of the Comprehensive Postacute Stroke Services Study, a randomized multicenter pragmatic trial of stroke transitional care. MMAP was designed to maximize survivor health, recovery, and functional independence in the community and to promote evidence-based rehabilitative care. MMAP provided training, tools, and resources to enable rehabilitation providers to (1) prescribe physical activity and exercise according to evidence-based guidelines and programs, (2) match service setting and parameters with survivor function and benefit coverage, and (3) align treatment with quality metric reporting to demonstrate value-based care. MMAP implementation strategies were aligned with the Expert Recommendations for Implementing Change project, and MMAP site champion and facilitator survey feedback were thematically organized into the Consolidated Framework for Implementation Research domains. MMAP implementation was challenging, required modification and was affected by provider- and system-level factors. Program and study participation were limited and affected by practice priorities, productivity standards, and stroke patient volume. Sites with successful implementation appeared to have empowered MMAP champions in vertically integrated systems that embraced innovation. Findings from this broad evaluation can serve as a road map for the design and implementation of other comprehensive, complex interventions that aim to bridge the currently disconnected realms of acute care, postacute care, and community resources.
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Affiliation(s)
- Amy M Pastva
- Duke University School of Medicine, Durham, North Carolina.
| | - Peter C Coyle
- University of Pittsburgh School of Health and Rehabilitation Science, Pittsburgh, Pennsylvania
| | - Sylvia W Coleman
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Meghan D Radman
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karen M Taylor
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Sara B Jones
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Wayne D Rosamond
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna M Johnson
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pamela W Duncan
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Janet K Freburger
- University of Pittsburgh School of Health and Rehabilitation Science, Pittsburgh, Pennsylvania
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Duncan PW, Bushnell CD, Jones SB, Psioda MA, Gesell SB, D'Agostino RB, Sissine ME, Coleman SW, Johnson AM, Barton-Percival BF, Prvu-Bettger J, Calhoun AG, Cummings DM, Freburger JK, Halladay JR, Kucharska-Newton AM, Lundy-Lamm G, Lutz BJ, Mettam LH, Pastva AM, Xenakis JG, Ambrosius WT, Radman MD, Vetter B, Rosamond WD. Randomized Pragmatic Trial of Stroke Transitional Care: The COMPASS Study. Circ Cardiovasc Qual Outcomes 2020; 13:e006285. [PMID: 32475159 DOI: 10.1161/circoutcomes.119.006285] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
- Pamela W Duncan
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Cheryl D Bushnell
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | - Matthew A Psioda
- Department of Biostatistics, Collaborative Studies Coordinating Center (M.A.P.), University of North Carolina at Chapel Hill
| | - Sabina B Gesell
- Social Sciences and Health Policy, Division of Public Health Sciences (S.B.G.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Ralph B D'Agostino
- Division of Public Health Sciences, Department of Biostatistics and Data Science (R.B.D., W.T.A.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Mysha E Sissine
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sylvia W Coleman
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | | | | | - Adrienne G Calhoun
- Area Agency on Aging, Piedmont Triad Regional Council, Kernersville, NC (B.F.B.-P., A.G.C.)
| | - Doyle M Cummings
- Brody School of Medicine, East Carolina University, Greenville, NC (D.M.C.)
| | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Science, University of Pittsburgh, PA (J.K.F.)
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (J.R.H.)
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | | | - Barbara J Lutz
- University of North Carolina at Wilmington School of Nursing (B.J.L.)
| | - Laurie H Mettam
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | - Amy M Pastva
- Duke University School of Medicine, Durham, NC (J.P.-B., A.M.P.)
| | - James G Xenakis
- Department of Biostatistics, Gillings School of Global Public Health (J.G.X.), University of North Carolina at Chapel Hill
| | - Walter T Ambrosius
- Division of Public Health Sciences, Department of Biostatistics and Data Science (R.B.D., W.T.A.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Meghan D Radman
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
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10
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Gesell SB, Bushnell CD, Jones SB, Coleman SW, Levy SM, Xenakis JG, Lutz BJ, Bettger JP, Freburger J, Halladay JR, Johnson AM, Kucharska-Newton AM, Mettam LH, Pastva AM, Psioda MA, Radman MD, Rosamond WD, Sissine ME, Halls J, Duncan PW. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res 2019; 19:978. [PMID: 31856808 PMCID: PMC6923985 DOI: 10.1186/s12913-019-4771-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/22/2019] [Indexed: 11/16/2022] Open
Abstract
Background The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework. Methods We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models. Results Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC. Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals. Implementation: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days. Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42–6.27, p = 0.002). Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC. Conclusions COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status. Trial registration ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.
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Affiliation(s)
- Sabina B Gesell
- Department of Social Sciences and Health Policy, Department of Implementation Science, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samantha M Levy
- Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - James G Xenakis
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Barbara J Lutz
- University of North Carolina at Wilmington, School of Nursing, Wilmington, NC, USA
| | | | - Janet Freburger
- University of Pittsburgh, School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Department of Epidemiology, University of Kentucky, College of Public Health, Lexington, KY, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Amy M Pastva
- Duke University, School of Medicine, Durham, NC, USA
| | - Matthew A Psioda
- Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joanne Halls
- Department of Earth and Ocean Sciences, University of North Carolina at Wilmington, Wilmington, NC, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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11
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Bettger JP, Jones SB, Kucharska-Newton AM, Freburger JK, Coleman SW, Mettam LH, Sissine ME, Gesell SB, Bushnell CD, Duncan PW, Rosamond WD. Meeting Medicare requirements for transitional care: Do stroke care and policy align? Neurology 2019; 92:427-434. [PMID: 30635495 DOI: 10.1212/wnl.0000000000006921] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 12/14/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study (1) describes transitional care for stroke patients discharged home from hospitals, (2) compares hospitals' standards of transitional care with core transitional care management (TCM) components recognized by Medicare, and (3) examines the association of policy and hospital specialty designations with TCM implementation. METHODS Hospitals participating in the Comprehensive Post-Acute Stroke Services (COMPASS) Study provided data on their hospital, stroke patient population, and standards of transitional care. Hospital-reported transitional care strategies were compared with the federal TCM definition (2-day follow-up, 14-day visit, non-face-to-face services). We examined the associations of TCM billing, stroke center certification, and Magnet nursing excellence designation with TCM implementation. RESULTS Transitional care varied widely among 41 hospitals in North Carolina and no one strategy was universally applied or provided across hospitals. One third of hospitals met the TCM definition (37% provided telephone follow-up, 76% provided face-to-face provider follow-up, all provided a type of non-face-to-face support). There were no differences between groups (TCM met/not met) in hospital characteristics or transitional care resources and processes. Stroke center certification, Magnet designation, and use of TCM billing codes were not different for hospitals that did and did not meet the TCM definition. CONCLUSIONS There was substantial variation in the provision of strategies supporting stroke patients' transition home from the hospital. Supportive stroke care transitions are essential when more than 50% of stroke patients are discharged home and more than half experience moderate to severe strokes. More research is needed to identify drivers of TCM uptake. CLINICALTRIALSGOV IDENTIFIER NCT02588664.
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Affiliation(s)
- Janet Prvu Bettger
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC.
| | - Sara B Jones
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Anna M Kucharska-Newton
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Janet K Freburger
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Sylvia W Coleman
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Laurie H Mettam
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Mysha E Sissine
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Sabina B Gesell
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Cheryl D Bushnell
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Pamela W Duncan
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
| | - Wayne D Rosamond
- From Duke University School of Medicine (J.P.B.), Durham; University of North Carolina at Chapel Hill (S.B.J., A.M.K.-N., L.H.M., W.D.R.); University of Pittsburgh (J.K.F.), PA; and Wake Forest School of Medicine (S.W.C., M.E.S., S.B.G., C.D.B., P.W.D.), Winston-Salem, NC
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Duncan PW, Abbott RM, Rushing S, Johnson AM, Condon CN, Lycan SL, Lutz BJ, Cummings DM, Pastva AM, D’Agostino RB, Stafford JM, Amoroso RM, Jones SB, Psioda MA, Gesell SB, Rosamond WD, Prvu-Bettger J, Sissine ME, Boynton MD, Bushnell CD. COMPASS-CP: An Electronic Application to Capture Patient-Reported Outcomes to Develop Actionable Stroke and Transient Ischemic Attack Care Plans. Circ Cardiovasc Qual Outcomes 2018; 11:e004444. [DOI: 10.1161/circoutcomes.117.004444] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Pamela W. Duncan
- Department of Neurology (P.W.D., R.M.A., C.N.C., S.L.L., M.E.S., C.D.B.)
| | - Rica M. Abbott
- Department of Neurology (P.W.D., R.M.A., C.N.C., S.L.L., M.E.S., C.D.B.)
| | - Scott Rushing
- Division of Public Health Sciences, Department of Biostatistical Sciences (S.R., R.B.D., J.M.S., R.M.A.)
| | - Anna M. Johnson
- Wake Forest School of Medicine, Winston-Salem, NC. Department of Epidemiology (A.M.J., S.B.J., W.D.R., R.M.A.)
| | | | - Sarah L. Lycan
- Department of Neurology (P.W.D., R.M.A., C.N.C., S.L.L., M.E.S., C.D.B.)
| | - Barbara J. Lutz
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill. School of Nursing, University of North Carolina Wilmington (B.J.L.)
| | - Doyle M. Cummings
- Department of Family Medicine, Brody School of Medicine, East Carolina University, Greenville, NC (D.M.C.)
| | - Amy M. Pastva
- Division of Physical Therapy, Department of Orthopaedic Surgery (A.M.P.)
| | - Ralph B. D’Agostino
- Division of Public Health Sciences, Department of Biostatistical Sciences (S.R., R.B.D., J.M.S., R.M.A.)
| | - Jeanette M. Stafford
- Division of Public Health Sciences, Department of Biostatistical Sciences (S.R., R.B.D., J.M.S., R.M.A.)
| | - Robert M. Amoroso
- Division of Public Health Sciences, Department of Biostatistical Sciences (S.R., R.B.D., J.M.S., R.M.A.)
- Wake Forest School of Medicine, Winston-Salem, NC. Department of Epidemiology (A.M.J., S.B.J., W.D.R., R.M.A.)
| | - Sara B. Jones
- Wake Forest School of Medicine, Winston-Salem, NC. Department of Epidemiology (A.M.J., S.B.J., W.D.R., R.M.A.)
| | | | | | - Wayne D. Rosamond
- Wake Forest School of Medicine, Winston-Salem, NC. Department of Epidemiology (A.M.J., S.B.J., W.D.R., R.M.A.)
| | - Janet Prvu-Bettger
- Department of Orthopaedic Surgery (J.P.-B.), Duke University School of Medicine, Durham, NC
| | - Mysha E. Sissine
- Department of Neurology (P.W.D., R.M.A., C.N.C., S.L.L., M.E.S., C.D.B.)
| | - Mark D. Boynton
- Sticht Center on Aging, Pain Management and Rehabilitation Advisory Council (M.D.B.)
| | - Cheryl D. Bushnell
- Department of Neurology (P.W.D., R.M.A., C.N.C., S.L.L., M.E.S., C.D.B.)
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13
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Bushnell CD, Duncan PW, Lycan SL, Condon CN, Pastva AM, Lutz BJ, Halladay JR, Cummings DM, Arnan MK, Jones SB, Sissine ME, Coleman SW, Johnson AM, Gesell SB, Mettam LH, Freburger JK, Barton-Percival B, Taylor KM, Prvu-Bettger J, Lundy-Lamm G, Rosamond WD. A Person-Centered Approach to Poststroke Care: The COMprehensive Post-Acute Stroke Services Model. J Am Geriatr Soc 2018; 66:1025-1030. [PMID: 29572814 DOI: 10.1111/jgs.15322] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post-Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster-randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow-up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self-reported assessments of functional and social determinants of health are captured during the clinic visit using a web-based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS model's pragmatic design and quality metrics may support measurable best practices for postacute stroke care.
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Affiliation(s)
- Cheryl D Bushnell
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Pamela W Duncan
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Sarah L Lycan
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Christina N Condon
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Amy M Pastva
- Division of Physical Therapy, School of Medicine, Duke University, Durham, North Carolina
| | - Barbara J Lutz
- School of Nursing, University of North Carolina at Wilmington, Wilmington, North Carolina
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Doyle M Cummings
- Family Medicine Center, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Martinson K Arnan
- Bronson Neuroscience Center, Bronson Methodist Hospital, Kalamazoo, Michigan
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mysha E Sissine
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sabina B Gesell
- Department of Social Sciences and Health Policy, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Laurie H Mettam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Karen M Taylor
- Department of Neurology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Janet Prvu-Bettger
- Department of Orthopaedic Surgery, School of Medicine, Duke University, Durham, North Carolina
| | | | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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14
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Johnson AM, Jones SB, Duncan PW, Bushnell CD, Coleman SW, Mettam LH, Kucharska-Newton AM, Sissine ME, Rosamond WD. Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study. Trials 2018; 19:74. [PMID: 29373987 PMCID: PMC5787294 DOI: 10.1186/s13063-017-2434-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
Background Pragmatic randomized clinical trials are essential to determine the effectiveness of interventions in “real-world” clinical practice. These trials frequently use a cluster-randomized methodology, with randomization at the site level. Despite policymakers’ increased interest in supporting pragmatic randomized clinical trials, no studies to date have reported on the unique recruitment challenges faced by cluster-randomized pragmatic trials. We investigated key challenges and successful strategies for hospital recruitment in the Comprehensive Post-Acute Stroke Services (COMPASS) study. Methods The COMPASS study is designed to compare the effectiveness of the COMPASS model versus usual care in improving functional outcomes, reducing the numbers of hospital readmissions, and reducing caregiver strain for patients discharged home after stroke or transient ischemic attack. This model integrates early supported discharge planning with transitional care management, including nurse-led follow-up phone calls after 2, 30, and 60 days and an in-person clinic visit at 7–14 days involving a functional assessment and neurological examination. We present descriptive statistics of the characteristics of successfully recruited hospitals compared with all eligible hospitals, reasons for non-participation, and effective recruitment strategies. Results We successfully recruited 41 (43%) of 95 eligible North Carolina hospitals. Leading, non-exclusive reasons for non-participation included: insufficient staff or financial resources (n = 33, 61%), lack of health system support (n = 16, 30%), and lack of support of individual decision-makers (n = 11, 20%). Successful recruitment strategies included: building and nurturing relationships, engaging team members and community partners with a diverse skill mix, identifying gatekeepers, finding mutually beneficial solutions, having a central institutional review board, sharing published pilot data, and integrating contracts and review board administrators. Conclusions Although we incorporated strategies based on the best available evidence at the outset of the study, hospital recruitment required three times as much time and considerably more staff than anticipated. To reach our goal, we tailored strategies to individuals, hospitals, and health systems. Successful recruitment of a sufficient number and representative mix of hospitals requires considerable preparation, planning, and flexibility. Strategies presented here may assist future trial organizers in implementing cluster-randomized pragmatic trials. Trial registration Clinicaltrials.gov, NCT02588664. Registered on 23 October 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2434-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna M Johnson
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA.
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
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15
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Fuchshuber P, Schwaitzberg S, Jones D, Jones SB, Feldman L, Munro M, Robinson T, Purcell-Jackson G, Mikami D, Madani A, Brunt M, Dunkin B, Gugliemi C, Groah L, Lim R, Mischna J, Voyles CR. The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose. Surg Endosc 2017; 32:2583-2602. [PMID: 29218661 DOI: 10.1007/s00464-017-5933-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Adverse events due to energy device use in surgical operating rooms are a daily occurrence. These occur at a rate of approximately 1-2 per 1000 operations. Hundreds of operating room fires occur each year in the United States, some causing severe injury and even mortality. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) therefore created the first comprehensive educational curriculum on the safe use of surgical energy devices, called Fundamental Use of Surgical Energy (FUSE). This paper describes the history, development, and purpose of this important training program for all members of the operating room team. METHODS The databases of SAGES and the FUSE committee as well as personal photographs and documents of members of the FUSE task force were used to establish a brief history of the FUSE program from its inception to its current status. RESULTS The authors were able to detail all aspects of the history, development, and national as well as global implementation of the third SAGES Fundamentals Program FUSE. CONCLUSIONS The written documentation of the making of FUSE is an important contribution to the history and mission of SAGES and allows the reader to understand the idea, concept, realization, and implementation of the only free online educational tool for physicians on energy devices available today. FUSE is the culmination of the SAGES efforts to recognize gaps in patient safety and develop state-of-the-art educational programs to address those gaps. It is the goal of the FUSE task force to ensure that general FUSE implementation becomes multinational, involving as many countries as possible.
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Affiliation(s)
- P Fuchshuber
- Department of Surgery, Kaiser Walnut Creek Medical Center, The Permanente Medical Group, Inc., 1425 South Main Street, Walnut Creek, CA, 94596, USA.
| | - S Schwaitzberg
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, The State University of New York, Buffalo General Hospital, 100 High Street, D-352, Buffalo, NY, 14203, USA
| | - D Jones
- Harvard Medical School, Boston, MA, USA.,Office of Technology and Innovation, Boston, MA, USA.,Division of Minimally Invasive Surgical Services, Boston, MA, USA.,Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - S B Jones
- Department of Anesthesiology, Harvard Medical School, Boston, MA, USA.,Department of Anesthesia/Crit Care/Pain, BIDMC, Boston, MA, USA
| | - L Feldman
- Department of Surgery, McGill University Health Centre, 1650 Cedar Ave L9-309, Montreal, QC, H3G 1A4, Canada
| | - M Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA and Kaiser Permanenete Los Angeles Medical Center, Los Angeles, CA, USA
| | - T Robinson
- Rocky Mountain VA Medical Center, University of Colorado, Aurora, Colorado, USA
| | - G Purcell-Jackson
- Vanderbilt University Medical Center, 2200 Children's Way, Doctor's Office Tower Suite 7100, Nashville, TN, 37232, USA
| | - D Mikami
- John A. Burn School of Medicine, University of Hawaii, 1356 Lusitania Street, 6th Floor, Honolulu, HI, 96813, USA
| | - A Madani
- Department of Surgery, McGill University, 1650 Cedar Ave, Rm D6-257, Montreal, QC, H3G 1A4, Canada
| | - M Brunt
- Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - B Dunkin
- Houston Methodist Institute for Technology, Innovation & Education, Institute for Academic Medicine, Houston Methodist, Weill Cornell Medical College, 6550 Fannin St #1601, Houston, TX, 77030, USA
| | - C Gugliemi
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - L Groah
- AORN, 2170 South Parker Road. Suite 400, Denver, CO, 80231, USA
| | - R Lim
- Uniformed Services University of Health Sciences, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 95869, USA
| | - J Mischna
- Fundamentals Department SAGES, 11300 West Olympic Blvd Suite 600, Los Angeles, CA, 90064, USA
| | - C R Voyles
- , 3838 Eastover Drive, Jackson, MS, 39211, USA
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Jones SB, Loehr L, Avery CL, Gottesman RF, Wruck L, Shahar E, Rosamond WD. Midlife Alcohol Consumption and the Risk of Stroke in the Atherosclerosis Risk in Communities Study. Stroke 2015; 46:3124-30. [PMID: 26405203 PMCID: PMC4725192 DOI: 10.1161/strokeaha.115.010601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 08/31/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Alcohol consumption is common in the United States and may confer beneficial cardiovascular effects at light-to-moderate doses. The alcohol-stroke relationship remains debated. We estimated the relationship between midlife, self-reported alcohol consumption and ischemic stroke and intracerebral hemorrhage (ICH) in a biracial cohort. METHODS We examined 12,433 never and current drinkers in the Atherosclerosis Risk in Communities study, aged 45 to 64 years at baseline. Participants self-reported usual drinks per week of beer, wine, and liquor at baseline. We used multivariate Cox proportional hazards regression to assess the association of current alcohol consumption relative to lifetime abstention with incident ischemic stroke and ICH and modification by sex-race group. We modeled alcohol intake with quadratic splines to further assess dose-response relationships. RESULTS One third of participants self-reported abstention, 39% and 24%, respectively, consumed ≤3 and 4 to 17 drinks/wk, and only 5% reported heavier drinking. There were 773 ischemic strokes and 81 ICH over follow-up (median≈22.6 years). For ischemic stroke, light and moderate alcohol consumption were not associated with incidence (hazard ratios, 0.98; 95% CI, 0.79-1.21; 1.06, 0.84-1.34), whereas heavier drinking was associated with a 31% increased rate relative to abstention (hazard ratios, 1.31; 95% CI, 0.92-1.86). For ICH, moderate-to-heavy (hazard ratios, 1.99; 95% CI, 1.07-3.70), but not light, consumption increased incidence. CONCLUSIONS Self-reported light-to-moderate alcohol consumption at midlife was not associated with reduced stroke risk compared with abstention over 20 years of follow-up in the Atherosclerosis Risk in Communities study. Heavier consumption increased the risk for both outcomes as did moderate intake for ICH.
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Affiliation(s)
- Sara B Jones
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.).
| | - Laura Loehr
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.)
| | - Christy L Avery
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.)
| | - Rebecca F Gottesman
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.)
| | - Lisa Wruck
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.)
| | - Eyal Shahar
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.)
| | - Wayne D Rosamond
- From the Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill (S.B.J., L.L., C.L.A., W.D.R.); Cerebrovascular Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.F.G.); Department of Biostatistics, Gillings School of Global Public Health, UNC-Chapel Hill, NC (L.W.); and Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson (E.S.)
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Lichtman JH, Wang Y, Jones SB, Leifheit-Limson EC, Shaw LJ, Vaccarino V, Rumsfeld JS, Krumholz HM, Curtis JP. Age and sex differences in inhospital complication rates and mortality after percutaneous coronary intervention procedures: evidence from the NCDR(®). Am Heart J 2014; 167:376-83. [PMID: 24576523 DOI: 10.1016/j.ahj.2013.11.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/03/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Older women experience higher complication rates and mortality after percutaneous coronary intervention (PCI) than men, but there is limited evidence about sex-based differences in outcomes among younger patients. We compared rates of complications and inhospital mortality by sex for younger and older PCI patients. METHODS A total of 1,079,751 hospital admissions for PCI were identified in the CathPCI Registry(®) from 2005 to 2008. Complication rates (general, bleeding, bleeding with transfusion, and vascular) and inhospital mortality after PCI were compared by sex and age (<55 and ≥55 years). Analyses were adjusted for demographic and clinical factors and stratified by PCI type (elective, urgent, or emergency). RESULTS Overall, 6% of patients experienced complications, and 1% died inhospital. Unadjusted complication rates were higher for women compared with men in both age groups. In risk-adjusted analyses, younger women (odds ratio 1.24, 95% CI 1.16-1.33) and older women (1.27, 1.09-1.47) were more likely to experience any complication than similarly aged men. The increased risk persisted across complication categories and PCI type. Within age groups, risk-adjusted mortality was marginally higher for young women (1.19, 1.00-1.41), but not for older women (1.03, 0.97-1.10). In analyses stratified by PCI type, young women had twice the mortality risk after an elective procedure as young men (2.04, 1.15-3.61). CONCLUSIONS Women, regardless of age, experience more complications after PCI than men; young women are at increased mortality risk after an elective PCI. Identifying strategies to reduce adverse outcomes, particularly for women younger than 55 years, is important.
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Machha VR, Jones SB, Waddle JR, Le VH, Wellman S, Lewis EA. Exploring the energetics of histone H1.1 and H1.4 duplex DNA interactions. Biophys Chem 2013; 185:32-8. [PMID: 24317196 DOI: 10.1016/j.bpc.2013.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/28/2013] [Accepted: 11/18/2013] [Indexed: 01/11/2023]
Abstract
H1.1 and H1.4 bind tightly to both short DNA oligomers and to CT-DNA (Ka≈1×10(7)). Binding is accompanied by an unfavorable enthalpy change (∆H≈+22 kcal/mol) and a favorable entropy change (-T∆S≈-30 kcal/mol). The Tm for the H1.4/CT-DNA complex is increased by 9 °C over the Tm for the free DNA. H1.4 titrations of the DNA oligomers yield stoichiometries (H1/DNA) of 0.64, 0.96, 1.29, and 2.04 for 24, 36, 48, and 72-bp DNA oligomers. The stoichiometries are consistent with a binding site size of 37±1 bp. CT-DNA titration data are consistent with binding site sizes of 32 bp for H1.1 and 36 bp for H1.4. The heat capacity changes, ΔCp, for formation of the H1.1 and H1.4/CT-DNA complexes are -160 cal mol(-1) K(-1) and -192 cal mol(-1)K(-1) respectively. The large negative ΔCp values indicate the loss of water from the protein DNA interface in the complex.
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Affiliation(s)
- V R Machha
- Department of Chemistry, Mississippi State University, Box 9573, Mississippi State, MS 39762, USA
| | - S B Jones
- Department of Chemistry, Mississippi State University, Box 9573, Mississippi State, MS 39762, USA
| | - J R Waddle
- Department of Chemistry, Mississippi State University, Box 9573, Mississippi State, MS 39762, USA
| | - V H Le
- Department of Chemistry, Mississippi State University, Box 9573, Mississippi State, MS 39762, USA
| | - S Wellman
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505, USA
| | - E A Lewis
- Department of Chemistry, Mississippi State University, Box 9573, Mississippi State, MS 39762, USA.
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Abstract
BACKGROUND AND PURPOSE The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown. METHODS Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions. RESULTS Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. CONCLUSIONS On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.
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Affiliation(s)
- Judith H Lichtman
- From the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT (J.H.L., E.C.L.-L., S.B.J.); Department of Biostatistics, Harvard School of Public Health, Boston, MA (Y.W.); and Department of Neurology, Duke Comprehensive Stroke Center, Duke University and Durham VAMC, Durham, NC (L.B.G.)
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Abstract
BACKGROUND AND PURPOSE Early risk of recurrence and mortality after stroke differs by subtype, but less is known about long-term recurrence and hospital readmissions. These differences have economic implications and will affect long-term disability and stroke survivor quality of life. We examined recurrent stroke, all-cause hospital readmission, and mortality by index pathogenic subtype. METHODS We identified 987 Atherosclerosis Risk in Communities Study cohort participants with first-ever stroke and followed them for a median 5.3 years after first stroke. Outcomes were compared across index subtypes (infarction: thrombotic, cardioembolic, and lacunar; hemorrhagic: subarachnoid and intracerebral) using Kaplan-Meier analysis and Cox proportional hazards regression, adjusting for age, sex, and race. RESULTS There were 183 recurrent strokes among 147 participants, 3234 hospitalizations among 746 participants, and 529 deaths; only 14% of participants were event-free over follow-up. The majority of recurrent events were of the same subtype, except for lacunar infarcts, which were followed ≈3 quarters of the time by nonlacunar events. Adjusted mortality was higher for intracerebral hemorrhage (hazard ratio, 2.3; 95% confidence interval, 1.7-3.0) compared with thrombotic stroke and lower for lacunar infarcts. Lacunar infarcts had somewhat higher recurrence compared with thrombotic infarcts (hazard ratio, 1.3; 95% confidence interval, 0.9-1.9), but lower all-cause readmission (hazard ratio, 0.8; 95% confidence interval, 0.7-1.0). Readmission was 40% higher for cardioembolic stroke relative to thrombotic stroke (hazard ratio, 1.4; 95% confidence interval, 1.1-1.7). CONCLUSIONS Although the highest mortality was observed for intracerebral hemorrhage, there was significant burden of recurrent stroke and hospital readmissions for lacunar and cardioembolic strokes, respectively. There may be opportunities to reduce the relatively high rate of poststroke readmissions.
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Affiliation(s)
- Sara B Jones
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27514, USA.
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Leifheit-Limson EC, Spertus JA, Reid KJ, Jones SB, Vaccarino V, Krumholz HM, Lichtman JH. Prevalence of traditional cardiac risk factors and secondary prevention among patients hospitalized for acute myocardial infarction (AMI): variation by age, sex, and race. J Womens Health (Larchmt) 2013; 22:659-66. [PMID: 23841468 DOI: 10.1089/jwh.2012.3962] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Modification of traditional cardiac risk factors is an important goal for patients after an acute myocardial infarction (AMI). Risk factor prevalence and secondary prevention efforts at discharge are well characterized among older patients; however, research is limited for younger and minority AMI populations, particularly among women. METHODS Among 2369 AMI patients enrolled in a 19-center prospective study, we compared the prevalence and cumulative number of five cardiac risk factors (hypertension, hypercholesterolemia, current smoking, diabetes, obesity) by age, sex, and race. We also compared secondary prevention strategies at discharge for these risk factors, including prescription of antihypertensive or lipid-lowering medications and counseling on preventive behaviors (smoking cessation, diabetes management, diet/weight management). RESULTS Approximately 93% of patients had ≥1 risk factor, 72% had ≥2 factors, and 40% had ≥3 factors. The prevalence of multiple risk factors was markedly higher for blacks than for whites within each age-sex group; black women had the greatest risk factor burden of any subgroup (60% of older black women and 54% of younger black women had ≥3 risk factors). Secondary prevention efforts for smoking cessation were less common for black compared with white patients, and younger black patients were less often prescribed antihypertensive and lipid-lowering medications compared with younger white patients. CONCLUSIONS Multiple cardiac risk factors are highly prevalent in AMI patients, particularly among black women. Secondary prevention efforts, however, are less common for blacks compared to whites, especially among younger patients. Our findings highlight the need for improved risk factor modification efforts in these high-risk subgroups.
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Affiliation(s)
- Erica C Leifheit-Limson
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut 06519, USA.
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Kieber RJ, Guy AL, Roebuck JA, Carroll AL, Mead RN, Jones SB, Giubbina FF, Campos MLAM, Willey JD, Avery GB. Determination of ambient ethanol concentrations in aqueous environmental matrixes by two independent analyses. Anal Chem 2013; 85:6095-9. [PMID: 23672335 DOI: 10.1021/ac400974m] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A new method for the determination of ethanol in aqueous environmental matrixes at nanomolar concentrations is presented and compared to an existing method that has been optimized for low-level alcohol determinations. The new analysis is based upon oxidation of ethanol by the enzyme alcohol oxidase obtained from the yeast Hansenula sp. which quantitatively produces acetaldehyde after reaction for 120 min at 40 °C and pH 9.0. The acetaldehyde reacts with 2,4-dinitrophenylhydrazine forming a hydrazone that is separated from interfering substances and quantified by high-performance liquid chromatography (HPLC) with UV detection at 370 nm. Comparison of initial acetaldehyde concentration with that after enzymatic oxidation yields the ethanol concentration with a corresponding detection limit of 10 nM. Analytical results were verified by intercomparison with a completely independent technique utilizing a solid-phase microextraction (SPME) Carboxen/PDMS SPME fiber. A 12 mL aqueous phase sample was heated at 50 °C for 10 min prior to loading onto the SPME fiber. Extraction of ethanol was performed by introducing the fiber into the headspace above a pH 4.4 buffered sample containing 30% NaCl for 20 min. Samples were agitated during heating and extraction by magnetic stirring at a rate of 750 rpm. The fiber was thermally desorbed for 1 min at 230 °C in the injection port of a gas chromatograph equipped with a flame ionization detector (FID) set at 250 °C. The resulting ethanol detection limit is 19 nM. Results of an intercomparison study between the enzymatic and SPME analyses produced a trend line with a slope of unity demonstrating that methods produced statistically equivalent ethanol concentrations in several natural waters including rainwater, fresh surface waters, and sediment pore waters.
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Affiliation(s)
- R J Kieber
- Department of Chemistry and Biochemistry, University of North Carolina-Wilmington, Wilmington, North Carolina 28403-5932, USA.
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Jones SB, Thomas GA, Hesselsweet SD, Alvarez-Reeves M, Yu H, Irwin ML. Effect of exercise on markers of inflammation in breast cancer survivors: the Yale exercise and survivorship study. Cancer Prev Res (Phila) 2013; 6:109-18. [PMID: 23213072 PMCID: PMC3839104 DOI: 10.1158/1940-6207.capr-12-0278] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Physical activity is associated with improved breast cancer survival, but the underlying mechanisms, possibly including modification of the inflammatory state, are not well understood. We analyzed changes in interleukin (IL)-6, C-reactive protein (CRP), and TNF-α in a randomized controlled trial of exercise in postmenopausal breast cancer survivors. Seventy-five women, recruited through the Yale-New Haven Hospital Tumor Registry, were randomized to either a six-month aerobic exercise intervention or usual care. Correlations were calculated between baseline cytokines, adiposity, and physical activity measures. Generalized linear models were used to assess the effect of exercise on IL-6, CRP, and TNF-α. At baseline, IL-6 and CRP were positively correlated with body fat and body mass index (BMI) and were inversely correlated with daily pedometer steps (P < 0.001). We found no significant effect of exercise on changes in inflammatory marker concentrations between women randomized to exercise versus usual care, though secondary analyses revealed a significant reduction in IL-6 among exercisers who reached 80% of the intervention goal compared with those who did not. Future studies should examine the effect of different types and doses of exercise and weight loss on inflammatory markers in large-scale trials of women diagnosed with breast cancer.
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Affiliation(s)
- Sara B. Jones
- Yale School of Public Health, New Haven, Connecticut
| | | | | | | | - Herbert Yu
- Yale School of Public Health, New Haven, Connecticut
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Lichtman JH, Jones SB, Wang Y, Leifheit-Limson EC, Goldstein LB. Seasonal variation in 30-day mortality after stroke: teaching versus nonteaching hospitals. Stroke 2013; 44:531-3. [PMID: 23299494 DOI: 10.1161/strokeaha.112.670547] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A systematic review found an association between the July start of internships and residencies and higher mortality rates for hospitalized patients, but data related to stroke are limited. We assessed seasonal variations in 30-day risk-adjusted mortality rates (RAMRs) after ischemic stroke by hospital teaching status. METHODS The analysis included all fee-for-service Medicare beneficiaries aged ≥ 65 years with a primary discharge diagnosis of ischemic stroke (International Classification of Diseases, 9th revision, codes 433, 434, and 436) from 1999 to 2006. Hierarchical linear regression models calculated RAMRs, adjusting for patient demographics and comorbidities. Annual data were combined and reconstructed for time series analyses; RAMRs were calculated for each month. Structural models compared monthly seasonal patterns stratified by hospital teaching status. RESULTS Of 2 824 694 ischemic stroke discharges, 51.7% were from teaching hospitals. There were seasonal patterns within each calendar year, with the highest 30-day RAMR in the winter and the lowest in the summer, but with a smaller peak in July. Thirty-day RAMRs decreased from 1999 to 2006, as did seasonal variations within each calendar year. Seasonal patterns were similar for teaching and nonteaching hospitals. CONCLUSIONS The 30-day RAMR decreased overall, but seasonal patterns were present, with the highest RAMR in January and a smaller peak in July. Because patterns were similar for teaching and nonteaching hospitals, the July peak cannot be explained by the introduction of new trainees in the beginning of the academic year. The reasons for these seasonal patterns warrant further investigation.
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Lichtman JH, Leifheit-Limson EC, Jones SB, Wang Y, Goldstein LB. 30-Day risk-standardized mortality and readmission rates after ischemic stroke in critical access hospitals. Stroke 2012; 43:2741-7. [PMID: 22935397 DOI: 10.1161/strokeaha.112.665646] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE The critical access hospital (CAH) designation was established to provide rural residents with local access to emergency and inpatient care. CAHs, however, have poorer short-term outcomes for pneumonia, heart failure, and myocardial infarction compared with other hospitals. We assessed whether 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) after ischemic stroke differ between CAHs and non-CAHs. METHODS The study included all fee-for-service Medicare beneficiaries 65 years of age or older with a primary discharge diagnosis of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, 436) in 2006. Hierarchical generalized linear models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, medical history, and comorbid conditions. Non-CAHs were categorized by hospital volume quartiles and the RSMR and RSRR posterior probabilities in comparison with CAHs were determined using linear regression with Markov chain Monte Carlo simulation. RESULTS There were 10 267 ischemic stroke discharges from 1165 CAHs and 300 114 discharges from 3381 non-CAHs. The RSMRs of CAHs were higher than non-CAHs (11.9%± 1.4% vs 10.9%± 1.7%; P<0.001), but the RSRRs were comparable (13.7%± 0.6% vs 13.7%± 1.4%; P=0.3). The RSMRs for the 2 higher volume quartiles of non-CAHs were lower than CAHs (posterior probability of RSMRs higher than CAHs=0.007 for quartile 3; P<0.001 for quartile 4), but there were no differences for lower volume hospitals; RSRRs did not vary by annual hospital volume. CONCLUSIONS CAHs had higher RSMRs compared with non-CAHs, but readmission rates were similar. The observed differences may be partly explained by patient characteristics and annual hospital volume.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA.
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Lichtman JH, Jones SB, Leifheit-Limson EC, Wang Y, Goldstein LB. Abstract 35: 30-Day Risk-Standardized Mortality and Readmission after Ischemic Stroke in Critical Access Hospitals. Stroke 2012. [DOI: 10.1161/str.43.suppl_1.a35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Critical access hospital (CAH) designation identifies hospitals providing emergency and inpatient care to residents of rural communities. Patients with cardiovascular disease and pneumonia have poorer outcomes at CAHs, but stroke outcomes have not been assessed.
Objective:
Compare risk-adjusted 30-day mortality and readmission rates after ischemic stroke for patients treated at critical access and non-critical access hospitals.
Methods:
The cohort included all fee-for-service Medicare beneficiaries 65+ years of age discharged with a primary diagnosis of ischemic stroke (ICD-9 433, 434, 436) in 2006. Risk-standardized mortality and readmission rates at 30 days were compared for patients treated at CAH versus other hospitals using hierarchical logistic regression models, adjusted for patient demographics, medical history, and comorbid conditions.
Results:
There were 10,267 ischemic stroke discharges from 1,165 CAHs and 300,114 discharges from 3,381 non-CAHs. Patients discharged from CAHs were older, more often women and white, and generally had more comorbid conditions. CAHs had higher unadjusted in-hospital (6.4% vs. 4.6%, p<0.001) and 30-day (19.9% vs. 10.9%, p<0.001) mortality rates than non-CAHs, but lower 30-day all-cause readmission (12.4% vs. 13.8%, p<0.001). In risk-standardized analyses, the differences were less marked for 30-day mortality (CAHs vs. non-CAHs; 11.9%±1.4% vs. 10.9%±1.7%, p<0.001), with no difference in 30-day readmission (13.7%±0.6% vs. 13.7%±1.4%, p=0.2787).
Conclusions:
Although there were no differences in readmission rates, stroke patients discharged from CAHs had higher unadjusted mortality than those discharged from non-CAHs. These differences, however, were at least partially explained by differences in patient characteristics. Further research is needed to identify factors contributing to these differences.
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Affiliation(s)
| | | | | | - Yun Wang
- Yale Sch of Medicine, New Haven, CT
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Lichtman JH, Jones SB, Wang Y, Leifheit-Limson EC, Goldstein LB. Abstract 3376: Utilization of Physician Services within the First Month after Hospitalization for Ischemic Stroke. Stroke 2012. [DOI: 10.1161/str.43.suppl_1.a3376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Stroke poses significant burdens on patients, their families, and informal caregivers in the days following hospitalization. Limited data are available assessing patient use of immediate poststroke outpatient services. Service utilization patterns have implications for understanding continuity of care and may affect 30-day mortality and readmission rates, measures being used in other conditions as indicators of the quality and efficiency of hospital-leve care.
Objective:
To determine physician specialty, frequency, and most common reasons for physician office visits for Medicare beneficiaries within 30 days of hospital discharge after an ischemic stroke.
Methods:
Data were derived by linking a 5% sample of Part B Medicare data (physician carrier file) with Part A inpatient data. The study cohort included fee-for-service beneficiaries 65+ years of age with a primary discharge diagnosis of ischemic stroke (ICD-9 433, 434, 436) in 2006 with linked in-patient and physician visit data. The 10 most frequent reasons for physician office visits were identified using principal ICD-9 diagnosis codes. Physician specialty was identified using the CMS provider specialty code.
Results:
Among 10,230 identified ischemic stroke patients, 9,523 were discharged alive and included in the study. Of these patients, 16% were rehospitalized for any cause, 42% had at least one hospital outpatient visit, and 88% had at least one physician office visit within 30 days. Primary reasons for physician office visits included stroke, atrial fibrillation, hypertension, diabetes, and heart failure (
Table
). Internists were seen most frequently, followed by radiologists, cardiologists, and family practice physicians. There were 1,449 visits to neurologists and 1,355 visits to physical medicine and rehabilitation physicians.
Conclusion:
Almost 90% of Medicare beneficiaries discharged with ischemic stroke were seen in a physician’s office within the first month. Reasons for visits included stroke as well as other cardiovascular conditions and common stroke risk factors. Additional research is needed to determine the accuracy of physician codes for follow-up visits as well as to assess how the utilization of outpatient services within the early recovery period influences 30-day mortality and readmission rates.
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Affiliation(s)
| | | | - Yun Wang
- Yale Sch of Medicine, New Haven, CT
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Lichtman JH, Jones SB, Leifheit-Limson EC, Wang Y, Goldstein LB. Abstract 33: Seasonal Patterns in Risk-Standardized Mortality after Ischemic Stroke: A Winter and July Effect. Stroke 2012. [DOI: 10.1161/str.43.suppl_1.a33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
A recent systematic review found that mortality rates were higher and efficiency of care lower in hospitals coincident with the introduction of new trainees in July, but there was significant heterogeneity in study quality, and none of the included studies focused on stroke care.
Purpose:
To assess seasonal variation in 30-day risk-standardized mortality rates (RSMRs) for elderly ischemic stroke patients from 1999 to 2006 and determine whether patterns differ for patients discharged from teaching versus non-teaching hospitals.
Methods:
The study cohort included all fee-for-service Medicare beneficiaries aged 65 years and older discharged with an ischemic stroke (ICD-9 primary codes 433, 434, 436) from 1999 to 2006 in the United States. A hierarchical logistic regression model fitted annual data to estimate the 30-day RSMR, adjusted for demographic and clinical characteristics. The annual datasets were combined and reconstructed to time series analyses, with month as a unit. The time series analysis included 96 months; RSMRs were calculated for each month. The unobserved components modeling approach was used to fit the time series data with risk-adjusted mortality as an outcome to compare seasonal patterns by month for teaching and non-teaching hospitals.
Results:
Of 2,824,694 ischemic stroke discharges, 51.7% were from teaching hospitals. The 30-day RSMR decreased steadily from 1999 to 2006 in teaching hospitals (
Figure 1
A). Seasonal patterns were present within each calendar year, with the highest 30-day RSMR occurring in the winter (January) and the lowest RSMR in the summer, with a secondary peak in July (p=0.004;
Figure 1
B). The same patterns were also seen for non-teaching hospitals (not shown).
Conclusions:
Thirty-day risk-standardized mortality rates after ischemic stroke in the elderly have decreased between 1999 to 2006. Seasonal patterns are evident, with the highest RSMR in January, and a secondary peak in July. Because these patterns were similar for teaching and non-teaching hospitals, the July peak can not be explained based on the introduction of new trainees. The reasons for these seasonal patterns, including higher mortality rates in July, are unclear.
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Affiliation(s)
| | | | | | - Yun Wang
- Yale Sch of Medicine, New Haven, CT
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Lichtman JH, Jones SB, Leifheit-Limson EC, Wang Y, Goldstein LB. 30-day mortality and readmission after hemorrhagic stroke among Medicare beneficiaries in Joint Commission primary stroke center-certified and noncertified hospitals. Stroke 2011; 42:3387-91. [PMID: 22033986 PMCID: PMC3292255 DOI: 10.1161/strokeaha.111.622613] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke patients treated at Joint Commission Primary Stroke Center (JC-PSC)-certified hospitals have better outcomes. Data reflecting the impact of JC-PSC status on outcomes after hemorrhagic stroke are limited. We determined whether 30-day mortality and readmission rates after hemorrhagic stroke differed for patients treated at JC-PSC-certified versus noncertified hospitals. METHODS The study included all fee-for-service Medicare beneficiaries aged 65 years or older with a primary discharge diagnosis of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) in 2006. Covariate-adjusted logistic and Cox proportional hazards regression assessed the effect of care at a JC-PSC-certified hospital on 30-day mortality and readmission. RESULTS There were 2305 SAH and 8708 ICH discharges from JC-PSC-certified hospitals and 3892 SAH and 22 564 ICH discharges from noncertified hospitals. Unadjusted in-hospital mortality (SAH: 27.5% versus 33.2%, P<0.0001; ICH: 27.9% versus 29.6%, P=0.003) and 30-day mortality (SAH: 35.1% versus 44.0%, P<0.0001; ICH: 39.8% versus 42.4%, P<0.0001) were lower in JC-PSC hospitals, but 30-day readmission rates were similar (SAH: 17.0% versus 17.0%, P=0.97; ICH: 16.0% versus 15.5%, P=0.29). Risk-adjusted 30-day mortality was 34% lower (odds ratio, 0.66; 95% confidence interval, 0.58-0.76) after SAH and 14% lower (odds ratio, 0.86; 95% confidence interval, 0.80-0.92) after ICH for patients discharged from JC-PSC-certified hospitals. There was no difference in 30-day risk-adjusted readmission rates for SAH or ICH based on JC-PSC status. CONCLUSIONS Patients treated at JC-PSC-certified hospitals had lower risk-adjusted mortality rates for both SAH and ICH but similar 30-day readmission rates as compared with noncertified hospitals.
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Affiliation(s)
- Judith H Lichtman
- Department of Epidemiology and Public Health, Yale University School of Medicine, PO Box 208034, New Haven, CT 06520, USA.
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Lichtman JH, Leifheit-Limson EC, Jones SB, Watanabe E, Bhat K, Savage SV, Phipps M, Bernheim SM, Krumholz HM. Abstract P27: Statistical Models of Readmission After Stroke: A Systematic Review. Circ Cardiovasc Qual Outcomes 2011. [DOI: 10.1161/circoutcomes.4.suppl_1.ap27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Hospital readmission has been used to risk-stratify patients and profile hospitals by public reporting of performance measures. We conducted a systematic review to identify models developed to compare hospital rates of readmission or predict patients' risk of readmission after stroke, and identify characteristics independently associated with readmission in these models.
Methods:
We identified English-language studies published from 1989-2009 using MEDLINE, PubMed, Scopus, PsychINFO, and all Ovid Evidence-Based Medicine Reviews. Eligible publications reported readmission within 1 year after stroke hospitalization and identified 1 or more predictors of readmission in risk-adjusted statistical models. Publications were excluded if they lacked primary data or quantitative outcomes, considered composite outcomes, or had fewer than 100 patients. Investigators independently reviewed abstracts to select publications that met criteria and used a standardized instrument to perform detailed data abstraction.
Results:
Of the 177 publications identified during the initial review, only 9 met the inclusion criteria. None of these papers developed models to compare readmission rates among hospitals or predicted patients' risk of readmission. The studies presented multivariable models that showed specific patient-level and/or process of care factors associated with readmission after stroke. Studies varied in their case definition of stroke, data source (VA, Medicare, administrative data, registries), outcomes (all-cause and/or stroke-related readmission), and follow-up period. There was little consistency of candidate variables across the studies, but more commonly included factors were age (n=8/9), sex (7), race (8), prior stroke (5), hypertension (5), diabetes (6), standardized stroke severity scale (3), other variables related to stroke severity (5), and length of stay (7). Five studies provided significance levels for covariates other than their primary predictor(s); however, few characteristics were consistently associated with readmission.
Conclusions:
The lack of risk-standardized models represents an important gap for ongoing efforts to profile hospitals through public reporting of performance measures.
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Lichtman JH, Jones SB, Watanabe E, Leifheit-Limson EC, Wang Y, Goldstein LB. Abstract P26: 30-Day Risk Standardized Mortality and Readmission After Ischemic Stroke by Hospital Minority Volume. Circ Cardiovasc Qual Outcomes 2011. [DOI: 10.1161/circoutcomes.4.suppl_1.ap26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Risk-standardized 30-day mortality (RSMR) and readmission (RSRR) rates in part reflect hospital-based and immediate post-discharge care. Differences in rates across hospitals based on the race-ethnic composition of their patient populations may indicate disparities in care. We examined whether hospital 30-day RSMRs and RSRRs after ischemic stroke vary by the proportions of African-Americans (AA) admitted at hospitals in 1994, 2000, and 2006.
Methods:
We used Medicare claims data to determine the hospital-level RSMR for any cause 30 days after the index admission and RSRR for any cause within 30 days of discharge among surviving fee-for-service Medicare patients >= 65 years of age discharged with a primary diagnosis of ischemic stroke (ICD-9 433, 434, 436) in 1994, 2000, and 2006. Hierarchical regression models calculated the RSMR and RSRR for hospitals, adjusting for patient demographics and clinical characteristics. Hospitals were grouped into quartiles based on the proportion of AA admitted. Mixed models and quantile regression models examined the relationship between AA volume and outcomes.
Results:
The RSMR decreased as the proportion of AA increased, whereas the RSRR increased as the proportion of AA increased (figure). These relationships were consistent within each year, and the variability lessened over time. Quantile regression confirms that the relationship persists across the distribution of RSMR and RSRR.
Conclusions:
RSMR and RSRR varied by hospital race-ethnic volume, but differences in outcome lessened over time. Identifying factors contributing to these differences may identify opportunities to improve stroke care among the elderly.
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Affiliation(s)
| | | | | | | | - Yung Wang
- YALE SCHOOL OF MEDICINE, New Haven, CT
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Lichtman JH, Jones SB, Wang Y, Watanabe E, Leifheit-Limson E, Goldstein LB. Outcomes after ischemic stroke for hospitals with and without Joint Commission-certified primary stroke centers. Neurology 2011; 76:1976-82. [PMID: 21543736 PMCID: PMC3109877 DOI: 10.1212/wnl.0b013e31821e54f3] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 12/27/2010] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Joint Commission (JC) began certifying primary stroke centers (PSCs) in the United States in 2003. We assessed whether 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates differed between hospitals with and without JC-certified PSCs in 2006. METHODS The study cohort included all fee-for-service Medicare beneficiaries ≥65 years old discharged with a primary diagnosis of ischemic stroke (International Classification of Diseases, ninth revision, Clinical Modification 433, 434, 436) in 2006. Hierarchical linear regression models calculated hospital-level RSMRs and RSRRs, adjusting for patient demographics, comorbid conditions, and hospital referral region. Hospitals were categorized as being higher than, no different from, or lower than the national average. RESULTS There were 310,381 ischemic stroke discharges from 315 JC-certified PSC and 4,231 noncertified hospitals. Mean overall 30-day RSMR and RSRR were 10.9% ± 1.7% and 12.5% ± 1.4%, respectively. The RSMRs of hospitals with JC-certified PSCs were lower than in noncertified hospitals (10.7% ± 1.7% vs 11.0% ± 1.7%), but the RSRRs were comparable (12.5% ± 1.3% vs 12.4% ± 1.7%). Almost half of JC-certified PSC hospitals had RSMRs lower than the national average compared with 19% of noncertified hospitals, but 13% of JC-certified PSC hospitals had lower RSRRs vs 15% of noncertified hospitals. CONCLUSIONS Hospitals with JC-certified PSCs had lower RSMRs compared with noncertified hospitals in 2006; however, differences were small. Readmission rates were similar between the 2 groups. PSC certification generally identified better-performing hospitals for mortality outcomes, but some hospitals with certified PSCs may have high RSMRs and RSRRs whereas some hospitals without PSCs have low rates. Unmeasured factors may contribute to this heterogeneity.
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Affiliation(s)
- J H Lichtman
- Yale University School of Medicine, PO Box 208034, New Haven, CT 06520, USA.
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West NX, Macdonald EL, Jones SB, Claydon NCA, Hughes N, Jeffery P. Randomized in situ clinical study comparing the ability of two new desensitizing toothpaste technologies to occlude patent dentin tubules. J Clin Dent 2011; 22:82-89. [PMID: 21905402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To compare the ability of two new desensitizing toothpaste technologies (one a 5% NovaMin-based toothpaste and the other an 8% arginine-based toothpaste) to occlude patent dentin tubules in a clinical environment relative to a negative control of water and a control toothpaste after four days of twice-daily brushing and dietary acidic challenges. METHODS The study design was a single-center, single-blind, randomized, split-mouth, four-treatment, two-period, crossover, in situ clinical study. Healthy subjects wore two lower intra-oral appliances, retaining four dentin samples for four treatment days for each period of the clinical study. Samples were brushed twice daily with a test product (days 1-4), with an additional acidic challenge introduced on two selective days. Scanning electron microscopy (SEM) images were taken of the dentin surface, and dentinal tubule occlusion assessed using a categorical scale. RESULTS The results demonstrated that the 5% NovaMin toothpaste was statistically superior at occluding patent dentin tubules compared to water (p = 0.009) and the control toothpaste (p = 0.02) at day 4. In contrast, the treatment effect resulting from the 8% arginine toothpaste did not demonstrate the same degree of occlusive propensity, showing no significant difference to the water and control toothpaste at the day 4 time point. CONCLUSION Application of the 5% NovaMin toothpaste to dentin showed better dentin tubule occlusion and retention abilities in an oral environment under dietary acid challenge conditions, more so than the 8% arginine toothpaste technology. Given modern dietary habits and practices, these results highlight differences in the acid resistance properties of occlusion technologies, and a potential impact on clinical performance.
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Affiliation(s)
- N X West
- Clinical Trials Unit, School of Oral and Dental Sciences University of Bristol, Bristol, UK.
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Lichtman JH, Naert L, Allen NB, Watanabe E, Jones SB, Barry LC, Bravata DM, Goldstein LB. Use of antithrombotic medications among elderly ischemic stroke patients. Circ Cardiovasc Qual Outcomes 2010; 4:30-8. [PMID: 21098780 DOI: 10.1161/circoutcomes.109.850883] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The use of antithrombotic medications after ischemic stroke is recommended for deep vein thrombosis prophylaxis and secondary stroke prevention. We assessed the rate of receipt of these therapies among eligible ischemic stroke patients age ≥65 years and determined the effects of age and other patient characteristics on treatment. METHODS AND RESULTS The analysis included Medicare fee-for-service beneficiaries discharged with ischemic stroke (ICD 433.x1, 434.x1, 436) randomly selected for inclusion in the Medicare Health Care Quality Improvement Program's National Stroke Project 1998 to 1999, 2000 to 2001. Patients discharged from nonacute facilities, transferred, or terminally ill were excluded. Receipt of in-hospital pharmacological deep vein thrombosis prophylaxis, antiplatelet medication, anticoagulants for atrial fibrillation, and antithrombotic medications at discharge were assessed in eligible patients, stratified by age (65 to 74, 75 to 84, and 85+ years). Descriptive models identified characteristics associated with treatment. Among 31 554 patients, 14.9% of those eligible received pharmacological deep vein thrombosis prophylaxis, 83.9% antiplatelet drugs, 82.8% anticoagulants for atrial fibrillation, and 74.2% were discharged on an antithrombotic medication. Rates of treatment decreased with age and were lowest for patients ages 85 years or older. Admission from a skilled nursing facility and functional dependence were associated with lower treatment rates. CONCLUSIONS There was substantial underutilization of antithrombotic therapies among elderly ischemic stroke patients, particularly among the very elderly, those admitted from skilled nursing facilities, and patients with functional dependence. The reasons for low use of antithrombotic therapies, including the apparent underutilization of deep vein thrombosis prophylaxis in otherwise eligible patients, require further investigation.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520, USA.
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Lichtman JH, Leifheit-Limson EC, Jones SB, Watanabe E, Bernheim SM, Phipps MS, Bhat KR, Savage SV, Goldstein LB. Predictors of hospital readmission after stroke: a systematic review. Stroke 2010; 41:2525-33. [PMID: 20930150 DOI: 10.1161/strokeaha.110.599159] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risk-standardized hospital readmission rates are used as publicly reported measures reflecting quality of care. Valid risk-standardized models adjust for differences in patient-level factors across hospitals. We conducted a systematic review of peer-reviewed literature to identify models that compare hospital-level poststroke readmission rates, evaluate patient-level risk scores predicting readmission, or describe patient and process-of-care predictors of readmission after stroke. METHODS Relevant studies in English published from January 1989 to July 2010 were identified using MEDLINE, PubMed, Scopus, PsycINFO, and all Ovid Evidence-Based Medicine Reviews. Authors of eligible publications reported readmission within 1 year after stroke hospitalization and identified ≥ 1 predictors of readmission in risk-adjusted statistical models. Publications were excluded if they lacked primary data or quantitative outcomes, reported only composite outcomes, or had < 100 patients. RESULTS Of 374 identified publications, 16 met the inclusion criteria for this review. No model was specifically designed to compare risk-adjusted readmission rates at the hospital level or calculate scores predicting a patient's risk of readmission. The studies providing multivariable models of patient-level and/or process-of-care factors associated with readmission varied in stroke definitions, data sources, outcomes (all-cause and/or stroke-related readmission), durations of follow-up, and model covariates. Few characteristics were consistently associated with readmission. CONCLUSIONS This review identified no risk-standardized models for comparing hospital readmission performance or predicting readmission risk after stroke. Patient-level and system-level factors associated with readmission were inconsistent across studies. The current literature provides little guidance for the development of risk-standardized models suitable for the public reporting of hospital-level stroke readmission performance.
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Lichtman JH, Jones SB, Wang Y, Watanabe E, Allen NB, Fayad P, Goldstein LB. Postendarterectomy mortality in octogenarians and nonagenarians in the USA from 1993 to 1999. Cerebrovasc Dis 2009; 29:154-61. [PMID: 19955740 DOI: 10.1159/000262312] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 09/11/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients >or=80 years of age. METHODS All fee-for-service Medicare patients (80-89 and >or=90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA. RESULTS A total of 140,376 CEA were performed in patients aged 80-89 years and 6,446 in those aged >or=90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased. CONCLUSIONS The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA. judith.lichtman @ yale.edu
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Lichtman JH, Watanabe E, Allen NB, Jones SB, Dostal J, Goldstein LB. Hospital Arrival Time and Intravenous t-PA Use in US Academic Medical Centers, 2001–2004. Stroke 2009; 40:3845-50. [DOI: 10.1161/strokeaha.109.562660] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Judith H. Lichtman
- From the Section of Chronic Disease Epidemiology (J.H.L., E.W., N.B.A., S.B.J.), Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; UHC University HealthSystem Consortium (J.D.), Oak Brook, Ill; and Department of Medicine (Neurology) (L.B.G.), Duke Stroke Center, Center for Clinical Health Policy Research, Duke University and Durham Veterans Affairs Medical Center, Durham, NC
| | - Emi Watanabe
- From the Section of Chronic Disease Epidemiology (J.H.L., E.W., N.B.A., S.B.J.), Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; UHC University HealthSystem Consortium (J.D.), Oak Brook, Ill; and Department of Medicine (Neurology) (L.B.G.), Duke Stroke Center, Center for Clinical Health Policy Research, Duke University and Durham Veterans Affairs Medical Center, Durham, NC
| | - Norrina B. Allen
- From the Section of Chronic Disease Epidemiology (J.H.L., E.W., N.B.A., S.B.J.), Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; UHC University HealthSystem Consortium (J.D.), Oak Brook, Ill; and Department of Medicine (Neurology) (L.B.G.), Duke Stroke Center, Center for Clinical Health Policy Research, Duke University and Durham Veterans Affairs Medical Center, Durham, NC
| | - Sara B. Jones
- From the Section of Chronic Disease Epidemiology (J.H.L., E.W., N.B.A., S.B.J.), Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; UHC University HealthSystem Consortium (J.D.), Oak Brook, Ill; and Department of Medicine (Neurology) (L.B.G.), Duke Stroke Center, Center for Clinical Health Policy Research, Duke University and Durham Veterans Affairs Medical Center, Durham, NC
| | - Jackie Dostal
- From the Section of Chronic Disease Epidemiology (J.H.L., E.W., N.B.A., S.B.J.), Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; UHC University HealthSystem Consortium (J.D.), Oak Brook, Ill; and Department of Medicine (Neurology) (L.B.G.), Duke Stroke Center, Center for Clinical Health Policy Research, Duke University and Durham Veterans Affairs Medical Center, Durham, NC
| | - Larry B. Goldstein
- From the Section of Chronic Disease Epidemiology (J.H.L., E.W., N.B.A., S.B.J.), Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn; UHC University HealthSystem Consortium (J.D.), Oak Brook, Ill; and Department of Medicine (Neurology) (L.B.G.), Duke Stroke Center, Center for Clinical Health Policy Research, Duke University and Durham Veterans Affairs Medical Center, Durham, NC
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Lichtman JH, Allen NB, Wang Y, Watanabe E, Jones SB, Goldstein LB. Stroke patient outcomes in US hospitals before the start of the Joint Commission Primary Stroke Center certification program. Stroke 2009; 40:3574-9. [PMID: 19797179 DOI: 10.1161/strokeaha.109.561472] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The Joint Commission (JC) began certifying Primary Stroke Centers in November 2003. Cross-sectional studies assessing the impact of certification could be biased if these centers had better outcomes before the start of the program. We determined whether hospitals certified within the first years of the JC program had better outcomes than noncertified hospitals before the start of the certification program. METHODS The study sample included Medicare fee-for-service beneficiaries >or=65 years of age discharged with ischemic stroke in 2002 from 5070 hospitals, 317 of which were JC-certified by June 2007. Hierarchical logistic regression and Cox proportional hazards models were used to compare in-hospital mortality, 30-day mortality, and 30-day readmission for patients treated at future JC-certified versus noncertified hospitals. RESULTS Among 366 551 patients, 18% (66 300) were treated at hospitals with centers that were JC-certified within the first few years of the program. These patients were younger, more likely to be white and male, and had fewer comorbidities and hospitalizations within the prior year. Unadjusted in-hospital mortality (4.7% versus 5.5%), 30-day mortality (9.8% versus 11.3%), and readmissions (13.8% versus 14.6%) were lower in the future JC-certified hospitals (all P<0.001). These differences remained after risk adjustment (in-hospital mortality: OR, 0.93; 95% CI, 0.90 to 0.96; 30-day mortality: OR, 0.92; 95% CI, 0.87 to 0.96; 30-day readmission: hazard ratio, 0.97; 95% CI, 0.95 to 0.99). CONCLUSIONS JC Primary Stroke Center-certified hospitals had better outcomes than noncertified hospitals even before the program began. Cross-sectional studies assessing the effects of stroke center certification need to account for these pre-existing differences.
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Affiliation(s)
- Judith H Lichtman
- Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale UniversitySchool of Medicine, New Haven, Conn 06520-8034, USA.
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Lichtman JH, Jones SB, Watanabe E, Allen NB, Wang Y, Howard VJ, Goldstein LB. Elderly women have lower rates of stroke, cardiovascular events, and mortality after hospitalization for transient ischemic attack. Stroke 2009; 40:2116-22. [PMID: 19228857 DOI: 10.1161/strokeaha.108.543009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Patients with transient ischemic attack (TIA) are at increased risk for stroke, cardiovascular events, and death, yet little is known about whether these risks differ for men and women. We determined whether there are sex-based differences in these outcomes 30 days and 1 year after TIA using a national sample of elderly patients. METHODS Rates of 30-day and 1-year hospitalization for TIA (International Classification of Diseases, 9th Revision Code 435), stroke (International Classification of Diseases, 9th Revision Codes 433, 434, and 436), coronary artery disease (International Classification of Diseases, 9th Revision Codes 410 to 414), all-cause readmission, and mortality were determined for fee-for-service Medicare patients >or=65 years of age discharged with a TIA in 2002. Cox proportional hazards models and random-effects logistic models compared outcomes with risk adjustment for demographics, medical history, comorbidities, and prior hospitalizations. RESULTS The study included 122063 TIA hospitalizations (mean age, 79.0+/-7.6 years; 62% women; 86% white). Men were younger but had higher rates of cardiac comorbidities than women. Women had lower unadjusted rates of stroke, coronary artery disease, and mortality at 30 days and 1 year after TIA admission. These relationships persisted in risk-adjusted analyses at 30 days for stroke (hazard ratio, 0.70; 95% CI, 0.64 to 0.77), coronary artery disease (hazard ratio, 0.86; 0.74 to 1.00), and mortality (odds ratio, 0.74; 0.68 to 0.82) as well as at 1 year for stroke (hazard ratio, 0.85; 0.81 to 0.89), coronary artery disease (hazard ratio, 0.81; 0.77 to 0.86), and mortality (odds ratio, 0.78; 0.75 to 0.81). CONCLUSIONS These data suggest that women have a better prognosis than men within the first year after hospital discharge for a TIA. Additional research is needed to identify factors that may explain these sex-related differences in outcomes.
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Affiliation(s)
- Judith H Lichtman
- Department of Epidemiology and Public Health, Yale University School of Medicine, PO Box 208034, New Haven, CT 06520-8034, USA.
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Abstract
The increasing popularity of minimally invasive surgery has grown concurrently with the demand for ambulatory surgery. Standard outpatient procedures such as tubal ligation are now being joined by ambulatory laparoscopic cholecystectomy. In order for ambulatory minimally invasive surgery to succeed, patient selection must be appropriate, careful attention paid to the physiologic changes of pneumoperitoneum, and pain and nausea treated pre-emptively.
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Affiliation(s)
- S B Jones
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9068, USA.
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Jones SB, Lanford GW, Chen YH, Morabito M, Moribito M, Kim K, Lu Q. Glutamate-induced delta-catenin redistribution and dissociation from postsynaptic receptor complexes. Neuroscience 2003; 115:1009-21. [PMID: 12453475 DOI: 10.1016/s0306-4522(02)00532-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Delta-catenin (or neural plakophilin-related arm-repeat protein/neurojungin) is primarily a brain specific member of the p120(ctn) subfamily of armadillo/beta-catenin proteins that play important roles in neuronal development. Our previous studies have shown that the ectopic expression of delta-catenin induces the formation of dendrite-like extensions and that the overexpression of delta-catenin promotes dendritic branching and increases spine density. Here we demonstrate that delta-catenin displays a dendritic distribution pattern in the adult mouse brain and is co-enriched with postsynaptic density-95 (PSD-95) in the detergent insoluble postsynaptic scaffolds. Delta-catenin forms stable complexes with excitatory neurotransmitter receptors including ionotropic N-methyl-D-aspartic acid receptor 2A (NR2A), metabotropic glutamate receptor 1alpha (mGluR1alpha), as well as PSD-95 in vivo. In cultured primary embryonic neurons, delta-catenin clusters co-distribute with filamentous actin and resist detergent extraction. In dissociated hippocampal neurons overexpressing delta-catenin, glutamate stimulation leads to a rapid redistribution of delta-catenin that can be attenuated by 6-cyano-7-nitroquinoxaline-2,3-dione and dizocilpine, selective inhibitors of ionotropic glutamate receptors. Upon glutamate receptor activation, delta-catenin becomes down-regulated and its association with NR2A and mGluR1alpha in cultured neurons is diminished. These findings support a possible functional connection between delta-catenin and the glutamatergic excitatory synaptic signaling pathway during neuronal development.
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Affiliation(s)
- S B Jones
- Department of Anatomy and Cell Biology, The Brody School of Medicine at East Carolina University, 7N 84 Brody Sciences Building, 600 Moye Boulevard, Greenville, NC 27858, USA
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Beauvais SL, Jones SB, Parris JT, Brewer SK, Little EE. Cholinergic and behavioral neurotoxicity of carbaryl and cadmium to larval rainbow trout (Oncorhynchus mykiss). Ecotoxicol Environ Saf 2001; 49:84-90. [PMID: 11386719 DOI: 10.1006/eesa.2000.2032] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Pesticides and heavy metals are common environmental contaminants that can cause neurotoxicity to aquatic organisms, impairing reproduction and survival. Neurotoxic effects of cadmium and carbaryl exposures were estimated in larval rainbow trout (RBT; Oncorhynchus mykiss) using changes in physiological endpoints and correlations with behavioral responses. Following exposures, RBT were videotaped to assess swimming speed. Brain tissue was used to measure cholinesterase (ChE) activity, muscarinic cholinergic receptor (MChR) number, and MChR affinity. ChE activity decreased with increasing concentrations of carbaryl but not of cadmium. MChR were not affected by exposure to either carbaryl or cadmium. Swimming speed correlated with ChE activity in carbaryl-exposed RBT, but no correlation occurred in cadmium-exposed fish. Thus, carbaryl exposure resulted in neurotoxicity reflected by changes in physiological and behavioral parameters measured, while cadmium exposure did not. Correlations between behavior and physiology provide a useful assessment of neurotoxicity.
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Affiliation(s)
- S L Beauvais
- Columbia Environmental Research Center, USGS/BRD, Columbia, Missouri 65201, USA
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Abstract
Studies of electrical stimulation of osteogenesis with stainless steel electrodes have previously established a dose-response relationship between current and bone growth. Examination of the effect of differing geometric current densities resulted in the conclusion that very little electrode surface area was involved in stimulation and led to the design of a multiport "distributive" cathode. A series of experiments were performed to extend these results to wire and multiport platinum electrodes. As before, a current-bone growth dose-response relationship was found. Peak bone growth was greater than for stainless steel. However, peak bone growth occurred at 2.0 microA (versus 20 microA for stainless steel). Correlation studies suggest that small changes in cathodic potential affect bone growth more than similar size changes in current. Finally, the generally benign local host response to platinum suggests that platinum may be a suitable material for chronic indwelling anodes for stimulation of osteogenesis.
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Abstract
Laparoscopy has revolutionized surgery and in the process influenced the practice of anesthesiology. This article reviews several minimal access procedures that have been accepted into practice, are gaining acceptance, or remain investigational. Absolute contraindications to laparoscopy have been emphasized. As the threshold for primary care physicians to refer sicker and sicker patients for surgery decreases, it is crucial for the anesthesiologist to understand physiologic stresses of pneumoperitoneum and the nuances of laparoscopic surgery. The anesthesiologist also can be recruited to adjust insufflation pressures, tweak images on monitors, rotate and position the patient, or pass balloons and bougies. With patient and surgeon expectation of no pain or nausea and early discharge, anesthetic choices become vital for the ultimate success of the procedure.
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Affiliation(s)
- S B Jones
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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Abstract
OBJECTIVE To determine whether thermal injury and sepsis cause an increase in bone marrow norepinephrine release and whether such a release influences bone marrow monocytopoiesis. SUMMARY BACKGROUND DATA The authors previously demonstrated enhanced bone marrow monocytopoiesis after burn with sepsis. They also showed that physiologic stress and bacterial challenge without injury could lead to a dynamic release of norepinephrine from the bone marrow compartment. In this study, they sought to determine the potential cause-and-effect relationship of bone marrow norepinephrine release on increased monocytopoiesis after burn sepsis. METHODS Norepinephrine release from bone marrow was determined by traditional pulse-chase methods. Tissue and bone marrow norepinephrine content was ablated by chemical sympathectomy with 6-hydroxydopamine treatment. Clonogenic potential in response to colony-stimulating factors was determined in total nucleated bone marrow cells. Dual color flow cytometry was used to document the distribution pattern of monocyte progenitors. RESULTS Burn sepsis induced increased norepinephrine release in bone marrow, spleen, and heart. Colony-forming assays demonstrated an increase in responsive colonies, which was significantly attenuated when norepinephrine content was reduced in animals before burn sepsis. Flow cytometric analysis of early and late monocyte progenitors showed a significantly altered distribution profile of monocyte progenitors in norepinephrine-depleted mice compared with norepinephrine-intact mice. Abrogation of bone marrow norepinephrine content resulted in a 62% survival rate in burn septic mice compared with no survivors in norepinephrine-intact mice. CONCLUSIONS These data suggest that enhanced bone marrow norepinephrine release after burn sepsis may play a role in bone marrow monocytopoiesis, thus contributing to the sustenance of inflammation.
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Affiliation(s)
- Y Tang
- Department of Physiology and the Burn and Shock Trauma Institute, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Brewer SK, Little EE, DeLonay AJ, Beauvais SL, Jones SB, Ellersieck MR. Behavioral dysfunctions correlate to altered physiology in rainbow trout (Oncorynchus mykiss) exposed to cholinesterase-inhibiting chemicals. Arch Environ Contam Toxicol 2001; 40:70-76. [PMID: 11116342 DOI: 10.1007/s002440010149] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
We selected four metrics of swimming behavior (distance swam, speed, rate of turning, and tortuosity of path) and the commonly used biochemical marker, brain cholinesterase (ChE) activity, to assess (1) the sensitivity and reliability of behavior as a potential biomarker in monitoring work, (2) the potential for these endpoints to be used in automated monitoring, and (3) the linkage between behavior and its underlying biochemistry. Malathion-exposed fish exhibited large decreases in distance and speed and swam in a more linear path than control fish after 24 h exposure. By 96 h exposure, fish still swam slower and traveled less distance; fish fully recovered after 48 h in clean water. Diazinon-exposed fish exhibited decreases in distance, speed, and turning rate compared to controls. After 48 h recovery in clean water, fish exposed to diazinon had not recovered to control levels. The behavioral responses provided measures of neurotoxicity that were easily quantifiable by automated means, implying that the inclusion of behavior in monitoring programs can be successful. Furthermore, correlations between behavior and biochemical endpoints, such as ChE inhibition, suggest that this approach can provide a meaningful link between biochemistry and behavior and can provide useful information on toxicant impacts.
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Affiliation(s)
- S K Brewer
- University of Missouri-Columbia, Department of Biological Sciences, Columbia, Missouri, USA
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Bingham GE, Jones SB, Or D, Podolski IG, Levinskikh MA, Sytchov VN, Ivanova T, Kostov P, Sapunova S, Dandolov I, Bubenheim DB, Jahns G. Microgravity effects on water supply and substrate properties in porous matrix root support systems. Acta Astronaut 2000; 47:839-848. [PMID: 11708347 DOI: 10.1016/s0094-5765(00)00116-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The control of water content and water movement in granular substrate-based plant root systems in microgravity is a complex problem. Improper water and oxygen delivery to plant roots has delayed studies of the effects of microgravity on plant development and the use of plants in physical and mental life support systems. Our international effort (USA, Russia and Bulgaria) has upgraded the plant growth facilities on the Mir Orbital Station (OS) and used them to study the full life cycle of plants. The Bulgarian-Russian-developed Svet Space Greenhouse (SG) system was upgraded on the Mir OS in 1996. The US developed Gas Exchange Measurement System (GEMS) greatly extends the range of environmental parameters monitored. The Svet-GEMS complex was used to grow a fully developed wheat crop during 1996. The growth rate and development of these plants compared well with earth grown plants indicating that the root zone water and oxygen stresses that have limited plant development in previous long-duration experiments have been overcome. However, management of the root environment during this experiment involved several significant changes in control settings as the relationship between the water delivery system, water status sensors, and the substrate changed during the growth cycles.
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Abstract
An entire spectrum of advanced technologies and concepts has been presented, from the new clinical applications to highly speculative possibilities. Not all of these technologies will survive the long process to clinical usefulness, but those that do may revolutionize surgery. With such change comes the ethical and moral responsibility to consider them not only in the light of improvement of patient care but also in their impact on society as a whole. If the remarkable rate of change of the past 2 decades continues, it is impossible to conceive of the role of future surgeons. Thus, to be prepared, surgeons must have an open mind, a willingness to consider and evaluate new directions, and the honesty and courage to change when a new approach is proven to be of value. A prepared mind is an open mind.
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Affiliation(s)
- R M Satava
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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Petty JD, Jones SB, Huckins JN, Cranor WL, Parris JT, McTague TB, Boyle TP. An approach for assessment of water quality using semipermeable membrane devices (SPMDs) and bioindicator tests. Chemosphere 2000; 41:311-321. [PMID: 11057592 DOI: 10.1016/s0045-6535(99)00499-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
As an integral part of our continued development of water quality assessment approaches, we combined integrative sampling, instrumental analysis of widely occurring anthropogenic contaminants, and the application of a suite of bioindicator tests as a specific part of a broader survey of ecological conditions, species diversity, and habitat quality in the Santa Cruz River in Arizona, USA. Lipid-containing semipermeable membrane devices (SPMDs) were employed to sequester waterborne hydrophobic chemicals. Instrumental analysis and a suite of bioindicator tests were used to determine the presence and potential toxicological relevance of mixtures of bioavailable chemicals in two major water sources of the Santa Cruz River. The SPMDs were deployed at two sites; the effluent weir of the International Wastewater Treatment Plant (IWWTP) and the Nogales Wash. Both of these systems empty into the Santa Cruz River and the IWWTP effluent is a potential source of water for a constructed wetland complex. Analysis of the SPMD sample extracts revealed the presence of organochlorine pesticides (OCs), polychlorinated biphenyls (PCBs), and polycyclic aromatic hydrocarbons (PAHs). The bioindicator tests demonstrated increased liver enzyme activity, perturbation of neurotransmitter systems and potential endocrine disrupting effects (vitellogenin induction) in fish exposed to the extracts. With increasing global demands on limited water resources, the approach described herein provides an assessment paradigm applicable to determining the quality of water in a broad range of aquatic systems.
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Affiliation(s)
- J D Petty
- USGS/Columbia Environmental Research Center, MO 65201, USA.
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Abstract
Sentinel lymph node biopsy, validated in melanoma staging, is currently under investigation for breast cancer staging. Reports suggest that the sentinel lymph node has a high predictive value in determining the presence of axillary metastases. Identification of a sentinel lymph node that is free of metastatic tumor cells may eliminate the necessity of performing a standard axillary lymph node dissection with its attendant morbidity. Numerous techniques are utilized to identify the sentinel node with approximately the same success rate. This paper will address some of the controversial areas of sentinel lymph node biopsy and offer an option for physicians who want to develop a sentinel lymph node program in their hospital.
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Affiliation(s)
- S S Jeffrey
- Division of Surgical Oncology, Stanford University School of Medicine, California, USA.
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