Preliminary Analysis of an Advanced Health Care Practitioner-Led Home-Visit Primary Care Program for High-Risk Patients Reduced Health Care Costs and Utilization

Background: MemorialCare Medical Group (MCMG) designed and implemented an advanced health care practitioner (AHP)-led home-visit primary care program to address the needs of a frail older adult population, who struggled with arriving for in-office care. We sought to perform a preliminary analysis to determine the program's efficacy. Methods: We conducted a retrospective review of patients enrolled in the program through tabulation of total costs of care, inpatient visits (IPVs), emergency department visits (EDVs), and 30-day readmissions (30DRs) 1-year pre-enrollment and postenrollment. Results: For the prior year and postyear windows, per-member per-month total cost of care decreased 21.4% ($5,883.44-$4,622.31), reflecting a gross savings of $2,693,480.32. Mean IPVs (2.42-1.56), EDVs (1.53-0.93), and 30DRs (0.27-0.13) were reduced. Conclusions: Initial analysis of an AHP-led in-home primary care program for frail seniors shows promise for improved outcomes with a clear decrease in the total cost of care.

Pain Management: Time to Minimize Variations in Practice

There continue to be great variations in the management of pain in palliative care. Efforts need to be made within the field develop strategies to address this to avoid undue distress in patients.

Risk factors for degenerative aortic valve disease in India: A case control study

Background

Degenerative aortic valve disease often co-exists with coronary artery disease (CAD) and studies done in western populations have shown that it shares the same risk factors which cause CAD. However little is known in this context among Asian Indians. The current study looks into the risk factors of degenerative aortic valve disease in Asian Indian population.

Methods

Ninety-one consecutive patients with severe aortic stenosis (AS) reporting for left heart catheterization prior to valve replacement surgery at a tertiary care centre were recruited for the study. They were compared with age and sex matched controls selected from a database of 3200 patients referred for elective diagnostic left heart catheterization for suspected CAD. Following traditional cardiovascular risk factors were assessed in all patients: age, gender, family history of CAD, smoking history, presence of diabetes, hypertension and dyslipidemia.

Results

The mean age of the study population was 57.8 ± 8.2 years (range, 40-80 years). Smoking, family history of CAD and hypercholesterolemia were significantly more prevalent in patients with degenerative AS compared to those with normal valves. No significant difference was noted in the presence of diabetes mellitus. On multivariate logistic regression, family history of premature CAD (OR 3.68; CI 1.38-9.78) smoking history (OR, 2.56; CI, 1.21-5.39), and raised LDL levels (OR, 5.55; CI, 2.63-11.69) were independently associated with the aortic stenosis patient cohort.

Conclusions

The study showed a significant association of cardiovascular risk factors with aortic stenosis independent of age and gender in Asian Indian patients.

Phenazopyridine-Induced Sulfhemoglobinemia

OBJECTIVE:

To report a case of sulfhemoglobinemia in a patient receiving phenazopyridine for a urinary tract infection.

CASE SUMMARY:

A 63-year-old white woman presented to the emergency department with complaints of fatigue and bluish discoloration of her body that had gradually progressed over the previous 6–8 weeks. About 4 months prior to presenting to the emergency department, she had started taking phenazopyridine, an over-the-counter medication for symptoms of dysuria. Because the cyanosis did not improve after the patient received oxygen and methylene blue, sulfhemoglobinemia was suspected and confirmed by spectrophotometer analysis.

DISCUSSION:

Sulfhemoglobin is a green-pigmented molecule containing a sulfur atom in one or more of the porphyrin rings. It is a rare cause of cyanosis, which is usually drug induced. Sulfhemoglobinemia is suspected when a cyanotic patient has normal to near-normal oxygen tension, laboratory reports of elevated methemoglobin, and does not respond to methylene blue therapy. Sulfhemoglobinemia is relatively rare, despite the widespread use of drugs that have been reported to cause it. Predisposing factors, such as chronic constipation, present in our patient, have been suggested as a source of hydrogen sulfide.

CONCLUSIONS:

This case of sulfhemoglobinemia, which occurred after the patient took phenazopyridine, is considered a probable adverse event according to the Naranjo probability scale.

Making the Case for Palliative Care at the System Level: Outcomes Data

BACKGROUND

A recent trend in health care is to integrate palliative care (PC) programs across multiple hospitals to reduce variation, improve quality, and reduce cost.

OBJECTIVE

The study objective was to demonstrate the benefits of PC for a system.

METHODS

The study was a descriptive study using retrospective medical records in seven federated hospitals where PC developed differently before system integration. Measured were length of stay (LOS), mortality, readmissions, saved intensive care unit (ICU) days, cost avoidance, and hospice referrals.

RESULTS

PC services within the first 48 hours of admission demonstrate a shorter LOS (5.08 days), reduced costs 40% ($2,362 per day), and decreased mortality (1.01 versus 1.10) for one hospital. Readmissions at 30, 60, and 90 days after a PC consult decreased (61.5%, 47.0%, and 42.1%, respectively). Annual pre- and postprogram referrals to hospice increased (65 to 107). Using modified matched pairs, LOS of PC patients seen within 48 hours of admission average 1.67 days less compared to non-PC patients. LOS for ICU patients with PC services in the ICU within the first 48 hours decreased by 1.12 days. Overall cost avoidance was 1.5 times total cost for PC programs systemwide. One pilot project using a full-time physician in the ICU reduced cost more than $600,000, with 315 saved ICU days, annualized. Systemwide, 69.3% of all referrals to hospice were made by the PC service.

CONCLUSION

Early involvement of PC services emerged as advantageous to the net benefit. Given that health care's changing landscape will increasingly include bundled payment and risk holding strategies to improve quality and reduce cost in health care systems, systemwide PC will play a vital role.

Antenna-coupled photon emission from hexagonal boron nitride tunnel junctions

The ultrafast conversion of electrical signals to optical signals at the nanoscale is of fundamental interest for data processing, telecommunication and optical interconnects. However, the modulation bandwidths of semiconductor light-emitting diodes are limited by the spontaneous recombination rate of electron-hole pairs, and the footprint of electrically driven ultrafast lasers is too large for practical on-chip integration. A metal-insulator-metal tunnel junction approaches the ultimate size limit of electronic devices and its operating speed is fundamentally limited only by the tunnelling time. Here, we study the conversion of electrons (localized in vertical gold-hexagonal boron nitride-gold tunnel junctions) to free-space photons, mediated by resonant slot antennas. Optical antennas efficiently bridge the size mismatch between nanoscale volumes and far-field radiation and strongly enhance the electron-photon conversion efficiency. We achieve polarized, directional and resonantly enhanced light emission from inelastic electron tunnelling and establish a novel platform for studying the interaction of electrons with strongly localized electromagnetic fields.

Association of timing of palliative care consult on quality care outcomes at a community based hospital

166

Background: Timing of palliative care (PC) consults in hospitalized patients can have an impact on outcomes. Aim: To study the impact of the timing of consults on length of stay (LOS) of PC patients in a community based hospital over a span of 1 year. Additional outcomes included mortality and readmission rates. Methods: We conducted a retrospective review of medical records of consecutive patients who were referred to PC during the time period (November 2012- October 2013). LOS of PC patients consulted within and after 48 hours of admission were analyzed. Based on the timing of consult, mortality ratio of the two patient groups were analyzed. In addition, we analyzed the 30, 60 and 90 day readmission rates pre and post PC consult. Results: The LOS of patients seen by PC within 48 hours (N = 353) of admission was 1.20 (variance from expected) versus after 48 hours (N = 187) of admission was 6.28 (variance from expected). The mean difference in LOS between the groups was 5.08 days. The mortality ratio of the two groups was 1.01 (within 48 hours) versus 1.10 (after 48 hours) (p = .131). In addition the decrease in the 30, 60 and 90 day readmission rate was 61.5%, 47% and 42.1% respectively. Conclusions: Early PC consults were associated with a decrease in LOS and readmission rates with no increase in mortality rate. Further studies are needed to validate these findings in the community setting.

The beneficial role of spiritual counseling in heart failure patients

To ascertain the beneficial role of spiritual counseling in patients with chronic heart failure. This is a pilot study evaluating the effects of adjunct spiritual counseling on quality of life (QoL) outcomes in patients with heart failure. Patients were assigned to "religious" or "non-religious" counseling services based strictly on their personal preferences and subsequently administered standardized QoL questionnaires. A member of the chaplaincy or in-house volunteer organization visited the patient either daily or once every 2 days throughout the duration of their hospitalization. All patients completed questionnaires at baseline, at 2 weeks, and at 3 months. Each of the questionnaires was totaled, with higher scores representing positive response, except for one survey measure where lower scores represent improvement (QIDS-SR16). Twenty-three patients (n = 23, age 57 ± 11, 11 (48 %) male, 12 (52 %) female, mean duration of hospital stay 20 ± 15 days) completed the study. Total mean scores were assessed on admission, at 2 weeks and at 3 months. For all patients in the study, the mean QIDS-SR16 scores were 8.5 (n = 23, SD = 3.3) versus 6.3 (n = 18, SD = 3.5) versus 7.3 (n = 7, SD = 2.6). Mean FACIT-Sp-Ex (version 4) scores were 71.1 (n = 23, SD = 15.1) versus 74.7 (n = 18, SD = 20.9) versus 81.4 (n = 7, SD = 8.8). The mean MSAS scores were 2.0 (n = 21, SD = 0.6) versus 1.8 (n = 15, SD = 0.7) versus 2.5 (n = 4, SD = 0.7). Mean QoL Enjoyment and Satisfaction scores were 47.2 % (n = 23, SD = 15.0 %) versus 53.6 % (n = 18, SD = 16.4 %) versus 72.42 % (n = 7, SD = 22 %). The addition of spiritual counseling to standard medical management for patients with chronic heart failure patients appears to have a positive impact on QoL.

Failing the failing heart: a review of palliative care in heart failure

Heart failure (HF) is the most common reason for hospital admission for patients older than 65 years. With an aging population and improving survival in heart failure patients, the number of people living with HF continues to grow. As this population increases, the importance of treating symptoms of fatigue, dyspnea, pain, and depression that diminish the quality of life in HF patients becomes increasingly important. Palliative care has been shown to help alleviate these symptoms and improve patients' satisfaction with the care they receive. Despite this growing body of evidence, palliative care consultation remains underutilized and is not standard practice in the management of HF. With an emphasis on communication, symptom management, and coordinated care, palliative care provides an integrated approach to support patients and families with chronic illnesses. Early communication with patients and families regarding the unpredictable nature of HF and the increased risk of sudden cardiac death enables discussions around advanced care directives, health care proxies, and deactivation of permanent pacemakers or implantable cardioverter defibrillators. Cardiologists and primary care physicians who are comfortable initiating these discussions are encouraged to do so; however, many fear destroying hope and are uncertain how to discuss end-of-life issues. Thus, in order to facilitate these discussions and establish an appropriate relationship, we recommend that patients and families be introduced to a palliative care team at the earliest appropriate time after diagnosis.

Evaluation of the prevalence and severity of pain in patients with stable chronic heart failure

AIM

To evaluate the prevalence and severity of pain in patients with chronic stable heart failure (HF) in an outpatient clinic setting.

METHODS

This is a cross-sectional study evaluating symptoms of generalized or specific pain in patients with chronic stable heart failure. A standardized questionnaire (Edmonton Symptom Assessment System) was administered during a routine outpatient clinic visit. The severity of pain and other symptoms were assessed on a 10 point scale with 10 being the worst and 0 representing no symptoms.

RESULTS

Sixty-two patients [age 56 ± 13 years, 51 males, 11 females, mean ejection fraction (EF) 33% ± 17%] completed the assessment. Thirty-two patients (52%) reported any pain of various character and location such as chest, back, abdomen or the extremities, with a mean pain score of 2.5 ± 3.1. Patients with an EF less than 40% (n = 45, 73%) reported higher pain scores than patients with an EF greater than 40% (n = 17, 27%), scores were 3.1 ± 3.3 vs 1.2 ± 1.9, P < 0.001. Most frequent symptoms were tiredness (in 75% of patients), decreased wellbeing (84%), shortness of breath (SOB, 76%), and drowsiness (70%). The most severe symptom was tiredness with a score of 4.0 ± 2.8, followed by decreased wellbeing (3.7 ± 2.7), SOB (3.6 ± 2.8), and drowsiness (2.8 ± 2.8).

CONCLUSION

Pain appears to be prevalent and significantly affects quality of life in HF patients. Adequate pain assessment and management should be an integral part of chronic heart failure management.

Philosophical implications of the systemic and patient-oriented management of chronic heart failure

Chronic heart failure is a lifelong disease that involves a large variety of symptoms and, ultimately, the entire organism relatively early in the disease process. At least in part, this is in contrast to other chronic conditions such as diabetes, renal failure or cancer. Modern treatment of patients with chronic heart failure goes beyond the mere prescription of vasodilators or inotropes. The multitude of multi-organ involvements and associated symptoms unrelated to pure cardiac contractile failure, as well as the psychosocial burden for patients and their direct environment, calls for a re-engagement with the philosophical aspects of medical care. Such a process may well challenge the approach commonly taken by health care providers. We further suggest a broader and more holistic view of medical care--in this case in regard to heart failure--and one that is based on patients' and physicians' understanding of health and disease, autonomy, suffering, existential values and expectations that might positively affect treatment strategies and outcomes.

Heart failure therapy: beyond the guidelines

Heart failure is a chronic and debilitating disease responsible for high cardiac morbidity and mortality in the world and is associated with over 290 000 deaths in the United States each year. This article reviews palliative care and self-care, which are critical components of heart failure management that are inadequately defined in the current American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management of Heart Failure. Palliative care describes a multidisciplinary approach to the treatment of heart failure therapy that addresses both the symptomatic and psychosocial aspects of the disease. Self-care aims to maintain disease stability and prevent clinical decline through a variety of patient-based behavioral and lifestyle modifications.

Revisiting the Use of Percutaneous Endoscopic Gastrostomy Tubes in Patients with Advanced Dementia

Mr. Smith is an 85-year-old nursing home patient who has suffered from dementia for the past eight years. He has been bed bound and uncommunicative for the last six months. He was admitted with aspiration pneumonia three times in the past year. Over the last few months he has lost weight due to poor dietary intake and has developed a decubitus ulcer. Mr. Smith's family inquires about the advantages and disadvantages of the placement of a percutaneous endoscopic gastrostomy (PEG) tube to help improve his weight loss.

Percutaneous Closure of Perimembranous Ventricular Septal Defect with Amplatzer Device

BACKGROUND

The Amplatzer perimembranous ventricular septal occluder is an innovative device for percutaneous closure of perimembranous ventricular septal defects (PMVSD). In appropriately selected cases this procedure is safe and effective.

METHODS

Fourteen patients with the mean age 10.53 years (range 18 months to 55 years) and mean body weight 20.64 kg (range 6 to 52 kg) underwent PMVSD closure.

RESULT

The PMVSD mean diameter was 5.28 mm (range from 4 to 9 mm). Implantation was successful in 92% of the cases and all patients had complete occlusion of the shunt within three months.

CONCLUSION

Device orientation was excellent in all cases. Device-related aortic insufficiency, tricuspid insufficiency or left ventricular dysfunction was not observed. One patient had embolisation of the device and another had complete heart block which required a permanent pacemaker implantation. The excellent short term results need to be confirmed over long-term follow-up.

Coronary Artery Revascularisation : Past, Present and Future

The high prevalence of coronary artery disease has inspired the development of technologies and techniques for coronary revascularisation, including coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI). PCI have witnessed the impact of innovation with newer hardware and drug eluting stents (DES). DES have indisputably reduced restenosis, however there is an emerging concern over the risk of late stent thrombosis associated with their use. We discuss the limitations of the current generation DES and review advances in the stent technology. The technology used in CABG has improved, resulting in off-pump coronary artery bypass (OPCAB), endoscopic, video-assisted, and robot-assisted CABG with automated one-shot distal anastomotic devices being used increasingly. The difference in adverse outcomes between CABG and PCI continues to decline and the future may witness a close collaboration between the two.

Survey of palliative care concepts among medical students in India

BACKGROUND

Students must develop a "tension for change" before new material is learned. Therefore, a needs assessment generally precedes curriculum change in order to identify what the target population thinks they already know about a subject. Undergraduate medical education in India is a 4(1/2) -year course. This is followed by a 1-year internship before the new physician can practice independently.

AIM

To assess the level of awareness in palliative care concepts among final-year students at Kasturba Medical College, Manipal, India.

MATERIALS AND METHODS

One hundred eleven final-year students participated in a survey study 6 months before graduation. The data were collected after the survey and the responses were analyzed.

RESULTS

The reported theoretical knowledge of palliative care concepts was better than the level of confidence in performing practical aspects of palliative care.

CONCLUSION

Before this survey, we hypothesized that medical students in India would have low levels of self-reported understanding of palliative care and its components. In contrast, they reported a high level of understanding of palliative care but very little understanding and confidence in performing the associated skills. From this, we conclude that these medical students are ready for instruction in the practical skills of palliative care.

Survey of Palliative Care Concepts among Medical Interns in India

BACKGROUND

Medical knowledge, if theoretical, will fade away if not reinforced especially if not clinically implemented. We conducted a survey study amongst interns to assess awareness and confidence of common palliative care issues. Undergraduate medical education in India is a 4(1/2) -year course. This is followed by a 1-year internship before the new physician can practice independently.

AIM

To compare the level of awareness in palliative care concepts among interns to that of final-year medical students at Kasturba Medical College, Manipal, India.

MATERIALS AND METHODS

Forty-four interns participated in a survey study. The data were collected after the survey and the responses were analyzed. We compared these data with those obtained from conducting the same survey among medical students.

RESULTS

The reported theoretical knowledge of palliative care concepts was better than the level of confidence in performing practical aspects of palliative care. The interns, overall, did not out-perform the students.

CONCLUSION

Before this survey, we hypothesized that interns in India would have low levels of self-reported understanding of palliative care and its components. We were hoping to see an improvement in knowledge and confidence with training. In contrast, there was not much of an improvement but rather a decline in some areas. From this, we conclude that when medical students become interns, they need reinforcement of knowledge and more hands-on experience.

Congenital atresia of left main coronary artery

We report a rare case of congenital atresia of left main coronary artery in an elderly male presenting with angina and positive stress thallium test. Coronary angiogram showed absence of left main coronary artery in the left aortic sinus. Collaterals from right coronary artery supplied left anterior descending artery and left circumflex artery territories. Despite collaterals, the left anterior descending and left circumflex arteries were rudimentary. Poor size of left-sided arteries precluded any surgical revascularization which is the treatment of choice in this rare entity.

Techniques in Cardiology : PDA Closure in Children

BACKGROUND

Transcatheter closure of patent ductus arteriosus (PDA) with various devices has been evaluated worldwide and in selected cases can be performed successfully, thus avoiding the morbidity associated with surgical closure.

METHODS AND RESULTS

A 2 year old female child presented with PDA and aortic angiography showed large PDA (tubular). This defect can be closed nonsurgically by coils and devices. The coil used are normally 0.038" having delivery system called Flipper, but this child had a large PDA and so was closed by thicker coil 0.052" using a coil-Bioptome-sheath system, which is the first reported case from the Armed Forces.

CONCLUSIONS

We report the initial experience at our center of closure of PDA with a new coil-Bioptome-sheath system.

Listeria Meningitis Associated with Infliximab

OBJECTIVE:

To report a case of Listeria monocytogenes meningitis in a 73-year-old man receiving infliximab for rheumatoid arthritis.

CASE SUMMARY:

A 73-year-old white man taking infliximab for rheumatoid arthritis developed listeria meningitis following his second dose. He was receiving other immunosuppressants; however, these remained constant immediately prior to the infection. Diagnosis was confirmed with L. monocytogenes isolated in the cerebrospinal fluid. The patient received 21 days of antibiotic therapy and recovered without any complications.

DISCUSSION:

L. monocytogenes is a gram-positive, non—spore-forming rod that has been associated with the ingestion of undercooked foods. This organism can cause sepsis or meningitis; however, immunocompromised patients, elderly patients, pregnant women, and neonates appear to be at greater risk for this type of infection. Tumor-necrosis factor-α (TNF-α) plays an important role in resistance to this type of infection, and listeria infections have been reported in 26 patients receiving TNF-α inhibitors. In our patient, the listeria infection occurred following his second course of infliximab, which provides a temporal relationship between the listeria infection and infliximab. However, his underlying rheumatoid arthritis and chronic steroid therapy would also increase his risk for a listeria infection.

CONCLUSIONS:

The listeria infection in our patient was a possible adverse event of infliximab according to the Naranjo probability scale. Because the majority of listeria infections occur in patients who are immunosuppressed, it would be reasonable to provide education for healthcare professionals on preventing these infections in all patients receiving immunosuppressants, including anti—TNF-α therapy. Those at risk due to their underlying health conditions should also be monitored closely.

Bone sarcoidosis

Sarcoidosis is a disease that exhibits extremely heterogeneous clinical manifestations. Although the lungs are the most commonly involved organs, the extension of the granulomatous process may also affect the bones. Almost any bone can be involved; curiously, the small bones of the hands and feet are most frequently affected. Diagnosis and recognition of osseous sarcoidosis is easy, but the therapy is disappointing. Corticosteroids and antimalarials may control pain and swelling, but usually do not influence the course of osseous sarcoidosis.