Prosthetic Outcomes after Amputation and the Impact of Mobility Level on Survival

BACKGROUND

Lower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5 year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation.

METHODS

This was a retrospective analysis of all patients that underwent lower-extremity amputation by surgeons in our practice from January 1, 2010 to December 31, 2019. Abstracted data included: age, sex, race, body mass index (BMI), comorbidities, American Society of Anesthesiologists (ASA) score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States' Medicare Functional Classification Level (MFCL) also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time dependent covariates was performed to assess risk factors associated with 5-year mortality.

RESULTS

464 patients were included in this study. The mean age was 65 years and mean body mass index 27 kg/m2. Majority of patients were male (68%), white (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (BKA) (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95%CI, 37.6%-46.6%) (BKA 47.7% [95%CI, 42.5%-53.5%], above-the-knee amputation 28.7 % [95%CI, 22.1%-37.2%]). On multivariable analysis age >60 years, CHF, AKA and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival.

CONCLUSION

This study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The MFCL K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival.

The use of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh in ventral hernia repair: a systematic review and meta-analysis

PURPOSE/BACKGROUND

Despite the growing use of bioabsorbable mesh in ventral hernia repairs (VHR), the evidence of its impact on patient outcomes remains limited. This study aims to investigate the efficacy and safety profile of poly-4-hydroxybutyrate (P4HB) mesh for ventral hernia repair through a systematic review and meta-analysis.

METHODS

A literature search of five databases (PubMed, Embase, Ovid, Medline, and Google Scholar) produced a list of publications that analyzed the use of P4HB mesh in ventral hernia repair in both clean and contaminated cases. The primary postoperative outcomes of hernia recurrence, surgical site infections (SSI), and any complications were analyzed through a pooled meta-analysis.

RESULTS

In our systematic review, 21 studies met the inclusion criteria with a total of 1858 patients (933 males and 925 females) and an average age of 56.8 years. The median follow-up ranged from 1.6 to 62.3 months. In our meta-analysis, the use of P4HB mesh in VHR in proportion of events demonstrated a recurrence rate of 9% [6%; 15%], SSI of 10% [6%; 16%] and 35% [9%; 42%] for rate of any complications. Sub-meta-analysis restricted to studies with follow up > 18 months continues to show low rates of recurrence of 9% (95%CI, 4-17%), SSI of 9% (95%CI, 4-16%), and 31% (95%CI, 23-41%) for any complications.

CONCLUSION

Our study demonstrates that the use of P4HB mesh is both safe and effective in ventral hernia repairs. When further analyzed past 18 months, the time where P4HB mesh fully resorbs, the rates of hernia recurrence, SSI, and any complications remain low of upwards of 5 years and comparable to the rates seen in synthetic and biologics in similar patient populations.

Coated poly-4-hydroxybutyrate (Phasix ST™) mesh is safe and effective for hiatal hernia repair: our institutional experience and review of the literature

BACKGROUND

Poly-4-hydroxybutyrate (P4HB) is a bioabsorbable mesh with a non-adhesive coating on one side that is being used to reinforce the hiatus during hiatal hernia repair; however, there is limited data regarding its use. The aim of this study was to investigate outcomes after hiatal hernia repair using this mesh at our institution and through a review of the literature.

METHODS

An institutional review board-approved prospective database was retrospectively reviewed for all patients undergoing hiatal hernia repair from April 2018 to December 2022. A systematic review with meta-analysis was conducted to evaluate outcomes using P4HB coated mesh.

RESULTS

In our institutional cohort, there were 230 patients (59 males; 171 females) with a mean follow-up of 20 ± 14.6 months. No mesh-related complications occurred. Hernia recurrence was diagnosed in 11 patients (4.8%) with a median time to recurrence of 16 months. In the systematic review, 4 studies with 221 patients (76 males; 145 females) were included. Median follow-up ranged from 12 to 27 months. Recurrence rate in these studies was reported from 0 to 8.8%, with a total of 12 recurrences identified. Like our institutional cohort, no mesh-related complications were reported. After our recurrences were combined with those from the systematic review, a total of 23 recurrences were included in the meta-analysis. Our meta-analysis revealed a low recurrence rate following hiatal hernia repair with P4HB coated mesh (incidence rate per 100 person-years, 2.82; 95% confidence interval, 1.60, 4.04).

CONCLUSION

P4HB coated mesh is safe and effective for hiatal hernia repairs.

Comparison of hospitalist service staffing models at Baylor University Medical Center

Background

Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges.

Methods

The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included.

Results

There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios.

Conclusions

These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.

Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study

Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .

Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature

INTRODUCTION

Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature.

METHODS

A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis.

RESULTS

A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively.

CONCLUSION

GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.

Comparison of long-term quality of life outcomes between endoscopic vacuum therapy and other treatments for upper gastrointestinal leaks

BACKGROUND

While endoscopic vacuum assisted closure (EVAC) therapy is a validated treatment for gastrointestinal leaks, its impact on long-term quality of life (QoL) is uncertain. The purpose of this study was to evaluate the impact of successful EVAC management on long-term QoL outcomes.

METHODS

An institutional review board approved prospectively maintained database was retrospectively reviewed to identify patients undergoing treatment for gastrointestinal leaks between June 2012 and July 2022. The Short-Form 36 (SF-36) survey was used to assess QoL. Patients were contacted by telephone and sent the survey electronically. QoL outcomes between patients who underwent successful EVAC therapy and those who required conventional treatment (CT) were analyzed and compared.

RESULTS

A total of 44 patients (17 EVAC; 27 CT) completed the survey and were included in our analysis. All included patients had foregut leaks with sleeve gastrectomy being the most common sentinel operation (n = 20). The mean time from the sentinel operation was 3.8 years and 4.8 years for the EVAC and CT groups, respectively. When evaluating long-term QoL, the EVAC group scored higher in all QoL domains when compared to the CT group with physical functioning (87.3 vs 69.3, p = 0.04), role limitations due to physical health (84.1 vs 45.7, p = 0.02), energy/fatigue (60.0 vs 40.9, p = 0.04), and social functioning (86.2 vs 64.1, p = 0.04) reaching statistical significance. Overall, patients who achieved organ preservation via successful EVAC therapy scored higher in all domains with role limitations due to physical health (p = 0.04) being statistically significant. In a multivariable regression analysis, increased age and a history of prior abdominal surgery at the time of the sentinel operation were patient characteristics that negatively impacted QoL outcomes.

CONCLUSION

Patients with gastrointestinal leaks successfully managed by EVAC therapy have better long-term QoL outcomes when compared to patients undergoing other treatments.

Predictive factors of first-time failure on the American Board of Colorectal Surgery certifying and qualifying examinations

Objective

To discover if first-attempt failure of the American Board of Colon and Rectal Surgery (ABCRS) board examination is associated with surgical training or personal demographic characteristics.

Methods

Current colon and rectal surgery program directors in the United States were contacted via email. Deidentified records of trainees from 2011 to 2019 were requested. Analysis was performed to identify associations between individual risk factors and failure on the ABCRS board examination on the first attempt.

Results

Seven programs contributed data, totaling 67 trainees. The overall first-time pass rate was 88% (n = 59). Several variables demonstrated potential for association, including Colon and Rectal Surgery In-Training Examination (CARSITE) percentile (74.5 vs 68.0, P = 0.09), number of major cases in colorectal residency (245.0 vs 219.2, P = 0.16), >5 publications during colorectal residency (75.0% vs 25.0%, P = 0.19), and first-time passage of the American Board of Surgery certifying examination (92.5% vs 7.5%, P = 0.18).

Conclusion

The ABCRS board examination is a high-stakes test, and training program factors may be predictive of failure. Although several factors showed potential for association, none reached statistical significance. Our hope is that by increasing our data set, we will identify statistically significant associations that can potentially benefit future trainees in colon and rectal surgery.

Instagram and Spine Fusion: An Analysis of Social Media and Its Relationship to Patient Perception of Surgery

STUDY DESIGN

Cross sectional study.

OBJECTIVES

To analyze posts shared on Instagram referencing spinal fusion for tone, gender, activities of daily living (ADLs), rehabilitation, incision, pain, neurological injury, and content of post.

METHODS

Public instragram posts, which were isolated and evaluated using the hashtags "#spinefusion" and "#spinalfusion." All posts were analyzed by the authors for the variables previously listed. In total, 264 posts were included for investigation and analysis of patient perception of spine fusion through social media.

RESULTS

Of all included posts, approximately 86% of posts had a positive tone. There was statistical significance between positive tone and activities of daily living (ADLs) (P = 0.047), as well as negative tone and persistent pain (P = 0.008). Adequate return to activities of daily living is perceived by patients as a positive outcome after surgery: odds ratio (OR) (95% CI) of 2.11 (1.01-4.39). Persistent post operative pain results negatively on perceived outcomes after surgery OR = 0.38 (0.18-0.78).

CONCLUSIONS

Reported outcomes after spine fusion has not been evaluated through social media avenues. This analysis of patients sharing their experience on social media after spinal fusion demonstrates that returning to activities of daily living is of the utmost importance to patients. Additionally, post-operative pain is a strong metric utilized by patients with their satisfaction after surgery.

MELD-Lactate Predicts Poor Outcome in Variceal Bleeding in Cirrhosis

BACKGROUND

Predictors of poor outcome associated with variceal bleeding remain suboptimal. In patients with cirrhosis, serum lactate combined with Model for End-Stage Liver Disease (MELD-LA) improved prediction across heterogeneous populations. However, prognostic properties have not yet been assessed in the context of variceal bleeding.

AIMS

We aimed to evaluate the predictive performance of MELD-LA compared to MELD, lactate, and nadir hemoglobin in cirrhosis patients with variceal bleeding.

METHODS

In this multicenter study, we identified 472 patients with variceal bleeding from a German primary cohort (University Hospitals Hamburg/Frankfurt/Cologne), and two independent external validation cohorts [Veterans Affairs (VA), Baylor University]. Discrimination for 30-day mortality was analyzed and scores were compared. MELD-LA was evaluated separately in validation cohorts to ensure consistency of findings.

RESULTS

In contrast to nadir hemoglobin, MELD and peak-lactate at time of bleeding were significantly higher in 30-day non-survivors in the primary cohort (p = 0.708; p < 0.001). MELD-LA had excellent discrimination for 30-day mortality (AUROC 0.82, 95% CI 0.76-0.88), better than MELD and peak-lactate (AUROC 0.78, 95% CI 0.71-0.84; AUROC 0.73, 95% CI 0.66-0.81). MELD-LA predicted 30-day mortality independently of age, sex, severity of liver disease and vasopressor support (HR 1.29 per 1-point-increase of MELD-LA; 95% CI 1.19-1.41; p < 0.001). Similarly, MELD-LA demonstrated excellent discrimination for 30-day mortality in the VA (AUROC = 0.86, 95% CI 0.79-0.93) and Baylor cohort (AUROC = 0.85, 95% CI 0.74-0.95).

CONCLUSIONS

MELD-LA significantly improves discrimination of short-term mortality associated with variceal bleeding, compared to MELD, peak-lactate and nadir hemoglobin. Thus, MELD-LA might represent a useful and objective marker for risk assessment and therapeutic intervention in patients with variceal bleeding.

Reducing inappropriate inpatient thrombophilia testing through an electronic health record intervention

Current literature does not support routine testing for hereditary and acquired thrombophilia disorders in the inpatient setting. Testing in the acute setting rarely changes patient management or could lead to patient mismanagement. Despite prior educational interventions, continued overuse of inpatient testing warrants further quality improvement measures. A hard-stop best practice advisory pop-up was implemented in the electronic medical record in a multicenter academic hospital system to provide clinicians guidance on the appropriate use of thrombophilia testing at the point of care. Pre- and postintervention retrospective data were collected to assess clinical features before and after implementation. Before the intervention, 271 patients underwent inpatient hypercoagulability testing; after the intervention, 238 patients underwent inpatient hypercoagulability testing. The total number of labs ordered per patient decreased from 1185 to 910, a 13% reduction (P = 0.003). Overall, there was a savings of $23,597 in total direct cost and $123,153 in total charges when comparing the 6-month timeframes before and after the intervention (P < 0.01). Although this study found only mild reductions in thrombophilia testing, it presents a new means of providing point-of-care intervention and education for hypercoagulability testing in the inpatient setting.

Sonographic Measurement of Renal Sinus Fat to Renal Cortical Thickness Ratio Is a Better Predictor of Chronic Kidney Disease Than Cortical Thickness Alone

Objective:

The aim was to determine if the renal sinus fat-to-cortical thickness ratio was a better predictor of chronic kidney disease (CKD) than cortical thickness alone.

Materials and Methods:

A total of 199 patients were included in the study. Renal fat, parenchyma, and cortical thicknesses were evaluated by sonography retrospectively. Same day serum glomerular filtration rate (GFR) values were obtained and correlated.

Results:

The study patients had an average fat-to-cortical thickness ratio <0.4 and had a 63% probability of developing renal failure. The probability increased almost linearly from 65% to 85% for patients with a ratio between 0.4 and 0.5, and then plateaued at 85% probability for a ratio >0.5. Additionally, the average fat-to-cortical thickness ratio was statistically significant ( P-value = .02) in predicting progression to renal failure, compared to a cortical thickness alone ( P-value = .12 and P-value = .39 for the left and right kidney, respectively). However, when evaluating individual kidneys for the average fat-to-cortical thickness ratio, only the left kidney showed a statistical significance ( P-value = .02 and P-value = .08 on the left and right, respectively).

Conclusion:

The renal sinus fat-to-cortical thickness ratio has a significant negative correlation to GFR, specifically for the left kidney. The probability of developing renal failure increases with higher ratios. The renal sinus fat-to-cortical thickness ratio may also be better than cortical thickness alone in predicting progression toward CKD and it acts as an internal control for differences in body size.

COVID-19 Vaccine-Associated Subclinical Axillary Lymphadenopathy on Screening Mammogram

BACKGROUND

Women who received a COVID-19 vaccination may display subclinical unilateral axillary lymphadenopathy on screening mammography, which can appear suspicious for malignancy, leading to additional diagnostic evaluation.

PURPOSE

To evaluate the prevalence of subclinical unilateral axillary lymphadenopathy (sLAD) on screening mammogram in women who received either the first or second dose of the Pfizer-BioNTech (Pfizer) or Moderna COVID-19 vaccines compared to women who have not.

MATERIALS AND METHODS

In this IRB-approved, HIPAA complaint study from 12/14/2020 to 4/14/2021, 1027 patients presented for screening mammography and met study inclusion criteria. Patients with history of baseline lymphadenopathy or prior cancer diagnosis were excluded.

RESULTS

Of the 1027 women, 43 were recalled for unilateral sLAD. 34 women received a COVID-19 vaccination ipsilateral to the sLAD (Pfizer n=19, 44.2%; Moderna n=15, 34.9%), 9 did not (20.9%). Incidence of unilateral axillary sLAD was significantly higher (p-value<0.01) in those who received a COVID-19 vaccination within approximately 7 weeks preceding screening mammogram. 13.2% of patients who received the Pfizer vaccine and 9.5% of patients who received the Moderna vaccine developed sLAD. Moderna's vaccine elicited a more robust reaction in the elderly (Moderna 63.7 years vs. Pfizer 59.7 years). For both vaccines, sLAD resolved on average 46.5 days after the last COVID-19 vaccine (p=0.44).

CONCLUSION

Women who have received either mRNA COVID-19 vaccines may benefit from scheduling their screening mammogram before vaccination or consider delaying screening mammography 8 weeks. While Pfizer may have an overall more robust immune response, Moderna may elicit a stronger immune response in elderly women.

SUMMARY

Women who received a COVID-19 vaccination before screening mammography were significantly more likely to present with subclinical axillary lymphadenopathy than women who did not receive the vaccine.

KEY RESULTS

13.2% of women who received a Pfizer-BioNTech vaccine exhibited subclinical axillary lymphadenopathy compared to 9.5% of those who received the Moderna vaccine. Only 1.2 % of those who did not receive a vaccine presented with subclinical unilateral axillary lymphadenopathy. The average time of resolution of the lymphadenopathy on diagnostic mammogram was 46.5 days overall, with Pfizer-BioNTech taking 50.7 days and Moderna 41.5 days.

Predicting opioid-induced oversedation in hospitalised patients: a multicentre observational study

OBJECTIVES

Opioid-induced respiratory depression (OIRD) and oversedation are rare but potentially devastating adverse events in hospitalised patients. We investigated which features predict an individual patient's risk of OIRD or oversedation; and developed a risk stratification tool that can be used to aid point-of-care clinical decision-making.

DESIGN

Retrospective observational study.

SETTING

Twelve acute care hospitals in a large not-for-profit integrated delivery system.

PARTICIPANTS

All inpatients ≥18 years admitted between 1 July 2016 and 30 June 2018 who received an opioid during their stay (163 190 unique hospitalisations).

MAIN OUTCOME MEASURES

The primary outcome was occurrence of sedation or respiratory depression severe enough that emergent reversal with naloxone was required, as determined from medical record review; if naloxone reversal was unsuccessful or if there was no evidence of hypoxic encephalopathy or death due to oversedation, it was not considered an oversedation event.

RESULTS

Age, sex, body mass index, chronic obstructive pulmonary disease, concurrent sedating medication, renal insufficiency, liver insufficiency, opioid naïvety, sleep apnoea and surgery were significantly associated with risk of oversedation. The strongest predictor was concurrent administration of another sedating medication (adjusted HR, 95% CI=3.88, 2.48 to 6.06); the most common such medications were benzodiazepines (29%), antidepressants (22%) and gamma-aminobutyric acid analogue (14.7%). The c-statistic for the final model was 0.755. The 24-point Oversedation Risk Criteria (ORC) score developed from the model stratifies patients as high (>20%, ≥21 points), moderate (11%-20%, 10-20 points) and low risk (≤10%, <10 points).

CONCLUSIONS

The ORC risk score identifies patients at high risk for OIRD or oversedation from routinely collected data, enabling targeted monitoring for early detection and intervention. It can also be applied to preventive strategies-for example, clinical decision support offered when concurrent prescriptions for opioids and other sedating medications are entered that shows how the chosen combination impacts the patient's risk.

Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival

BACKGROUND

Despite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival.

METHODS

This was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality.

RESULTS

There were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m². The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective.

CONCLUSIONS

We identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care.

Effect of extracorporeal membrane oxygenation transport on short- and long-term survival in patients with acute respiratory distress syndrome

Venovenous extracorporeal membrane oxygenation (ECMO) has emerged as an important tool in the treatment of acute respiratory distress syndrome (ARDS). The creation of portable ECMO circuits and pumps has supported the development of interfacility ECMO programs. Prior studies have demonstrated that ECMO transport is safe; however, long-term outcomes for these patients remain unknown. Retrospective analysis of our 5-year experience identified 58 patients transported on ECMO and 82 patients cannulated at our institution. When short-term (30 days) and long-term (1 year) outcomes were compared between these cohorts, there was no statistically significant difference in survival (P = 0.44 and 0.49). There were no deaths related to transport, and the rate of ECMO-related complications was similar between the groups. With established patient safety and similar long-term survival, ECMO transport is a feasible solution to provide access to ECMO for all communities.

Factors contributing to unintentional parathyroidectomy during thyroid surgery

Unintentional parathyroidectomy during thyroid surgery has an incidence ranging between 1% and 31% across institutions. Many studies have identified malignancy and central neck dissection as risk factors for losing parathyroid glands, but few studies have evaluated the impact of other factors such as lymphocytic thyroiditis, hyperthyroidism, or concomitant primary hyperparathyroidism. The purpose of this study was to investigate which factors contribute to parathyroid loss during thyroid surgery. Charts of 269 patients undergoing thyroid surgery at a tertiary care medical center from 2010 to 2013 were retrospectively reviewed. Sixty-six patients (24.5%) experienced unintentional parathyroidectomy. Bivariate analysis showed no significant differences in patient characteristics. Patients with unintentional parathyroid removal had a significantly smaller largest thyroid nodule size (P = 0.002), higher rate of central neck dissection (30.3% vs 7.9%, P < 0.0001), and higher rate of malignancy (50% vs 36.0%, P = 0.04). Multivariable analysis showed that the strongest risk factor for unintentional parathyroidectomy was central neck dissection (P = 0.0008; odds ratio 4.72, confidence interval 1.91-11.71). In conclusion, central neck dissection for thyroid malignancy is the strongest risk factor for unintentional thyroidectomy. The presence of concomitant primary hyperparathyroidism, lymphocytic thyroiditis, or hyperthyroidism did not appear to increase the risk of unintentional parathyroidectomy.

Increasing Health Care Burden of Chronic Liver Disease Compared With Other Chronic Diseases, 2004-2013

BACKGROUND & AIMS

Chronic liver disease (CLD) is a common and expensive condition, and studies of CLD-related hospitalizations have underestimated the true burden of disease. We analyzed data from a large, diverse health care system to compare time trends in CLD-related hospitalizations with those in congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD).

METHODS

We collected data from a large health care system in Texas on hospitalizations related to CLD (n = 27,783), CHF (n = 60,415), and COPD (n = 34,199) from January 1, 2004 through December 31, 2013. We calculated annual hospitalization rates (per 100,000) and compared hospital course, inpatient mortality, ancillary services, and readmissions.

RESULTS

Compared with patients with CHF (median age, 71 years) or COPD (median age, 69 years), patients with CLD were significantly younger (median age, 57 years) (P < .01 vs CHF and COPD). Higher proportions of patients with CLD were uninsured (11.7% vs 5.4% for CHF and 5.4% for COPD, P < .01) and Hispanic (17% for CLD vs 9.3% for CHF and 5.0% for COPD, P < .01). A lower proportion of patients with CLD had Medicare (41.5% vs 68.6% with CHF and 70.1% with COPD, P < .01). From 2004 through 2013, the rate of CLD-related hospitalization increased by 92% (from 1295/100,000 to 2490/100,000), compared with 6.7% for CHF (from 3843/100,000 to 4103/100,000) and 48.8% for COPD (from 1775/100,000 to 2642/100,000). During this time period, CLD-related hospitalizations covered by Medicare increased from 31.8% to 41.5%, whereas hospitalizations covered by Medicare did not change for CHF (remained at 70%) or COPD (remained at 70%). Patients with CLD had longer hospital stays (7.3 days vs 6.2 days for CHF and 5.9 days for COPD, P < .01). A higher proportion of patients with CLD died or were discharged to hospice (14.2% vs 11.5% of patients with CHF and 9.3% of patients with COPD, P < .01), and a smaller proportion had access to postacute care (13.2% vs 23.2% of patients with CHF and 27.4% of patients with COPD, P < .01). A higher proportion of patients with CLD were readmitted to the hospital within 30 days (25% vs 21.9% of patients with CHF and 20.6% with COPD, P < .01).

CONCLUSIONS

Patients with CLD, compared with selected other chronic diseases, had increasing rates of hospitalization, longer hospital stays, more readmissions, and, despite these adverse outcomes, less access to postacute care. Disease management models for CLD are greatly needed to manage the anticipated increase in hospitalizations for CLD.

A comparison of lipid minimization strategies in children with intestinal failure

PURPOSE

The purpose of this study was to compare outcomes of lipid minimization with either Intralipid (IL) or Omegaven® in children with intestinal failure (IF) who developed intestinal failure-associated liver disease (IFALD) while receiving parenteral nutrition (PN).

METHODS

A retrospective review of children with IF requiring PN who developed IFALD (direct bilirubin >2 mg/dL) while receiving IL (2009-2016) was performed. Clinical characteristics, nutritional, and laboratory values were compared between children treated with reduced IL or Omegaven®.

RESULTS

16 children were reviewed (8 treated with IL and 8 treated with Omegaven® at a median dose of 1g/kg/d). Both groups had similar demographics, small bowel length, and parenteral nutritional intake during the study (82.9±27.1 kcal/kg/d vs. 75.9±16.5 kcal/kg/d, p=0.54). The mean direct bilirubin (DBili) prior to initiating treatment was 7.8±4.3 mg/dL and 7.5±3.5 mg/dL (p=0.87) in the IL and Omegaven® groups, respectively. The IL group took a median of 113 days to achieve a DBili <0.5 mg/dL compared to 124 days in the Omegaven® group (p=0.49). There were no differences in markers of liver function or growth trajectories among groups.

CONCLUSIONS

Lipid minimization with either IL or Omegaven® has similar success in achieving a normal DBili in children with IF and IFALD without major differences in nutritional status or growth.

TYPE OF STUDY

Treatment Study LEVEL OF EVIDENCE: III.

Postoperative continuous catheter-infused local anesthetic reduces pain scores and narcotic use after lower extremity revascularization

Objective

Postoperative pain following lower extremity revascularization procedures is traditionally controlled with narcotic administration. However, this may not adequately control the pain and puts the patient at risk for complications from opiate use. Here we report an alternative strategy for pain management using a continuous catheter-infused local anesthetic into the operative limb.

Design

Retrospective case–control study.

Methods

Patients undergoing lower extremity revascularization procedures using continuous catheter-infused local anesthetic were compared to similar patients undergoing similar procedures during the same time period who did not receive continuous catheter-infused local anesthetic. Records were reviewed for pain scores, narcotics consumption, length of stay, need for postoperative chest X-ray, supplemental oxygen use, wound complications, and 30-day readmission.

Results

There were 153 patients (mean age 69.5 years) from September 2011 to December 2014 who underwent common femoral artery procedures, femoral-popliteal bypass, femoral-tibial bypass, popliteal aneurysm repair, popliteal to pedal bypass, popliteal artery thrombo-embolectomy, sapheno-popliteal venous bypass, or ilio-femoral bypass. There were no significant differences between the continuous catheter-infused local anesthetic ( n=57) and control ( n=96) groups regarding age, body mass index, cardiac history, diabetes, hypertension, and procedures performed. The continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1–3, and better average pain scores on postoperative days 2–3 ( P<0.03). The continuous catheter-infused local anesthetic group had lower median narcotics consumption on postoperative days 1–2 ( P=0.02). No differences were found in postoperative length of stay, urinary catheter use, number of postoperative chest X-rays, oxygen use, mobilization, or fever. Wound complications occurred in 8.8% of the continuous catheter-infused local anesthetic group and in 11.5% of controls (P=0.79). Readmission rates were 23% (continuous catheter-infused local anesthetic) and 21% (controls; P=0.84).

Conclusion

Postoperative continuous catheter-infused local anesthetic reduces pain scores and pain medication use compared to standard opiate therapy in these patients, without increasing wound complication or readmission rates. Continuous catheter-infused local anesthetic appeared to have no effect on the incidence of pulmonary complications, mobilization, or fever.

Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation : Washington, DC, USA. 14-15 December 2015

A1 Introduction to the 8^th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health

David Chambers, Lisa Simpson

D1 Discussion forum: Population health D&I research

Felicia Hill-Briggs

D2 Discussion forum: Global health D&I research

Gila Neta, Cynthia Vinson

D3 Discussion forum: Precision medicine and D&I research

David Chambers

S1 Predictors of community therapists’ use of therapy techniques in a large public mental health system

Rinad Beidas, Steven Marcus, Gregory Aarons, Kimberly Hoagwood, Sonja Schoenwald, Arthur Evans, Matthew Hurford, Ronnie Rubin, Trevor Hadley, Frances Barg, Lucia Walsh, Danielle Adams, David Mandell

S2 Implementing brief cognitive behavioral therapy (CBT) in primary care: Clinicians' experiences from the field

Lindsey Martin, Joseph Mignogna, Juliette Mott, Natalie Hundt, Michael Kauth, Mark Kunik, Aanand Naik, Jeffrey Cully

S3 Clinician competence: Natural variation, factors affecting, and effect on patient outcomes

Alan McGuire, Dominique White, Tom Bartholomew, John McGrew, Lauren Luther, Angie Rollins, Michelle Salyers

S4 Exploring the multifaceted nature of sustainability in community-based prevention: A mixed-method approach

Brittany Cooper, Angie Funaiole

S5 Theory informed behavioral health integration in primary care: Mixed methods evaluation of the implementation of routine depression and alcohol screening and assessment

Julie Richards, Amy Lee, Gwen Lapham, Ryan Caldeiro, Paula Lozano, Tory Gildred, Carol Achtmeyer, Evette Ludman, Megan Addis, Larry Marx, Katharine Bradley

S6 Enhancing the evidence for specialty mental health probation through a hybrid efficacy and implementation study

Tonya VanDeinse, Amy Blank Wilson, Burgin Stacey, Byron Powell, Alicia Bunger, Gary Cuddeback

S7 Personalizing evidence-based child mental health care within a fiscally mandated policy reform

Miya Barnett, Nicole Stadnick, Lauren Brookman-Frazee, Anna Lau

S8 Leveraging an existing resource for technical assistance: Community-based supervisors in public mental health

Shannon Dorsey, Michael Pullmann

S9 SBIRT implementation for adolescents in urban federally qualified health centers: Implementation outcomes

Shannon Mitchell, Robert Schwartz, Arethusa Kirk, Kristi Dusek, Marla Oros, Colleen Hosler, Jan Gryczynski, Carolina Barbosa, Laura Dunlap, David Lounsbury, Kevin O'Grady, Barry Brown

S10 PANEL: Tailoring Implementation Strategies to Context - Expert recommendations for tailoring strategies to context

Laura Damschroder, Thomas Waltz, Byron Powell

S11 PANEL: Tailoring Implementation Strategies to Context - Extreme facilitation: Helping challenged healthcare settings implement complex programs

Mona Ritchie

S12 PANEL: Tailoring Implementation Strategies to Context - Using menu-based choice tasks to obtain expert recommendations for implementing three high-priority practices in the VA

Thomas Waltz

S13 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Siri, rate my therapist: Using technology to automate fidelity ratings of motivational interviewing

David Atkins, Zac E. Imel, Bo Xiao, Doğan Can, Panayiotis Georgiou, Shrikanth Narayanan

S14 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Identifying indicators of implementation quality for computer-based ratings

Cady Berkel, Carlos Gallo, Irwin Sandler, C. Hendricks Brown, Sharlene Wolchik, Anne Marie Mauricio

S15 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Improving implementation of behavioral interventions by monitoring emotion in spoken speech

Carlos Gallo, C. Hendricks Brown, Sanjay Mehrotra

S16 Scorecards and dashboards to assure data quality of health management information system (HMIS) using R

Dharmendra Chandurkar, Siddhartha Bora, Arup Das, Anand Tripathi, Niranjan Saggurti, Anita Raj

S17 A big data approach for discovering and implementing patient safety insights

Eric Hughes, Brian Jacobs, Eric Kirkendall

S18 Improving the efficacy of a depression registry for use in a collaborative care model

Danielle Loeb, Katy Trinkley, Michael Yang, Andrew Sprowell, Donald Nease

S19 Measurement feedback systems as a strategy to support implementation of measurement-based care in behavioral health

Aaron Lyon, Cara Lewis, Meredith Boyd, Abigail Melvin, Semret Nicodimos, Freda Liu, Nathanial Jungbluth

S20 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Common loop assay: Methods of supporting learning collaboratives

Allen Flynn

S21 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Innovating audit and feedback using message tailoring models for learning health systems

Zach Landis-Lewis

S22 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Implementation science and learning health systems: Connecting the dots

Anne Sales

S23 Facilitation activities of Critical Access Hospitals during TeamSTEPPS implementation

Jure Baloh, Marcia Ward, Xi Zhu

S24 Organizational and social context of federally qualified health centers and variation in maternal depression outcomes

Ian Bennett, Jurgen Unutzer, Johnny Mao, Enola Proctor, Mindy Vredevoogd, Ya-Fen Chan, Nathaniel Williams, Phillip Green

S25 Decision support to enhance treatment of hospitalized smokers: A randomized trial

Steven Bernstein, June-Marie Rosner, Michelle DeWitt, Jeanette Tetrault, James Dziura, Allen Hsiao, Scott Sussman, Patrick O’Connor, Benjamin Toll

S26 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A patient-centered approach to successful community transition after catastrophic injury

Michael Jones, Julie Gassaway

S27 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - Conducting PCOR to integrate mental health and cancer screening services in primary care

Jonathan Tobin

S28 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A comparative effectiveness trial of optimal patient-centered care for US trauma care systems

Douglas Zatzick

S29 Preferences for in-person communication among patients in a multi-center randomized study of in-person versus telephone communication of genetic test results for cancer susceptibility

Angela R Bradbury, Linda Patrick-Miller, Brian Egleston, Olufunmilayo I Olopade, Michael J Hall, Mary B Daly, Linda Fleisher, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Dana Farengo-Clark, Andrea Forman, Rikki S Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Rachelle Lorenz Chambers, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Michelle Savage, Christina Seelaus, Jessica Stoll, Jill Stopfer, Shirley Yao and Susan Domchek

S30 Working towards de-implementation: A mixed methods study in breast cancer surveillance care

Erin Hahn, Corrine Munoz-Plaza, Jianjin Wang, Jazmine Garcia Delgadillo, Brian Mittman Michael Gould

S31Integrating evidence-based practices for increasing cancer screenings in safety-net primary care systems: A multiple case study using the consolidated framework for implementation research

Shuting (Lily) Liang, Michelle C. Kegler, Megan Cotter, Emily Phillips, April Hermstad, Rentonia Morton, Derrick Beasley, Jeremy Martinez, Kara Riehman

S32 Observations from implementing an mHealth intervention in an FQHC

David Gustafson, Lisa Marsch, Louise Mares, Andrew Quanbeck, Fiona McTavish, Helene McDowell, Randall Brown, Chantelle Thomas, Joseph Glass, Joseph Isham, Dhavan Shah

S33 A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol

Jane Liebschutz, Karen Lasser

S34 Implementing collaborative care for substance use disorders in primary care: Preliminary findings from the summit study

Katherine Watkins, Allison Ober, Sarah Hunter, Karen Lamp, Brett Ewing

S35 Sustaining a task-shifting strategy for blood pressure control in Ghana: A stakeholder analysis

Juliet Iwelunmor, Joyce Gyamfi, Sarah Blackstone, Nana Kofi Quakyi, Jacob Plange-Rhule, Gbenga Ogedegbe

S36 Contextual adaptation of the consolidated framework for implementation research (CFIR) in a tobacco cessation study in Vietnam

Pritika Kumar, Nancy Van Devanter, Nam Nguyen, Linh Nguyen, Trang Nguyen, Nguyet Phuong, Donna Shelley

S37 Evidence check: A knowledge brokering approach to systematic reviews for policy

Sian Rudge

S38 Using Evidence Synthesis to Strengthen Complex Health Systems in Low- and Middle-Income Countries

Etienne Langlois

S39 Does it matter: timeliness or accuracy of results? The choice of rapid reviews or systematic reviews to inform decision-making

Andrea Tricco

S40 Evaluation of the veterans choice program using lean six sigma at a VA medical center to identify benefits and overcome obstacles

Sherry Ball, Anne Lambert-Kerzner, Christine Sulc, Carol Simmons, Jeneen Shell-Boyd, Taryn Oestreich, Ashley O'Connor, Emily Neely, Marina McCreight, Amy Labebue, Doreen DiFiore, Diana Brostow, P. Michael Ho, David Aron

S41 The influence of local context on multi-stakeholder alliance quality improvement activities: A multiple case study

Jillian Harvey, Megan McHugh, Dennis Scanlon

S42 Increasing physical activity in early care and education: Sustainability via active garden education (SAGE)

Rebecca Lee, Erica Soltero, Nathan Parker, Lorna McNeill, Tracey Ledoux

S43 Marking a decade of policy implementation: The successes and continuing challenges of a provincial school food and nutrition policy in Canada

Jessie-Lee McIsaac, Kate MacLeod, Nicole Ata, Sherry Jarvis, Sara Kirk

S44 Use of research evidence among state legislators who prioritize mental health and substance abuse issues

Jonathan Purtle, Elizabeth Dodson, Ross Brownson

S45 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 1 designs

Brian Mittman, Geoffrey Curran

S46 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 2 designs

Geoffrey Curran

S47 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 3 designs

Jeffrey Pyne

S48 Linking team level implementation leadership and implementation climate to individual level attitudes, behaviors, and implementation outcomes

Gregory Aarons, Mark Ehrhart, Elisa Torres

S49 Pinpointing the specific elements of local context that matter most to implementation outcomes: Findings from qualitative comparative analysis in the RE-inspire study of VA acute stroke care

Edward Miech

S50 The GO score: A new context-sensitive instrument to measure group organization level for providing and improving care

Edward Miech

S51 A research network approach for boosting implementation and improvement

Kathleen Stevens, I.S.R.N. Steering Council

S52 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - The value of qualitative methods in implementation research

Alison Hamilton

S53 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Learning evaluation: The role of qualitative methods in dissemination and implementation research

Deborah Cohen

S54 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Qualitative methods in D&I research

Deborah Padgett

S55 PANEL: Maps & models: The promise of network science for clinical D&I - Hospital network of sharing patients with acute and chronic diseases in California

Alexandra Morshed

S56 PANEL: Maps & models: The promise of network science for clinical D&I - The use of social network analysis to identify dissemination targets and enhance D&I research study recruitment for pre-exposure prophylaxis for HIV (PrEP) among men who have sex with men

Rupa Patel

S57 PANEL: Maps & models: The promise of network science for clinical D&I - Network and organizational factors related to the adoption of patient navigation services among rural breast cancer care providers

Beth Prusaczyk

S58 A theory of de-implementation based on the theory of healthcare professionals’ behavior and intention (THPBI) and the becker model of unlearning

David C. Aron, Divya Gupta, Sherry Ball

S59 Observation of registered dietitian nutritionist-patient encounters by dietetic interns highlights low awareness and implementation of evidence-based nutrition practice guidelines

Rosa Hand, Jenica Abram, Taylor Wolfram

S60 Program sustainability action planning: Building capacity for program sustainability using the program sustainability assessment tool

Molly Hastings, Sarah Moreland-Russell

S61 A review of D&I study designs in published study protocols

Rachel Tabak, Alex Ramsey, Ana Baumann, Emily Kryzer, Katherine Montgomery, Ericka Lewis, Margaret Padek, Byron Powell, Ross Brownson

S62 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Model simulation techniques to estimate the cost of implementing foundational public health services

Cezar Brian Mamaril, Glen Mays, Keith Branham, Lava Timsina

S63 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Inter-organizational network effects on the implementation of public health services

Glen Mays, Rachel Hogg

S64 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Implementation fidelity, coalition functioning, and community prevention system transformation using communities that care

Abigail Fagan, Valerie Shapiro, Eric Brown

S65 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Expanding capacity for implementation of communities that care at scale using a web-based, video-assisted training system

Kevin Haggerty, David Hawkins

S66 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Effects of communities that care on reducing youth behavioral health problems

Sabrina Oesterle, David Hawkins, Richard Catalano

S68 When interventions end: the dynamics of intervention de-adoption and replacement

Virginia McKay, M. Margaret Dolcini, Lee Hoffer

S69 Results from next-d: can a disease specific health plan reduce incident diabetes development among a national sample of working-age adults with pre-diabetes?

Tannaz Moin, Jinnan Li, O. Kenrik Duru, Susan Ettner, Norman Turk, Charles Chan, Abigail Keckhafer, Robert Luchs, Sam Ho, Carol Mangione

S70 Implementing smoking cessation interventions in primary care settings (STOP): using the interactive systems framework

Peter Selby, Laurie Zawertailo, Nadia Minian, Dolly Balliunas, Rosa Dragonetti, Sarwar Hussain, Julia Lecce

S71 Testing the Getting To Outcomes implementation support intervention in prevention-oriented, community-based settings

Matthew Chinman, Joie Acosta, Patricia Ebener, Patrick S Malone, Mary Slaughter

S72 Examining the reach of a multi-component farmers’ market implementation approach among low-income consumers in an urban context

Darcy Freedman, Susan Flocke, Eunlye Lee, Kristen Matlack, Erika Trapl, Punam Ohri-Vachaspati, Morgan Taggart, Elaine Borawski

S73 Increasing implementation of evidence-based health promotion practices at large workplaces: The CEOs Challenge

Amanda Parrish, Jeffrey Harris, Marlana Kohn, Kristen Hammerback, Becca McMillan, Peggy Hannon

S74 A qualitative assessment of barriers to nutrition promotion and obesity prevention in childcare

Taren Swindle, Geoffrey Curran, Leanne Whiteside-Mansell, Wendy Ward

S75 Documenting institutionalization of a health communication intervention in African American churches

Cheryl Holt, Sheri Lou Santos, Erin Tagai, Mary Ann Scheirer, Roxanne Carter, Janice Bowie, Muhiuddin Haider, Jimmie Slade, Min Qi Wang

S76 Reduction in hospital utilization by underserved patients through use of a community-medical home

Andrew Masica, Gerald Ogola, Candice Berryman, Kathleen Richter

S77 Sustainability of evidence-based lay health advisor programs in African American communities: A mixed methods investigation of the National Witness Project

Rachel Shelton, Lina Jandorf, Deborah Erwin

S78 Predicting the long-term uninsured population and analyzing their gaps in physical access to healthcare in South Carolina

Khoa Truong

S79 Using an evidence-based parenting intervention in churches to prevent behavioral problems among Filipino youth: A randomized pilot study

Joyce R. Javier, Dean Coffey, Sheree M. Schrager, Lawrence Palinkas, Jeanne Miranda

S80 Sustainability of elementary school-based health centers in three health-disparate southern communities

Veda Johnson, Valerie Hutcherson, Ruth Ellis

S81 Childhood obesity prevention partnership in Louisville: creative opportunities to engage families in a multifaceted approach to obesity prevention

Anna Kharmats, Sandra Marshall-King, Monica LaPradd, Fannie Fonseca-Becker

S82 Improvements in cervical cancer prevention found after implementation of evidence-based Latina prevention care management program

Deanna Kepka, Julia Bodson, Echo Warner, Brynn Fowler

S83 The OneFlorida data trust: Achieving health equity through research & training capacity building

Elizabeth Shenkman, William Hogan, Folakami Odedina, Jessica De Leon, Monica Hooper, Olveen Carrasquillo, Renee Reams, Myra Hurt, Steven Smith, Jose Szapocznik, David Nelson, Prabir Mandal

S84 Disseminating and sustaining medical-legal partnerships: Shared value and social return on investment

James Teufel

Probability modeling of the number of positive cores in a prostate cancer biopsy session, with applications

Among men, prostate cancer (CaP) is the most common newly diagnosed cancer and the second leading cause of death from cancer. A major issue of very large scale is avoiding both over-treatment and under-treatment of CaP cases. The central challenge is deciding clinical significance or insignificance when the CaP biopsy results are positive but only marginally so. A related concern is deciding how to increase the number of biopsy cores for larger prostates. As a foundation for improved choice of number of cores and improved interpretation of biopsy results, we develop a probability model for the number of positive cores found in a biopsy, given the total number of cores, the volumes of the tumor nodules, and - very importantly - the prostate volume. Also, three applications are carried out: guidelines for the number of cores as a function of prostate volume, decision rules for insignificant versus significant CaP using number of positive cores, and, using prior distributions on total tumor size, Bayesian posterior probabilities for insignificant CaP and posterior median CaP. The model-based results have generality of application, take prostate volume into account, and provide attractive tradeoffs of specificity versus sensitivity. Copyright © 2015 John Wiley & Sons, Ltd.

Analysis of the direct cost of surgery for four diagnostic categories of adult spinal deformity

BACKGROUND CONTEXT

Existing literature on adult spinal deformity (ASD) offers little guidance regarding an evidence-based approach to care. To optimize the value of medical treatment, a thorough understanding of the cost of surgical treatment for ASD is required.

PURPOSE

To evaluate four clinically and radiographically distinct groups of ASD and identify and compare the cost of surgical treatment among the groups.

STUDY DESIGN/SETTING

Multicenter retrospective study of consecutive surgeries for ASD.

PATIENT SAMPLE

Three hundred twenty-five consecutive ASD patients treated between 2008 and 2010.

OUTCOME MEASURES

Cost data were collected from hospital administrative records on the direct costs (DCs) incurred for the episode of surgical care, excluding overhead.

METHODS

Based on preoperative radiographs and history, patients were categorized into one of four diagnostic categories of deformity: primary idiopathic scoliosis (PIS), primary degenerative scoliosis (PDS), primary sagittal plane deformity (PSPD), and revision (R). Analysis of variance and generalized linear model regressions were used to analyze the DCs of surgery and to assess differences in costs across the four diagnostic categories considered.

RESULTS

Significant differences were observed in DC of surgery for different categories of ASD, with surgical treatment for PDS the most expensive followed in decreasing order by PSPD, PIS, and R (p<.01). Results further revealed a significant positive relationship between age and DC (p<.01) and a significant positive relationship between length of stay and DC (p<.01). Among PIS patients, for every incremental increase in levels fused, the expected DC increased by $3,997 (p=.00). Fusion to pelvis also significantly increased the DC of surgery for patients aged 18 to 29 years (p<.01) and 30 to 59 years (p<.01) but not for 60 years or more (p=.86).

CONCLUSIONS

There is an increasing DC of surgery with increasing age, length of hospital stay, length of fusion, and fusions to the pelvis. Revision surgery is the least expensive surgery on average and should therefore not preclude its consideration from a pure cost perspective.

Cost-Effectiveness of Surgical Treatment for Adult Spinal Deformity: A Comparison of Dollars per Quality of Life Improvement Across Health Domains

DESIGN

Retrospective, single-center analysis of consecutive patients undergoing surgical treatment for adult spinal deformity (ASD).

OBJECTIVE

Assess the value of surgical treatment for ASD across different health domains.

SUMMARY OF BACKGROUND DATA

The cost of improvement in health-related quality of life (HRQOL) is an important consideration for resource allocation. There is also growing concern among policy makers regarding the incorporation of patient-specific preferences in the appropriate definition and assessment health care value.

METHODS

Single-center, retrospective study of consecutive ASD patients undergoing primary surgery with principal diagnosis code 737.0-737.9 from 2005 through May 2010. Patients less than 18 years of age were excluded. The HRQOL measures were based on the Short Form-36, the Oswestry Disability Index (ODI), and the Scoliosis Research Society (SRS)-22 questionnaire after at least 2 years after surgery. The SRS scores were translated to a 100-point scale. Costs were collected from hospital data on the total costs incurred for the episode of surgical care. Confidence intervals were calculated using nonparametric bootstrap methods.

RESULTS

Baseline and minimum 2-year HR follow-up data were available for 164 patients, with an average follow-up of 3.2 years and a range of 2 to 7.4 years. Patients were predominantly female (14; 88%) and ranged from 18 to 82 years of age at index surgery (average of 51 years of age). The cost-effectiveness (CE) ratios varied across different HRQOL outcomes, ranging from an average cost of $5,658 per 1-point improvement in SRS Self-image to an average cost of $25,918 per 1-point improvement in SF-36 Physical Component Score (PCS). Results revealed statistically significant differences (p < .05) in CE ratios across different HRQOL outcomes.

CONCLUSIONS

Statistically significant differences were found in CE ratios across HRQOL sub-domains. This has important implications in the assessment of patient-specific value of health care services, and illustrates that surgical treatment for ASD may be more cost-effective for some purposes (eg, pain reduction) and less cost-effective for others (eg, improved functional activity).

Prevalence and risks factors of age-related macular degeneration in Oklahoma Indians: the Vision Keepers Study

OBJECTIVE

To determine the prevalence of age-related macular degeneration (AMD) and to identify its risk factors in an Oklahoma Indian population.

DESIGN

Cross-sectional study design.

PARTICIPANTS

Included 1019 Oklahoma Indians who participated in baseline and second examinations of the Strong Heart Study.

METHODS

Retinal photographs of at least 1 eye were obtained and graded for AMD by the University of Wisconsin Ocular Epidemiology Reading Center. Retinal photographs of 986 participants were considered gradable and were included in the study.

MAIN OUTCOME MEASURES

Age-related macular degeneration (early and late).

RESULTS

The overall prevalence of AMD in the study was 35.2%, including a prevalence of 0.81% for late AMD. The prevalence of early AMD increased from 30.6% in those aged 48 to 59 years to 46.1% in those 70 to 82 years of age. When potential risk factors were analyzed individually (univariate analyses), men with hypertension had a significantly higher prevalence of AMD (P = 0.02) than those without hypertension. In women, high-density lipoprotein cholesterol and sun exposure were associated positively with the prevalence of AMD (P = 0.01), whereas a history of using multivitamins was associated with lower AMD prevalence (P = 0.005). When multiple risk factors were analyzed simultaneously using logistic regression, only age showed significant association with AMD in both men (P = 0.02) and women (P<0.0001) and was the only significant risk factor in men. In women, multivitamin use and total cholesterol had a significant inverse association with AMD, whereas sun exposure and high-density lipoprotein cholesterol had a positive association. When men and women were combined, age and high-density lipoprotein cholesterol had significant positive associations, whereas total cholesterol, multivitamin use, and current alcohol use showed a significant inverse association with AMD.

CONCLUSIONS

This study was the first to report a detailed prevalence of AMD in Oklahoma Indians and its risk factors. The prevalence seemed to be relatively high compared with that in other ethnic groups. Some of the modifiable risk factors identified confirmed previous findings and can be used to design preventive programs to reduce the burden of AMD, although longitudinal data are still needed.

Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care

OBJECTIVE

To determine the impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care.

DESIGN

Observational study.

SETTING

Eight acute care hospitals and two specialty heart hospitals.

PARTICIPANTS

All adults (>18 years) discharged from one of the included hospitals between December 2007 and March 2009 with a diagnosis of heart failure, who had not undergone heart transplant, did not have a left ventricular assistive device, and with a length of stay of 120 or less days.

INTERVENTIONS

A standardized heart failure order set was developed internally, with content driven by the prevailing American College of Cardiology/American Heart Association clinical practice guidelines, and deployed systemwide via an intranet physician portal.

MAIN OUTCOME MEASURES

Publicly reported process of care measures, in-patient mortality, 30-day mortality, 30-day readmission, length of stay, and direct cost of care were compared for heart failure patients treated with and without the order set.

RESULTS

Order set used reached 73.1% in March 2009. After propensity score adjustment, order set use was associated with significantly increased core measures compliance [odds ratio (95% confidence interval) = 1.51(1.08; 2.12)] and reduced in-patient mortality [odds ratio (95% confidence interval) = 0.49(0.28; 0.88)]. Reductions in 30-day mortality and readmission approached significance. Direct cost for initial admissions alone and in combination with readmissions were significantly lower with order set use.

CONCLUSIONS

Implementing an evidence-based standardized order set may help improve outcomes, reduce costs of care and increase adherence to evidence-based processes of care.

Ribosomal protein mRNAs are translationally-regulated during human dendritic cells activation by LPS

BACKGROUND

Dendritic cells (DCs) are the sentinels of the mammalian immune system, characterized by a complex maturation process driven by pathogen detection. Although multiple studies have described the analysis of activated DCs by transcriptional profiling, recent findings indicate that mRNAs are also regulated at the translational level. A systematic analysis of the mRNAs being translationally regulated at various stages of DC activation was performed using translational profiling, which combines sucrose gradient fractionation of polysomal-bound mRNAs with DNA microarray analysis.

RESULTS

Total and polysomal-bound mRNA populations purified from immature, 4 h and 16 h LPS-stimulated human monocyte-derived DCs were analyzed on Affymetrix microarrays U133 2.0. A group of 375 transcripts was identified as translationally regulated during DC-activation. In addition to several biochemical pathways related to immunity, the most statistically relevant biological function identified among the translationally regulated mRNAs was protein biosynthesis itself. We singled-out a cluster of 11 large ribosome proteins mRNAs, which are disengaged from polysomes at late time of maturation, suggesting the existence of a negative feedback loop regulating translation in DCs and linking ribosomal proteins to immuno-modulatory function.

CONCLUSION

Our observations highlight the importance of translation regulation during the immune response, and may favor the identification of novel protein networks relevant for immunity. Our study also provides information on the potential absence of correlation between gene expression and protein production for specific mRNA molecules present in DCs.

Impact of clinical preventive services in the ambulatory setting

Indicators of the performance of clinical preventive services (CPS) have been adopted in the ambulatory setting to improve quality of care. The impact of CPS was evaluated in a network of 49 primary care practices providing care to an estimated 245,000 adults in the Dallas-Fort Worth area through a sample chart review to determine delivery of recommended evidence-based CPS combined with medical literature estimates of the effectiveness of CPS. In this population in 2005, CPS were estimated to have prevented 36 deaths and 97 incident cases of cancer; 420 coronary heart disease events (including 66 sudden deaths) and 118 strokes; 816 cases of influenza and pneumonia (including 24 hospital admissions); and 87 osteoporosis-related fractures. Thus, CPS have substantial benefits in preventing deaths and illness episodes.

High-intensity interval training for intermittent claudication in a vascular rehabilitation program

This article reports an observational study investigating the safety and effectiveness of a high-intensity interval exercise program for patients with peripheral arterial disease. Patients were asked to walk on a treadmill to maximal claudication pain six times in each exercise session, with 3-minute rests in between. Once a patient could walk continuously for 6 minutes without reaching maximal pain, speed and/or grade was increased. To account for the changes in speed and grade, patients' walking ability was measured as a rehabilitation score, calculated as the product of the two. A total of 47 patients were included in the study. Results showed overall improvement in the rehabilitation score with participation in the program, and specifically showed that participation in more exercise sessions led to greater improvement. Moreover, no adverse events occurred in the study patients, suggesting patients with peripheral arterial disease can safely tolerate high-intensity exercise programs.

Visual impairment and eye abnormalities in Oklahoma Indians

OBJECTIVE

To determine the prevalence of visual impairment and eye abnormalities in Oklahoma Indians.

METHODS

The cross-sectional study included 1019 Oklahoma Indians, aged 48 to 82 years; 60.2% were women. All participants gave a personal interview, and all underwent an eye examination, including the determination of best-corrected visual acuity and an ophthalmoscopic examination. In addition, two 45 degrees fundus photographs were taken of each eye, and these photographs were graded by the Fundus Photography Reading Center at the University of Wisconsin, Madison.

RESULTS

Among the 1019 participants, 77.4% had a visual acuity of 20/20 or better, 19.5% and 2.5% had visual acuities of between 20/25 and 20/40 and between 20/50 and 20/190, respectively; and 0.6% were legally blind, all in the better eye. Cataract was the most frequent contributing cause and age-related macular degeneration the second most frequent contributing cause of visual impairment. The overall prevalence proportions of age-related macular degeneration, cataract, diabetic retinopathy, and definite glaucoma were 33.6%, 39.6%, 20.1%, and 5.6%, respectively. Most of the other eye abnormalities were rare in the study participants, except for pinguecula (42.4%) and dermatochalasis (30.1%).

CONCLUSIONS

Oklahoma Indians have a higher prevalence of visual impairment, age-related macular degeneration, and diabetic retinopathy than other ethnic groups. The implementation of adequate treatment and prevention programs for eye diseases is indicated.