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Bancks MP, Lin MY, Bertoni A, Futrell WM, Liu Z, Ostasiewski B, Wells BJ, Hanchate A. Impact of the COVID-19 Pandemic on Diabetes Care Among a North Carolina Patient Population. Clin Diabetes 2022; 40:467-476. [PMID: 36385975 PMCID: PMC9606556 DOI: 10.2337/cd21-0136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this study, researchers reviewed electronic health record data to assess whether the coronavirus disease 2019 pandemic was associated with disruptions in diabetes care processes of A1C testing, retinal screening, and nephropathy evaluation among patients receiving care with Wake Forest Baptist Health in North Carolina. Compared with the pre-pandemic period, they found an increase of 13-21 percentage points in the proportion of patients delaying diabetes care for each measure during the pandemic. Alarmingly, delays in A1C testing were greatest for individuals with the most severe disease and may portend an increase in diabetes complications.
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Affiliation(s)
| | - Meng-Yun Lin
- Wake Forest School of Medicine, Winston-Salem, NC
| | | | | | - Zhixiu Liu
- Soterea Technology (Shanghai) Co., Ltd., Pudong New District, Shanghai, China
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Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD, Herrington DM, Diaz-Garelli JF, Futrell WM, Hiestand BC, Miller CD. Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circulation 2019; 138:2456-2468. [PMID: 30571347 DOI: 10.1161/circulationaha.118.036528] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. METHODS A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ≥21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data. RESULTS Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33). CONCLUSIONS HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.
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Affiliation(s)
- Simon A Mahler
- Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC.,Department of Implementation Science (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC.,Department of Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Kristin M Lenoir
- Department of Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian J Wells
- Department of Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory L Burke
- Public Health Sciences (G.L.B.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Pamela W Duncan
- Departments of Neurology, Sticht Center on Aging, Gerontology, and Geriatric Medicine (P.W.D.), Wake Forest School of Medicine, Winston-Salem, NC
| | - L Douglas Case
- Department of Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Herrington
- Department of Internal Medicine, Division of Cardiovascular Medicine (D.M.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jose-Franck Diaz-Garelli
- Department of Physiology and Pharmacology (J.-F.D.-G.), Wake Forest School of Medicine, Winston-Salem, NC.,Clinical and Translational Science Institute (J.-F.D.-G., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Wendell M Futrell
- Clinical and Translational Science Institute (J.-F.D.-G., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Chadwick D Miller
- Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC
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Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD, Herrington DM, Diaz-Garelli JF, Futrell WM, Hiestand BC, Miller CD. Response by Mahler et al to Letter Regarding Article, "Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge: HEART Pathway Accelerated Diagnostic Protocol". Circulation 2019; 139:e915-e916. [PMID: 31059320 DOI: 10.1161/circulationaha.119.039922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/16/2022]
Affiliation(s)
- Simon A Mahler
- Departments of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC.,Implementation Science and Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Kristin M Lenoir
- Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian J Wells
- Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory L Burke
- Public Health Sciences (G.L.B.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Pamela W Duncan
- Departments of Neurology, Sticht Center on Aging, Gerontology, and Geriatric Medicine (P.W.D.), Wake Forest School of Medicine, Winston-Salem, NC
| | - L Douglas Case
- Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Herrington
- Department of Internal Medicine, Division of Cardiovascular Medicine (D.M.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jose-Franck Diaz-Garelli
- Department of Physiology and Pharmacology (J.-F.D.-C.), Wake Forest School of Medicine, Winston-Salem, NC.,Clinical and Translational Science Institute (J.-F.D.-C., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Wendell M Futrell
- Clinical and Translational Science Institute (J.-F.D.-C., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Departments of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Chadwick D Miller
- Departments of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC
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Stone AV, Jinnah A, Wells BJ, Atkinson H, Miller AN, Futrell WM, Lenoir K, Emory CL. Nutritional markers may identify patients with greater risk of re-admission after geriatric hip fractures. Int Orthop 2017; 42:231-238. [PMID: 28988402 DOI: 10.1007/s00264-017-3663-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/24/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Osteoporotic hip fractures are increasing in prevalence with the growing elderly population. Morbidity and mortality remain high following osteoporotic hip fractures despite advances in medical and surgical treatments. The associated costs and medical burdens are increased with a re-admission following hip fracture treatment. This study sought to identify demographic and clinical values that may be a predictive model for 30-day re-admission risk following operative management of an isolated hip fracture. METHODS Between January 1, 2013 and April 30, 2015 all patients admitted to a single academic medical centre for treatment of a hip fracture were reviewed. Candidate variables included standard demographics, common laboratory values, and markers of comorbid conditions and nutrition status. A 30-day, all-cause re-admission model was created utilizing multivariate logistic regression. RESULTS A total of 607 patients with hip fractures were identified and met the inclusion criteria; of those patients, 67 were re-admitted within 30 days. Univariate analysis indicates that the re-admission group had more comorbidities (p < 0.001) and lower albumin (p = 0.038) and prealbumin (p < 0.001). The final, reduced model contained 12 variables and incorporated four out of five nutritional makers with an internally, cross-validated C-statistic of 0.811 (95% CI: 0.754, 0.867). CONCLUSION Our results indicate that specific nutritional laboratory markers at the index admission may identify patients that have a greater risk of re-admission after hip fracture. This model identifies potentially modifiable risk factors and may allow orthogeriatricians to better educate patients and better treat post-operative nutritional status and care.
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Affiliation(s)
- Austin V Stone
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alexander Jinnah
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
| | - Brian J Wells
- Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Family Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Public Health Sciences, Wake Forest University Graduate School of Arts and Sciences, Winston-Salem, NC, USA
| | - Hal Atkinson
- Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Wendell M Futrell
- Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kristin Lenoir
- Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Cynthia L Emory
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
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