The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study

BACKGROUND

Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs).

OBJECTIVE

To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD.

EXPOSURE

OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD.

KEY RESULTS

The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD.

CONCLUSIONS

This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.

Preventing Avoidable Rehospitalizations through Standardizing Management of Chronic Conditions in Skilled Nursing Facilities

OBJECTIVES

This study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs).

DESIGN

A retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions.

SETTINGS AND PARTICIPANTS

Patients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD.

METHODS

The standardized protocols included medical provider or nurse assessments on SNF admission, multidisciplinary care planning, and medication management to avoid unplanned readmissions to the hospital. Descriptive analyses were conducted to illustrate the 30-day readmission rates before and after protocol implementation.

RESULTS

There were 1128 patients in the pre-J-CHiP cohort and 2297 patients in the J-CHiP cohort. About half of the patients with a recorded diagnosis of CHF without COPD had the standardized protocol initiated, whereas 47% of the patients with a recorded diagnosis of COPD without CHF had the standardized protocol initiated. Of patients with recorded diagnoses of COPD and CHF, 49% had both protocols initiated. A reduction in the readmission rate was observed for patients with COPD protocols, from 23.5% in 2011 to 12.1% in 2015. However, fluctuations in the readmission rates were observed for patients who initiated the CHF protocols.

CONCLUSIONS AND IMPLICATIONS

There were improvements in the readmission rates in this study, especially for patients who had initiated standardized care protocols in the SNFs. Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems. Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions.

Transforming Health Care from Volume to Value: Moving the Needle Through Population Health

United States health systems face unique challenges in transitioning from volume-based to value-based care, particularly for academic institutions. Providing complex specialty and tertiary care dependent on servicing large geographic areas, and concomitantly meeting education and research academic missions may limit the time and resources available for focusing on the care coordination needs of complex local populations. Despite these challenges, academic medicine is well situated to capitalize on the promise of value-based care and to lead broad improvements in both teaching and nonteaching hospitals. If properly executed, value-based care and complex specialty care can be complementary and synergistic. We postulate that the transition from volume to value in population health requires all health care organizations to advance and formalize infrastructure in 3 core areas: organizational capabilities; provider engagement; and engagement of the patient, family, and community. Although these apply to all organizations, for academic health systems, this transition must also be interwoven with the other domains of the tripartite mission.

Planning for the future of population health: the Johns Hopkins Medicine experience

Johns Hopkins Medicine underwent a significant evolution with a new Office of Population Health (OPH), inclusive of a hybrid clinical and administrative structure, to optimally align expertise with care delivery functions. Initial priorities included identification of high-risk patients to receive care management, integrated behavioral health, and wraparound supports to address social determinants of health. A cross-functional care team provides multidisciplinary support for primary care practice patient needs, and efforts through the Baltimore Metropolitan Diabetes Regional Partnership have helped accelerate scaling of evidence-based diabetes prevention and management programs across the state. Through a multistakeholder process, OPH and partners developed a 3-year strategic plan, with guiding stars of reducing avoidable utilization and disparities in care. The plan prioritized (1) generation of a data and analytics road map, (2) advanced population management clinical services for priority populations, (3) improved performance on value-based care programming, and (4) enhanced health system coordination. With a new OPH, Johns Hopkins Medicine is better positioned to execute on value-based initiatives in support of its patients.

Who represents me? A patient-derived model of patient engagement via patient and family advisory councils (PFACs)

BACKGROUND

Despite increasing attention to patient and family advisory councils (PFACs), what patients who are not PFAC members expect of PFACs remains understudied. Understanding their expectations is critical if PFACs are to help health systems achieve certain outcomes (eg increased patient satisfaction with health systems).

OBJECTIVE

To obtain rich insights about what patients who are not PFAC members expect of PFACs.

DESIGN

From July to September 2018, we conducted a qualitative study using focus groups.

SETTING AND PARTICIPANTS

We recruited patients and caregivers who receive their care from the Johns Hopkins Medicine Alliance for Patients (JMAP), LLC, a Medicare accountable care organization that in 2014 established a PFAC, the Beneficiary Advisory Council.

APPROACH

Using grounded theory, we analysed field notes, analytic memos and transcripts to develop a theoretical model of patient engagement via PFACs.

RESULTS

Forty-two patients and caregivers participated in five focus groups that included individuals of different ages, races, health statuses and socio-economic statuses. Participants were largely unaware of PFACs. Participants wanted to know who represented them (interpreted as a form of political representation) and emphasized the need for representatives' diversity. Who mattered because who could affect what PFACs do. Participants expected that all patients should be able to communicate with PFACs and that meaningful engagement could enhance perceptions of health systems.

CONCLUSIONS

Eliciting views about patient representation from patients who have not been engaged as advisors or representatives has the potential to inform PFACs' activities. Attention should be given to improving and measuring patients' awareness of, and interactions with, their patient representatives.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP)

IMPORTANCE

The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland.

OBJECTIVE

To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending.

DESIGN, SETTING, AND PARTICIPANTS

Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents.

INTERVENTIONS

The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations.

MAIN OUTCOMES AND MEASURES

Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants.

RESULTS

The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings.

CONCLUSIONS AND RELEVANCE

A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

Implementation of a comprehensive program to improve coordination of care in an urban academic health care system

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.

A Concise Tool for Measuring Care Coordination from the Provider's Perspective in the Hospital Setting

BACKGROUND

To support hospital efforts to improve coordination of care, a tool is needed to evaluate care coordination from the perspective of inpatient healthcare professionals.

OBJECTIVES

To develop a concise tool for assessing care coordination in hospital units from the perspective of healthcare professionals, and to assess the performance of the tool in measuring dimensions of care coordination in 2 hospitals after implementation of a care coordination initiative.

METHODS

We developed a survey consisting of 12 specific items and 1 global item to measure provider perceptions of care coordination across a variety of domains, including teamwork and communication, handoffs, transitions, and patient engagement. The questionnaire was distributed online between October 2015 and January 2016 to nurses, physicians, social workers, case managers, and other professionals in 2 tertiary care hospitals.

RESULTS

A total of 841 inpatient care professionals completed the survey (response rate = 56.6%). Among respondents, 590 (75%) were nurses and 37 (4.7%) were physicians. Exploratory factor analysis revealed 4 subscales: (1) Teamwork, (2) Patient Engagement, (3) Handoffs, and (4) Transitions (Cronbach's alpha 0.84-0.90). Scores were fairly consistent for 3 subscales but were lower for patient engagement. There were minor differences in scores by profession, department, and hospital.

CONCLUSIONS

The new tool measures 4 important aspects of inpatient care coordination with evidence for internal consistency and construct validity, indicating that the tool can be used in monitoring, evaluating, and planning care coordination activities in hospital settings.

Regional cost and experience, not size or hospital inclusion, helps predict ACO success

The Medicare Shared Savings Program (MSSP) continues to expand and now includes 434 accountable care organizations (ACOs) serving more than 7 million beneficiaries. During 2014, 86 of these ACOs earned over $300 million in shared savings payments by promoting higher-quality patient care at a lower cost.Whether organizational characteristics, regional cost of care, or experience in the MSSP are associated with the ability to achieve shared savings remains uncertain.Using financial results from 2013 and 2014, we examined all 339 MSSP ACOs with a 2012, 2013, or 2014 start-date. We used a cross-sectional analysis to examine all ACOs and used a multivariate logistic model to predict probability of achieving shared savings.Experience, as measured by years in the MSSP program, was associated with success and the ability to earn shared savings varied regionally. This variation was strongly associated with differences in regional Medicare fee-for-service per capita costs: ACOs in high cost regions were more likely to earn savings. In the multivariate model, the number of ACO beneficiaries, inclusion of a hospital or involvement of an academic medical center, was not associated with likelihood of earning shared savings, after accounting for regional baseline cost variation.These results suggest ACOs are learning and improving from their experience. Additionally, the results highlight regional differences in ACO success and the strong association with variation in regional per capita costs, which can inform CMS policy to help promote ACO success nationwide.

Academic Medical Centers Forming Accountable Care Organizations and Partnering With Community Providers: The Experience of the Johns Hopkins Medicine Alliance for Patients

Academic medical centers (AMCs)--which include teaching hospital(s) and additional care delivery entities--that form accountable care organizations (ACOs) must decide whether to partner with other provider entities, such as community practices. Indeed, 67% (33/49) of AMC ACOs through the Medicare Shared Savings Program through 2014 are believed to include an outside community practice. There are opportunities for both the AMC and the community partners in pursuing such relationships, including possible alignment around shared goals and adding ACO beneficiaries. To create the Johns Hopkins Medicine Alliance for Patients (JMAP), in January 2014, Johns Hopkins Medicine chose to partner with two community primary care groups and one cardiology practice to support clinical integration while adding approximately 60 providers and 5,000 Medicare beneficiaries. The principal initial interventions within JMAP included care coordination for high-risk beneficiaries and later, in 2014, generating dashboards of ACO quality measures to facilitate quality improvement and early efforts at incorporating clinical pathways and Choosing Wisely recommendations. Additional interventions began in 2015.The principal initial challenges JMAP faced were data integration, generation of quality measure reports among disparate electronic medical records, receiving and then analyzing claims data, and seeking to achieve provider engagement; all these affected timely deployment of the early interventions. JMAP also created three regional advisory councils as a forum promoting engagement of local leadership. Network strategies among AMCs, including adding community practices in a nonemployment model, will continue to require thoughtful strategic planning and a keen understanding of local context.

Low high-sensitivity troponin I and zero coronary artery calcium score identifies coronary CT angiography candidates in whom further testing could be avoided

RATIONALE AND OBJECTIVES

Pilot study to determine whether among subjects receiving coronary computed tomography angiography (CTA), the combination of high-sensitivity troponin I (hsTnI) and coronary artery calcium score (CACS) identifies a low-risk population in whom CTA might be avoided.

MATERIALS AND METHODS

A cross-sectional study of 314 symptomatic patients receiving CTA as part of their acute coronary syndrome evaluation was conducted. hsTnI was measured with Abbott Laboratories' hsTnI assay. CACSs were calculated via the Agatston method. Patients were followed for at least 30 days after discharge for the occurrence of major adverse cardiac events (MACEs; all-cause mortality, acute coronary syndrome, and revascularization).

RESULTS

Of 314 subjects studied, 213 (67.8%) had no coronary artery stenosis, and 67 (21.3%), 28 (8.9%), and 6 (1.9%) had maximal coronary artery stenosis of 1%-49%, 50%-69%, and 70% or greater, respectively. All MACEs occurred during index hospitalization and include one myocardial infarction and four revascularizations. Sixty-two percent (189/307) of subjects had zero CACS, and 24% (76/314) of subjects had undetected hsTnI. No subjects with undetectable hsTnI or zero CACS had an MACE. A strategy of avoiding further testing in subjects with undetectable initial hsTnI, performing CACS on subjects with detectable initial hsTnI but nonincreased hsTnI (less than 99th percentile), and obtaining CTA in subjects with Agatston greater than 0 will have a negative predictive value of 100.0% (95% confidence interval, 98.2%-100.0%). This strategy will avoid CTA in 63% (198/314) of subjects.

CONCLUSIONS

In this pilot study, the addition of CACS to hsTnI improves the identification of low-risk subjects in whom CTA might be avoided.

Medicare Shared Savings Program: public reporting and shared savings distributions

OBJECTIVES

To determine if Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) are meeting public reporting requirements related to shared savings plans, to quantitate the composition of shared savings distribution plans, and to investigate whether early ACO success is associated with specific plan or ACO characteristics.

STUDY DESIGN

Cross-sectional study.

METHODS

ACO descriptive characteristics and distribution plan details were abstracted from official ACO websites for all 338 active MSSP ACOs launched through January 2014. Publicly available MSSP results from 2012 and 2013 start date ACOs were used to investigate associations with successful shared savings generation.

RESULTS

Of current MSSP ACOs, 313 of 338 (93%) maintain a website, 284 of 338 (84%) provided at least a general statement about shared savings distributions, and 176 of 338 (52%) reported detailed allocation percentages to ACO participants. On average, ACOs reporting detailed allocations planned to give 63% (range = 0%-100%; SD = 26.3) to their primary care providers (PCPs), specialists, and/or hospitals, and 33% (range = 0%-100%; SD = 25.6) to infrastructure. ACOs including a hospital planned to give a larger average percentage to participating entities than those without (69% vs 58%; P = .01). ACOs planning to give > 50% to their PCPs and specialists were more likely to have generated savings (P = .001), as were ACOs composed of > 10 participating entities (P = .004).

CONCLUSIONS

Just over one-half of MSSP ACOs report detailed shared savings distribution plans online, and these plans vary widely. There appears to be no single shared savings distribution plan determinate of ACO success. Continued investigation of predictors for generating savings is needed to inform future shared savings models.

Accountable Care Organizations and Otolaryngology

Accountable care organizations represent a shift in health care delivery while providing a significant potential for improved quality and coordination of care across multiple settings. Otolaryngologists have an opportunity to become leaders in this expanding arena. However, the field of otolaryngology-head and neck surgery currently lacks many of the tools necessary to implement value-based care, including performance measurement, electronic health infrastructure, and data management. These resources will become increasingly important for surgical specialists to be active participants in population health. This article reviews the fundamental issues that otolaryngologists should consider when pursuing new roles in accountable care organizations.

Accountable care organization readiness and academic medical centers

As academic medical centers (AMCs) consider becoming accountable care organizations (ACOs) under Medicare, they must assess their readiness for this transition. Of the 253 Medicare ACOs prior to 2014, 51 (20%) are AMCs. Three critical components of ACO readiness are institutional and ACO structure, leadership, and governance; robust information technology and analytic systems; and care coordination and management to improve care delivery and health at the population level. All of these must be viewed through the lens of unique AMC mission-driven goals.There is clear benefit to developing and maintaining a centralized internal leadership when it comes to driving change within an ACO, yet there is also the need for broad stakeholder involvement. Other important structural features are an extensive primary care foundation; concomitant operation of a managed care plan or risk-bearing entity; or maintaining a close relationship with post-acute-care or skilled nursing facilities, which provide valuable expertise in coordinating care across the continuum. ACOs also require comprehensive and integrated data and analytic systems that provide meaningful population data to inform care teams in real time, promote quality improvement, and monitor spending trends. AMCs will require proven care coordination and management strategies within a population health framework and deployment of an innovative workforce.AMC core functions of providing high-quality subspecialty and primary care, generating new knowledge, and training future health care leaders can be well aligned with a transition to an ACO model. Further study of results from Medicare-related ACO programs and commercial ACOs will help define best practices.

Abstract 157: Use of a Novel Risk Score in the Emergency Department Discriminates Acute Coronary Syndrome Among Chest Pain Patients with Known Coronary Artery Disease

Background: Patients with known coronary artery disease (CAD) presenting to the Emergency Department (ED) with chest pain thought to be of ischemic origin are often admitted to the hospital, yet less than half are eventually diagnosed with acute coronary syndrome (ACS). We assessed whether the use of a novel risk score in the ED could discriminate which of these high-risk patients actually do or do not have ACS.

Methods and Results: Chart review was performed on a prospectively defined cohort of 142 patients with known CAD presenting to the ED with chest pain thought to be of ischemic origin, all of whom were admitted to the hospital from December 2012 to April 2013. Known CAD was defined as history of myocardial infarction, PCI, CABG, angiographic coronary stenosis >50%, or a positive stress test. Troponin I was measured using the Beckman Coulter assay. Variables were assessed with logistic regression for their association with ACS as determined by the inpatient attending physician at hospital discharge. The cohort included 59 women (42%) and 90 African American individuals (63%). One-hundred sixteen patients (82%) had a history of revascularization (104 PCI, 53 CABG, 41 both). ACS was eventually diagnosed in 43 (30%) of the patients. Non-ACS patients had a 2.8 day average length of stay and $9,908 average inpatient (post-ED) hospital charges (not including physician fees), which is $980,926 for the 99 (70%) non-ACS patients. A novel risk score, including (1) elevated troponin I (>0.05 ng/mL) in the ED, (2) dynamic ECG changes in the ED, (3) body mass index (BMI), (4) home aspirin use, (5) age older than 65, (6) history of chronic kidney disease (CKD), and (7) associated illness at presentation to the ED (anemia, arrhythmia, hypertension, infection, COPD exacerbation, diabetic ketoacidosis or hyperosmolar hyperglycemic state), discriminated ACS and non-ACS with an area under ROC curve (AUC) of 0.829. In the multi-variable regression, troponin I elevation was the most predictive of ACS (OR 7.22, p <0.001), followed by home aspirin use (OR 6.07, p 0.036), age older than 65 (OR 4.06, p 0.012), dynamic ECG changes (OR 2.68, p 0.046), and BMI (OR 1.09, p 0.008). The presence of an associated illness was associated with decreased likelihood of ACS (OR 0.24, p 0.013), as was CKD (OR 0.17, p 0.008).

Conclusions: A novel risk score including elevated troponin I in the ED, dynamic ECG changes in the ED, body mass index, home aspirin use, age older than 65, history of chronic kidney disease, and associated illness at presentation to the ED, is a valuable tool for discriminating between ACS and non-ACS among patients with known CAD presenting to the ED with chest pain. This preliminary analysis provides a foundation for larger and prospective studies for validation. Application of this risk score, along with other clinical factors, may reduce the number of potentially avoidable admissions and associated costs.

Individualizing HbA1c targets for patients with diabetes: impact of an automated algorithm within a primary care network

AIMS

To develop glycaemic goal individualization algorithms and assess potential impact on a healthcare system and different segments of the population with diabetes.

METHODS

A cross-sectional observational study of patients with diabetes in a primary care network age > 18 years with an HbA1c measured between 1 January and 31 December 2011. We applied diabetes guidelines to create targeted algorithms 1 and 2, which assigned HbA1c goals based on age, duration of diabetes (< 15 years or < 10 years), diabetes complications and Charlson co-morbidity score (< 6 or < 4) [targeted algorithm 2 was designed to assign more patients a goal < 64 mmol/mol (8.0%) than targeted algorithm 1]. Each patient's HbA1c was compared with these targeted goals and to the 'standard' goal < 53 mmol/mol (7.0%). Agreement was tested using McNemar's test.

RESULTS

Overall, 55.7% of 12 199 patients would be considered controlled under the 'standard' approach, 61.2% under targeted algorithm 1 and 67.5% under targeted algorithm 2. Targeted algorithm 1 reclassified 1213 (23.6%) patients considered uncontrolled under the standard approach to controlled, P < 0.001. Targeted algorithm 2 reclassified 1844 (35.2%) patients, P < 0.001. Compared with those controlled under the standard goal, there was no significant difference in the proportion of those controlled using targeted goals who had Medicaid, had less than a high school diploma or received primary care in a federally qualified health centre.

CONCLUSIONS

Two automated targeted algorithms would reclassify one quarter to one third of patients from uncontrolled to controlled within a primary care network without differentially affecting vulnerable patient subgroups.

Medicare beneficiaries most likely to be readmitted

Recent legislation requires reducing Medicare payments to hospitals with higher than expected 30-day readmission rates, but there is no consensus strategy to identify patients who should optimally be targeted with care coordination services to mitigate this risk. To determine which hospital and patient factors predict variation in all discharge hospital readmission rates, a 5% sample of all Medicare fee-for-service beneficiaries with continuous Part A and B coverage was examined for the first 9 months of 2008 in combination with other administrative data available to the Centers for Medicare and Medicaid Services. We included age, sex, race, dual-eligibility status, number of comorbid conditions, geographic region, hospital case mix, and reason for entitlement in the multiple regression model to assess how they influenced the 30-day readmission rate. Beneficiaries with 10 or more chronic conditions were more than 6 times more likely to be readmitted than beneficiaries with 1 to 4 chronic conditions. These beneficiaries represent only 8.9% of all Medicare beneficiaries (31.0% of all hospitalizations), but they were responsible for 50.2% of all readmissions. The 31.8% of beneficiaries with 5 to 9 chronic conditions (55.5% of all hospitalizations) had the second highest odds ratio (2.5) and were responsible for 45% of all readmissions.

Improving regional variation using quality of care measures

There is significant regional variability in the quality of care provided in the United States. This article compares regional performance for three measures that focus on transitions in care, and the care of patients with multiple conditions. Admissions for people with ambulatory care-sensitive conditions, hospital readmissions within 30 days of discharge, and compliance with practice guidelines for people with three chronic conditions (congestive heart failure, chronic obstructive pulmonary disease, and diabetes) were analyzed using data drawn from the Centers for Medicare & Medicaid Services’ Standard Analytic Files for 5% of a 2004 national sample of Medicare beneficiaries which was divided by hospital referral regions and regional performance. There were significant regional differences in performance which we hypothesize could be improved through better care coordination and system management.

Ischemic necrosis following clubfoot surgery: the purple hallux sign

Ischemic necrosis, which develops rarely after clubfoot surgery, may have a vascular etiology, since many idiopathic and neurogenic clubfeet have congenital deficiency of the anterior tibial and dorsalis pedis arteries. Dorsalis pedis deficiency is demonstrated more frequently in those clubfeet showing greater deformity. Substantial hypoplasia of the profunda femoris and posterior and anterior tibial arteries was evident in the affected limb of a patient in this series who underwent postoperative arteriography. Herein, we report massive necrosis in seven limbs of six patients after clubfoot surgery and have combined this series with seven previously published cases. Additional cases support our hypothesis that arterial deficiencies put some postoperative clubfeet at risk of perioperative ischemic necrosis. Necrosis occurs in those regions supplied by the congenitally diminished anterior tibial and dorsalis pedis arteries. Knowing that children with congenital vascular deficiency are at risk for ischemic necrosis, surgeons should be alert to the subtle, early signs of ischemia and be prepared to prevent or ameliorate the consequences of this condition. Since hypoperfusion in these postoperative feet is a surgical emergency, we propose clinical guidelines for treatment for this phenomenon, which we have named the purple hallux sign.

Linear multidimensional liquid chromatography in the preparative scale purification of calmodulin from brain extract

Rapid preparative scale purification of calmodulin from crude bovine brain extract is achieved in a single chromatographic run by physically coupling two different liquid chromatography columns which employ different separation mechanisms. In this case columns packed with newly commercialized 40-microns silica-based hydrophobic interaction and 5-microns micron silica-based weak anion-exchange chromatography media were used. The only sample preparation required for conducting this purification procedure is the addition of salt to the crude brain supernatant to promote the initial binding of calmodulin to the hydrophobic interaction chromatography media. Chromatography carried out on such linear arrangements of columns has been referred to as linear multidimensional liquid chromatography.

Intrinsic calcium sensitivity of tubulin polymerization. The contributions of temperature, tubulin concentration, and associated proteins

The calcium concentration required to inhibit tubulin polymerization by 50% (Ca2+ sensitivity) extends from the micromolar to the millimolar range and is a function of a number of factors that include 1) a steep, inverse dependence on tubulin concentration: two-cycle tubulin has lower Ca2+ sensitivity than pure tubulin (prepared by a novel method described under "Appendix"); 2) temperature: Ca2+ sensitivity shows a steep increase below 24 degrees C; 3) microtubule seeds: these decrease sensitivity to Ca2+ inhibition; 4) the presence of 16 S oligomers or microtubule-associated proteins. Ca2+ increases the critical concentration for microtubule protein and decreases the initial rate of polymerization. All tubulin preparations examined contain small amounts of calmodulin. However, the molar ratio of calmodulin to tubulin is less than 0.01, hence this protein is not required for high Ca2+ sensitivity. Nevertheless, calmodulin at high molar ratios can increase the sensitivity of microtubule assembly toward Ca2+. We conclude that tubulin possesses high intrinsic as well as a calmodulin-mediated Ca2+ sensitivity, and propose that high Ca2+ sensitivity may be a property of the nucleation process.

Spurious protein activators of Bordetella pertussis adenylate cyclase

A variety of proteins and tissue preparations (rabbit erythrocyte lysate, catalase, peroxidase, creatine phosphokinase, and lima bean trypsin inhibitor) contain protein activator(s) of the extracellular adenylate cyclase of intact Bordetella pertussis organisms. Stimulation of adenylate cyclase activity of up to 1000-fold over basal activity can be obtained. Activation of the adenylate cyclase is due to the presence of calmodulin in these protein preparations. The criteria to establish this were: Ca2+ dependence of the activation, inhibition by trifluoperazine, heat stability of the activator, chromatographic behavior like authentic calmodulin, and stimulation of cyclic nucleotide phosphodiesterase by the activators. The great sensitivity of the B.pertussis adenylate cyclase assay makes this and ideal system for the detection of trace amounts of calmodulin, in the presence of large amounts of other proteins.

Nucleation and the kinetics of microtubule assembly

A kinetic model was developed for the purpose of interpreting scanning calorimetric data of microtubule assembly. The model consists of two steps. The first step is a highly exothermic nucleation with a strong dependence upon temperature and concentration. The second step is the elongation of the nuclei or microtubules by the addition of tubulin dimer to growing ends. Computer fits to the data provided the values of the parameters of the model. The model successfully simulated various experiments.

Observation of an exothermic process associated with the in vitro polymerization of brain tubulin

The polymerization of tubulin has been studied with a high-sensitivity differential scanning microcalorimeter, with results which indicate that microtubule assembly can proceed via one or possibly two exothermic reactions. The amount of heat evolution has been found to be far in excess of GTP hydrolysis. The heat liberated has been observed to depend strongly upon the exact experimental conditions, varying from many hundreds of kilocalories per mole of tubulin dimer when dilute tubulin solutions are heated rapidly to a few kilocalories per mole of tubulin dimer when concentrated tubulin solutions are heated slowly. The results are tentatively interpreted in terms of the existence of at least two pathways for the formation of energetically distinct polymers. These findings indicate the importance of kinetic factors in studying tubulin polymerization.

Calmodulin activates prokaryotic adenylate cyclase

The adenylate cyclase of Bordetella pertussis is stimulated 100- to 1000-fold in a dose-dependent manner by calf brain calmodulin. The system has the following properties. (i) The activation is prevented by ethylene glycol bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid and restored by Ca2+. (ii) Oxidation of the methionine residues of calmodulin abolishes the ability to activate the cyclase. (iii) Trifluoperazine inhibits calmodulin-activated cyclase. (iv) A troponin C preparation stimulates the B. pertussis cyclase with < 0.01 the potency of calmodulin. Although calmodulin has not been demonstrated in prokaryotes, this is an example of a (eukaryotic) calmodulin effect in a prokaryote.

Turbidity measurements in an analytical ultracentrifuge. Determinations of mass per length for filamentous viruses fd, Xf, and Pf3

An analytical ultracentrifuge has been used to measure light-scattering intensities by the transmittance method. The technique, which is applicable to particles of many sizes and shapes, has the principal advantage that samples can be kept free of dust during the measurements. Also, sample volumes are small, and the scanner and interference optics can be used simultaneously to obtain, for a given sedimenting boundary, turbidity steps at different wavelengths and the concentration step. In the present application the data yield mass per length estimates for three filamentous viruses, 19 100 daltons/nm for fd, 19 600 daltons/nm for Pf3, and 19 100 daltons/nm for Xf.

Separation and characterization of microtubule proteins from calf brain

Electrophoresis of microtubule preparations purified from calf brain by repeated cycles of assembly and disassembly shows that they contain many proteins in addition to alpha- and beta-tubulin. These additional proteins constitute about 17% of the total material present after five cycles of assembly and disassembly. Both one-dimensional and two-dimensional (P.H. O'Farrell (1975), J. Biol. Chem. 250, 4007) electrophoretic techniques have been used to characterize them. They can be divided into two groups: one that contains proteins which remain in constant quantitative ratio to tubulin during the purification cycles, and one composed of proteins which are removed during purification, although inefficiently. Gel-filtration chromatography of cold-depolymerized microtubule preparations yields a polydisperse fraction of high molecular weight containing most of the non-tubulin proteins. This fraction contains flexible filaments about 100 A in diameter similar to those reported by R.A.B. Keats and R.H. Hall ((1975), Nature (London) 247, 418). It is suggested that these fibers are neurofilaments, and that they may be the major source of the group of inefficiently removed proteins.