A System-Wide Population Health Value Approach to Reduce Hospitalization Among Chronic Kidney Disease Patients: an Observational Study

BACKGROUND

Chronic kidney disease (CKD) is a leading cause of healthcare morbidity, utilization, and expenditures nationally, and caring for late-stage CKD populations is complex. Improving health system efficiency could mitigate these outcomes and, in the COVID-19 era, reduce risks of viral exposure.

OBJECTIVE

As part of a system-wide transformation to improve healthcare value among populations with high healthcare utilization and morbidity, UCLA Health evaluated a new patient-centered approach that we hypothesized would reduce inpatient utilization for CKD patients.

DESIGN

For 18 months in 2015-2016 and 12 months in 2017, we conducted an interrupted time series regression analysis to evaluate the intervention's impact on inpatient utilization. We used internal electronic health records and claims data across six payers.

PARTICIPANTS

A total of 1442 stage 4-5 CKD patients at a large academic medical center.

INTERVENTION

Between October and December 2016, the organization implemented a Population Health Value CKD intervention for the CKD stages 4-5 population. A multispecialty leadership team risk stratified the population and identified improvement opportunities, redesigned multispecialty care coordination pathways across settings, and developed greater ambulatory infrastructure to support care needs.

MAIN MEASURES

Outcomes included utilization of hospitalizations, emergency department (ED) visits, inpatient bed days, and 30-day all-cause readmissions.

KEY RESULTS

During the 12 months following intervention implementation, the monthly estimated rate of decline for hospitalizations was 5.4% (95% CI: 3.4-7.4%), which was 3.4 percentage points faster than the 18-month pre-intervention decline of 2.0% (95% CI: 1.0-2.2%) per month (p = 0.004). Medicare CKD patients' monthly ED visit rate of decline was 3.0% (95% CI: 1.2-4.8%) after intervention, which was 2.6 percentage points faster than the pre-intervention decline of 0.4% (95% CI: - 0.8 to 1.6%) per month (p = 0.02).

CONCLUSIONS

By creating care pathways that link primary and specialty care teams across settings with increased ambulatory infrastructure, healthcare systems have potential to reduce inpatient healthcare utilization.

Feasibility study of NeoMend, a percutaneous arterial closure device that uses a nonthrombogenic bioadhesive

OBJECTIVE

The aim of this prospective single-center phase I feasibility study was to investigate the safety and efficacy of a novel vascular sealing device, the NeoMend Arterial Closure Device, that uses a bioadhesive after percutaneous endovascular procedures.

SUBJECTS AND METHODS

In 26 consecutive patients, the sealing device was deployed at the femoral artery access site immediately after a catheterization procedure using a 6-French (1.91-mm) sheath. Patients were followed up at 24 hr with Doppler sonography of the treated femoral artery puncture site, and at 1 week and 1 month by a telephone interview.

RESULTS

Successful hemostasis was achieved with the NeoMend Arterial Closure Device in 21 (88%) of 24 patients. One major complication required surgery: formation of puncture site hematoma and pseudoaneurysm 3 days after the intervention after successful primary hemostasis. Two device failures required crossover to manual compression, which was done without further complications. The mean time to hemostasis was 7.0 +/- 4.5 min. Mean time to ambulation was 6.0 hr. At follow-up, the patients did not report any puncture-site-related complaints. Doppler sonography of the puncture sites revealed three insignificant hematomas of less than 20 mL and patent common femoral vessels without stenoses.

CONCLUSION

The NeoMend Arterial Closure Device appears to achieve rapid hemostasis with the potential of early ambulation after arterial punctures with a 6-French sheath. The device is an alternative in situations in which suture- or collagen-mediated devices show high complication rates.

Sonoclot analysis in healthy children

Although use of the Sonoclot device (Sienco, Inc., Morrison, CO) has been reported in isolated pediatric cases and in small reports in neonates, there are no published data for normal pediatric patients. As the device is used in situations of abnormal coagulation, such as cardiac and liver transplantation surgery, our aim was to determine normal data ranges in healthy pediatric surgical patients. Blood was withdrawn after anesthetic induction, and the Sonoclot activated clotting time, rate of clot formation, time to peak amplitude, and peak amplitude was compared among four pediatric groups (< 12 mo, 13-24 mo, 25-48 mo, 49 mo-9 yr) and an adult group. The Sonoclot activated clotting time in the < 12-mo and the Adult groups were shorter than the oldest group of children (P < 0.05), although all were within the anticipated normal range, and there were no significant differences in clot rate, peak amplitude, and time to peak amplitude among groups without apparent trends with increasing age. These Sonoclot variables quantify adequate global clot formation in pediatric patients and will facilitate clinical coagulation management with appropriate pediatric normal ranges, avoiding the application of extrapolated adult data to children.

IMPLICATIONS

Sonoclot variables are presented for 95 healthy pediatric surgical patients in four age groups, with small differences found in the Sonoclot (Sienco, Inc., Morrison, CO) activated clotting time between two groups and no significant differences in three other variables among groups.

Celite-activated thrombelastography in children

STUDY OBJECTIVE

To quantify global coagulation and establish normal ranges for the celite-activated thrombelastograph (TEG) in healthy pediatric patients.

DESIGN

Prospective observational study.

SETTING

Operating suite of a university-based hospital.

PATIENTS

110 healthy pediatric patients in four age groups and 25 healthy adult patients.

INTERVENTIONS

Blood sampling for the celite-activated TEG was carried out after anesthetic induction.

MEASUREMENTS

TEG indices: R time (reflecting time to fibrin formation), K time and alpha angle (fibrinogen-platelet interaction), maximum amplitude (reflecting maximal clot strength, platelet and fibrinogen function), TEG index (mathematical incorporation of the prior four measurements), and percent fibrinolysis at 30 minutes, were all recorded.

MAIN RESULTS

Statistically significant differences between <12-month group in angle (compared to 25-48 month group) and % fibrinolysis (compared to all other pediatric groups). Significant differences in angle between two pediatric groups and adult group, and in the TEG index between three pediatric groups and adult group (all differences p < 0.05).

CONCLUSIONS

These data identify changes of small magnitude in three celite-TEG parameters in healthy children compared to adults, without implication of abnormal coagulation between groups. Changes do not seem to be consistently related to age and will be useful for clinicians using the TEG to monitor (ab) normal coagulation in pediatric patients.

Internal iliac artery embolization in the stent-graft treatment of aortoiliac aneurysms: analysis of outcomes and complications

PURPOSE

To analyze the complications of internal iliac artery (IIA) embolization in conjunction with stent-graft treatment of aortoiliac aneurysms.

MATERIALS AND METHODS

Seventy-one patients with aortoiliac (n = 47) or iliac (n = 24) aneurysms were treated with endoluminal placement of stent-grafts. Thirty-two patients (31 men, one woman; mean age, 73 years; range, 56-88 years) had embolization or occlusion of one (n = 27) or both (n = 5) IIAs. Status of the IIAs and the collateral circulation was assessed by retrospective review of angiographic images. Follow-up consisted of a standardized patient questionnaire and review of radiologic and medical records.

RESULTS

The mean follow-up time was 35 months (range, 5-64 months). Eleven of the 47 patients with abdominal aortic aneurysms (AAA) (23%) and 19 of the 24 patients with iliac aneurysms (79%) required IIA embolization. One patient with AAA and another with iliac aneurysm had unintentional occlusion of an IIA by extension of the stent-graft over their origins. A total of seven patients had bilateral occlusion of the IIAs after the procedure. Additionally, the inferior mesenteric arteries (IMAs) of two other patients with AAA were also embolized. In six patients, all three vessels were occluded after placement of the stent-grafts. Symptoms were reported in nine of the 20 (45%) patients with iliac aneurysms and in three of the 12 (25%) patients with AAA. Symptoms consisted of buttock claudication (nine of 32, 28%), new sexual dysfunction (two of 16, 12%), and transient urinary retention (3%). Seven of the claudicants had resolution of symptoms after a mean interval of 14 months (range, 1-36 months). There were no instances of bowel ischemia, neurologic sequelae, or buttock necrosis related to these procedures.

CONCLUSION

Embolization of the IIA is associated with symptoms in a significant number of patients. While symptoms are transient in most patients, they can be problematic. Efforts should be made to preserve the pelvic circulation if possible.

Management of biopsy needle artifacts: techniques for RF-refocused MRI

Several methods were investigated to improve the depiction of biopsy needles in radiofrequency (RF)-refocused magnetic resonance imaging. Distortion correction is performed by the use of view angle tilting (VAT): a gradient is employed on the slice-select axis during readout. Needle conspicuity is increased by offsetting the gradient echo from the spin echo and by inverting the 90 degrees RF pulse slice-select gradient. VAT effectively re-registers in-plane shifts. Since this method changes the projection angle through the slice, some structures appear blurred, while other structures appear sharper. VAT does not correct errors in slice selection. Offsetting the spin echo from the gradient echo increases needle conspicuity but can result in a shift in the apparent location of the needle. Inverting the 90 degrees slice-select gradient effectively increases the needle conspicuity with no shift in the needle location. These methods provide an easy and interactive means to manipulate needle artifacts but should be used cautiously.

Percutaneous creation of acute type-B aortic dissection: an experimental model for endoluminal therapy

PURPOSE

To evaluate the feasibility of a percutaneously created type-B aortic dissection as an experimental model for percutaneous therapy. This model was used to evaluate the hemodynamic effects of single-balloon fenestration of the intimal flap.

MATERIALS AND METHODS

Acute type-B dissections were created in descending aortae of 15 swine via a femoral (n = 6) or carotid (n = 9) approach. The initial subintimal tear was made with use of a Colapinto needle. The dissections were extended to a predefined position in the aorta. The proximal and distal tears were balloon dilated. The mural flap was balloon fenestrated in six animals, just above the celiac artery. Aortograms were obtained to establish the presence and extent of the dissection. Manometry was performed in both lumina to evaluate the hemodynamics of the dissected aorta and the effects of balloon fenestration in this model. Pathologic specimens were also examined.

RESULTS

Creation of dissection was successful in 11 of 15 animals, with six developing true lumen narrowing (group A). The other five animals (group B) had flow in both lumina without evidence of true lumen narrowing. After the creation of a single-balloon fenestration in the group A swine, the arteriograms revealed no evidence of blood admixture between the true and false lumina, and there was no change in the intravascular pressures. Examination of the explanted aortae showed a more extensive circumferential dissection in group A animals as compared with group B.

CONCLUSION

The percutaneously created acute type-B aortic dissection is a feasible model for experimentation. The hemodynamics of the aorta did not change after single-balloon fenestration in this model.

Transbronchial Palmaz stent placement for tracheo-bronchial stenosis

PURPOSE

Evaluation of the efficacy of transbronchial Palmaz stent placement in the treatment of tracheo-bronchial narrowing.

MATERIALS AND METHODS

Twelve patients with stenoses of the tracheo-bronchial tree were treated with balloon-expandable Palmaz stents. Etiology was anastomotic stenosis after lung transplantation (n = 3), bronchogenic carcinoma (n = 2), external compression from thoracic aortic aneurysm (n = 2), Mycobacterium tuberculosis (n = 1), esophageal carcinoma (n = 1), after lobectomy (n = 1), after lobectomy and endobronchial radiation (n = 1), and lye ingestion (n = 1). All patients had respiratory symptoms, radiologic findings of persistent atelectasis, or worsening pulmonary function tests. Bronchoscopy was used to delineate the stenosis prior to intervention. With use of fluoroscopic guidance, stents were placed in the mainstem bronchus (n = 11), lower lobe bronchus (n = 5), bronchus intermedius (n = 5), trachea (n = 3), and middle lobe bronchus (n = 1).

RESULTS

Initial technical success was achieved in all patients. Ten of the 12 patients (83%) had improvement of clinical pulmonary signs or symptoms. During follow-up, five patients died. One was lost to follow-up and was presumed dead. The 30-day mortality rate was 17% (two of 12 patients). The two complications were superficial laceration of the bronchial mucosa during balloon dilation in one patient and compression of stents by a thoracic aortic aneurysm in another patient.

CONCLUSION

Initial results suggest that transbronchial Palmaz stent placement is a feasible and effective method of treating tracheo-bronchial stenosis.

Central nervous system involvement in patients with scrub typhus

Scrub typhus, which is caused by Orientia tsutsugamushi, is a systemic illness that causes generalized vasculitis. The central nervous system (CNS) is the most crucial target in other rickettsial diseases; however, there have been several reports of encephalitis or meningitis without direct evidence of rickettsial invasion of the CNS in cases of scrub typhus. To investigate CNS involvement in cases of scrub typhus, we analyzed the CSF profiles (cell count and levels of protein and glucose) and amplified rickettsial DNA in CSF specimens by means of nested polymerase chain reaction (PCR) for 25 patients with the infection. Mild pleocytosis was present in 48% of the patients: CSF white blood cell counts ranged from 0 to 110/mm3 (mean [+/- SD] count, 16.3 +/- 27.0/mm3), and the mean (+/- SD) lymphocyte proportion was 51.9% +/- 23.9%. The CSF protein level was increased (>50 mg/dL) in seven patients. Nested PCR amplified six products from the 25 CSF specimens: four of the products were Boryong genotypes, and two were Karp genotypes. The results of this study suggest that O. tsutsugamushi does invade the CSF and that scrub typhus should be considered one of the causes of mononuclear meningitis in areas of endemicity.

Identification of Borrelia burgdorferi isolated in Korea using outer surface protein A (OspA) serotyping system

Two characteristic strains (935T, 934U) of B. burgdorferi isolated from Ixodes persulcatus and a wild rodent (Apodemus agrarius) in Korea were selected and analyzed by an immunoblot method using the monoclonal antibodies directed to different epitopes of outer surface protein A (OspA). The reactive pattern of strain 934U with these monoclonal antibodies was identical to that of strains belonging to B. afzelii and that of strain 935T was different from other isolates. Monoclonal antibody (5TEE3) which is specific to strain 935T did not react with any other Western and Japanese isolates. So, it was suggested that there exist at least two groups of B. burgdorferi in Korea. One could be classified as B. afzelii and the other is a divergent group from three known species of B. burgdorferi sensu stricto, B. garinii and B. afzelii.

Intestinal lymphatic pressure increases during intravenous infusions in awake sheep

Intravenous fluid infusions cause increased venous pressure and increased lymph flow throughout the body. Together the increased lymph flow and increased venous pressure (the outflow pressure to the lymphatic system) should increase the pressure within the postnodal intestinal lymphatics. To test this, we measured the pressure in postnodal intestinal lymphatics and the neck vein pressure in five awake sheep. At baseline, the neck vein pressure was 1.2 +/- 1.5 (SD) cmH2O and the lymphatic pressure was 12.5 +/- 1.7 cmH2O. When we infused Ringer solution intravenously (10% body weight in approximately 50 min), the neck vein pressure increased to 17.3 +/- 0.9 cmH2O and the lymphatic pressure increased to 24.6 +/- 3.8 cmH2O (both P < 0.05). In two additional sheep, the thoracic duct lymph flow rate increased from 0.8 +/- 0.4 ml/min at baseline to 5.5 +/- 2.0 ml/min during the infusions. Our results show that postnodal intestinal lymphatic pressure may increase substantially during intravenous fluid infusions. This is important because increases in postnodal lymphatic pressure may slow lymph flow from the intestine.

Anxiety and endocrine responses to surgery: paradoxical effects of preoperative relaxation training

It has been argued that surgery is a form of psychological stress, and that the response to it should therefore be modifiable by psychological means. To test this hypothesis, we assessed the effect of preoperative relaxation instructions on endocrine, cardiovascular, and subjective responses in 21 patients undergoing minor abdominal surgery. Controls (N = 19) received general procedural information. In the relaxation group only, there was a significant increase in cortisol and adrenaline concentration from immediately before induction of anesthesia to immediately after surgery. Noradrenaline values were unaffected by relaxation. In contrast, relaxation reduced state-anxiety on the preoperative day and the two postoperative days; maximal peroperative systolic and diastolic blood pressures were also reduced. The results are consistent with previous evidence that adrenaline and cortisol responses to surgery are greater in less anxious patients.

A survey of secondary transfers of head injured patients in the south of England

A survey by questionnaire was carried out to look into the provision of facilities for the secondary transfer of head injured patients, as well as difficulties encountered. An 84.6% response rate was achieved from 110 hospitals in six regions in the south of England. The results showed that 21% of hospitals had been unable to make a transfer in the previous year, and delays were commonly experienced by 23.7% of hospitals. The nursing attendance during transfer was satisfactory, but the quality of medical escort was poor, and the standard of monitoring equipment available was unacceptable. Methods of improving the situation include implementation of the recommendations of the Royal College of Surgeons, as well as the Association of Anaesthetists' recommendations for standards of monitoring and provision of intensive care.

Interhospital transfer of the critically ill patient by helicopter

The transfer of critically ill patients between hospitals is difficult for staff and dangerous for patients. A dedicated helicopter transfer scheme has been designed to deal with these problems.

Self-management for medication reduction in chronic low back pain

It has been demonstrated that pain relief is seldom produced by medication or surgical methods where there is evidence of emotional disturbance, as indicated by the MMPI. A program that attempts to engender a high level of patient responsibility in a population of chronic low back pain patients is described. Self-managed reduction of drug dependence is a major component of this program. The data indicate that the program produces a significant reduction in dependence on opiates, derivatives, synthetic opiates, hypnotics, sedatives, tranquilizers, and analgesics. Follow-up data (with attrition controlled) at six months and 12 months postdischarge do not provide any evidence for deterioration (ie, return to pretreatment levels of drug dependence). Thus, it appears that the programmatic impact is stable over at least a 12-month period postdischarge. Implications of these findings for the low back pain population, as well as other chronic pain populations, are discussed.