Cost-effectiveness of an Emergency Department-Based Intensive Care Unit

IMPORTANCE

Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care.

OBJECTIVE

To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021.

EXPOSURES

Implementation of an ED-ICU.

MAIN OUTCOMES AND MEASURES

Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED.

RESULTS

A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001).

CONCLUSIONS AND RELEVANCE

Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.

Hospital Participation Decisions In Medicare Bundled Payment Program Were Influenced By Third-Party Conveners

The Bundled Payments for Care Improvement initiative Advanced Model (BPCI Advanced) is a voluntary Medicare bundled payment model in which hospitals may participate with third-party conveners-private consulting firms that share in the financial risk built into the program. We found that nonteaching and for-profit status was associated with a higher probability of hospital partnership with third-party conveners in BPCI Advanced. Among hospitals participating in at least one inpatient clinical episode, hospitals that partnered with third-party conveners were more likely to select episodes with higher target prices: A $1,000 increase in episode target price was associated with a 1.66-percentage-point increase in the probability of episode participation in BPCI Advanced compared with a 0.72-percentage-point increase for participating hospitals without third-party conveners. Hospitals with third-party conveners also were more likely than those without them to select inpatient clinical episodes with greater opportunities to reduce spending on postacute care and readmissions. These findings have important implications for understanding the role of private consulting firms in the program and for planning potential program modifications in the future.

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians

BACKGROUND

Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care.

OBJECTIVE

To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care.

DESIGN

Cross-sectional survey of ACO clinicians in 2018.

PARTICIPANTS

1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%.

MAIN MEASURES

Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care.

RESULTS

Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation.

CONCLUSIONS

Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

Metal-insulator transition in a semiconductor nanocrystal network

Many envisioned applications of semiconductor nanocrystals (NCs), such as thermoelectric generators and transparent conductors, require metallic (nonactivated) charge transport across an NC network. Although encouraging signs of metallic or near-metallic transport have been reported, a thorough demonstration of nonzero conductivity, σ, in the 0 K limit has been elusive. Here, we examine the temperature dependence of σ of ZnO NC networks. Attaining both higher σ and lower temperature than in previous studies of ZnO NCs (T as low as 50 mK), we observe a clear transition from the variable-range hopping regime to the metallic regime. The critical point of the transition is distinctly marked by an unusual power law close to σ ∝ T ^1/5. We analyze the critical conductivity data within a quantum critical scaling framework and estimate the metal-insulator transition (MIT) criterion in terms of the free electron density, n, and interparticle contact radius, ρ.

Availability and variation of publicly reported prescription drug prices

OBJECTIVES

To examine how often retail prices for prescription drugs are available on state public reporting websites, the variability of these reported prices, and zip code characteristics associated with greater price variation.

STUDY DESIGN

Searches of state government-operated websites in Michigan, Missouri, New York, and Pennsylvania for retail prices for Advair Diskus (250/50 fluticasone propionate/salmeterol), Lyrica (pregabalin 50 mg), Nasonex (mometasone 50 mcg nasal spray), Spiriva (tiotropium 18 mcg cp-handihaler), Zetia (ezetimibe 10 mg), atorvastatin 20 mg, and metoprolol 50 mg.

METHODS

Data were collected for a 25% random sample of 1330 zip codes. For zip codes with at least 1 pharmacy, we used χ2 tests to compare how often prices were reported. For zip codes with at least 2 reported prices, we used Kruskal-Wallis tests to compare the median difference between the highest and lowest prices and a generalized linear model to identify zip code characteristics associated with greater price variation.

RESULTS

Price availability varied significantly (P <.001) across states and drugs, ranging from 52% for metoprolol in Michigan to 1% for atorvastatin in Michigan. Price variation also varied significantly (P <.001) across states and drugs, ranging from a median of $159 for atorvastatin in Pennsylvania to a median of $24 for Nasonex in Missouri. The mean price variation was $52 greater (P <.001) for densely populated zip codes and $60 greater (P <.001) for zip codes with mostly nonwhite residents.

CONCLUSIONS

Publicly reported information on state prescription drug price websites is often deficient. When prices are reported, there can be significant variation in the prices of prescriptions, which could translate into substantial savings for consumers who pay out-of-pocket for prescription drugs.

Population Health: A New Paradigm for Medicine

Healthcare delivery system reform has become a dominant topic of conversation throughout the United States. Driven in part by ever-higher national expenditures on health, an increasing number of payers and provider organizations are working to reduce the costs and improve the quality of healthcare. In this article, we demystify the term "Population Health," review some of the larger payer initiatives currently in effect and discuss specific provider group efforts to improve the quality and cost of healthcare for patients.

Dynamic detection of electron spin accumulation in ferromagnet-semiconductor devices by ferromagnetic resonance

A distinguishing feature of spin accumulation in ferromagnet-semiconductor devices is its precession in a magnetic field. This is the basis for detection techniques such as the Hanle effect, but these approaches become ineffective as the spin lifetime in the semiconductor decreases. For this reason, no electrical Hanle measurement has been demonstrated in GaAs at room temperature. We show here that by forcing the magnetization in the ferromagnet to precess at resonance instead of relying only on the Larmor precession of the spin accumulation in the semiconductor, an electrically generated spin accumulation can be detected up to 300 K. The injection bias and temperature dependence of the measured spin signal agree with those obtained using traditional methods. We further show that this approach enables a measurement of short spin lifetimes (<100 ps), a regime that is not accessible in semiconductors using traditional Hanle techniques.

Predicting emergency department volume using forecasting methods to create a "surge response" for noncrisis events

OBJECTIVES

This study investigated whether emergency department (ED) variables could be used in mathematical models to predict a future surge in ED volume based on recent levels of use of physician capacity. The models may be used to guide decisions related to on-call staffing in non-crisis-related surges of patient volume.

METHODS

A retrospective analysis was conducted using information spanning July 2009 through June 2010 from a large urban teaching hospital with a Level I trauma center. A comparison of significance was used to assess the impact of multiple patient-specific variables on the state of the ED. Physician capacity was modeled based on historical physician treatment capacity and productivity. Binary logistic regression analysis was used to determine the probability that the available physician capacity would be sufficient to treat all patients forecasted to arrive in the next time period. The prediction horizons used were 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 12 hours. Five consecutive months of patient data from July 2010 through November 2010, similar to the data used to generate the models, was used to validate the models. Positive predictive values, Type I and Type II errors, and real-time accuracy in predicting noncrisis surge events were used to evaluate the forecast accuracy of the models.

RESULTS

The ratio of new patients requiring treatment over total physician capacity (termed the care utilization ratio [CUR]) was deemed a robust predictor of the state of the ED (with a CUR greater than 1 indicating that the physician capacity would not be sufficient to treat all patients forecasted to arrive). Prediction intervals of 30 minutes, 8 hours, and 12 hours performed best of all models analyzed, with deviances of 1.000, 0.951, and 0.864, respectively. A 95% significance was used to validate the models against the July 2010 through November 2010 data set. Positive predictive values ranged from 0.738 to 0.872, true positives ranged from 74% to 94%, and true negatives ranged from 70% to 90% depending on the threshold used to determine the state of the ED with the 30-minute prediction model.

CONCLUSIONS

The CUR is a new and robust indicator of an ED system's performance. The study was able to model the tradeoff of longer time to response versus shorter but more accurate predictions, by investigating different prediction intervals. Current practice would have been improved by using the proposed models and would have identified the surge in patient volume earlier on noncrisis days.

Identification of a novel HLA-A allele, A*29:28, in an East African population

The new allele is identical to A*29:01:01:01 in exons 2 and 3, except for a single-nucleotide substitution (TTG to TGG) at codon 156.

Quantitative assessment of myocardial perfusion during graded coronary artery stenoses by intravenous myocardial contrast echocardiography

OBJECTIVES

The purpose of this study was to examine whether coronary stenoses of variable severity could be quantitatively assessed by analysis of myocardial perfusion as determined by intravenous (IV) myocardial contrast echocardiography.

BACKGROUND

Recently, new contrast agents and imaging technology have been developed that may enable improved assessment of myocardial perfusion by IV contrast injection.

METHODS

Variable obstruction of the left anterior descending (LAD) coronary artery in dogs was produced by a screw occluder. Coronary artery flow was measured with a transit time flowmeter during baseline, pharmacological vasodilation, a non-flow-limiting stenosis at rest in conjunction with vasodilation, a flow-limiting stenosis, and total occlusion. Myocardial contrast echocardiography was performed after IV injection of the contrast agent NC 100100. Time-intensity curves were obtained off-line for the LAD risk area and the adjacent left circumflex (LCx) territory, and peak background-subtracted video intensity was determined. Fluorescent microspheres were injected at each intervention for determination of regional myocardial blood flow.

RESULTS

During non-flow-limiting stenosis, flow limiting stenosis and total occlusion, LAD/LCx ratios of peak myocardial videointensity and blood flow decreased proportionately. Both LAD/LCx ratios of video intensity and blood flow identified the non-flow-limiting and the flow-limiting stenoses as well as total occlusion of the LAD artery. A significant correlation between LAD/LCx video intensity and blood flow ratios was observed (r = 0.83, p < 0.0001).

CONCLUSIONS

The degree of blood flow mismatch between ischemic and normal myocardial regions during graded coronary stenoses can be estimated in the dog by quantitative assessment of myocardial perfusion produced by IV myocardial contrast echocardiography.

Nucleotide Metabolism in Salt-Stressed Zea mays L. Root Tips: I. Adenine and Uridine Nucleotides

Corn plants (Zea mays L. cv Pioneer 3906) were grown in a glass house on control and saline nutrient solutions, in winter and summer. There were two saline treatments, both with osmotic potential = -0.4 megapascal but with different Ca(2+)/Na(+) ratios: 0.03 and 0.73. Root tips and shoot meristems (culm tissue) of 26 day-old plants were analyzed for nucleotides to ascertain if there were correlations between nucleotide pool size and the reduced growth on saline cultures. Several other cell components also were determined. Plants grown in winter were only half as large as those grown in summer mainly because of the lower light intensity and lower temperature. But the relative yield reduction on salt treatment compared to the control was similar in winter and summer. The two different salt treatments caused similar yield reductions. Neither salt treatment affected nucleotide pools in culm tissue, with the possible exception of UDPG in winter. In the case of root tips, salt treatment had little or no effect on nucleotide pool sizes in winter when many already seemed near a critical minimum, but in summer it reduced several pools including ATP, total adenine nucleotide, UTP, total uridine nucleotide, and UDP-glucose. The reductions were greatest on the salt treatment with low Ca(2+)/Na(+). There was no simple correlation between the effects of salt stress on growth and on nucleotide pool size. The nucleotide pools of culm tissue indicated that in some respects this tissue was effectively insulated from the salt stress. Roots that were in direct contact with the saline solution indicated significant reductions in nucleotide pools only in the summer whereas growth was reduced both summer and winter. It is possible that the nucleotide concentrations of root cells in winter were already near a critical minimum so that nucleotide synthesis and growth were tightly linked. Significant reductions in nucleotide pools that would be expected to affect growth were more evident in summer when pools were larger and growth was more rapid. But even where ATP and total adenine nucleotides were reduced, the ratio of ATP:ADP and the adenylate energy charge remained unchanged indicating an active adenylate kinase that had access to most of the adenine nucleotide pools, and possible catabolism of excess AMP.

Interactive roles of progesterone, prostaglandins, and collagenase in the ovulatory mechanism of the ewe

Interrelationships between production of progesterone (P4), prostaglandin (PG) E2 and PGF2 alpha, and collagenase by periovulatory ovine follicles and their possible involvements in the ovulatory process were investigated. Follicles were isolated from ovaries at intervals (0 to 24 h) after the initiation of the preovulatory surge of luteinizing hormone (LH). Progesterone and PGs within follicles were determined by radioimmunoassay. Digestion of radioactive collagen during coincubation with tissue homogenates was used to assess the production of a bioactive follicular collagenase(s). Follicular accumulation of PGs and P4 increased at 12 and 16 h, respectively, after the onset of the surge of LH; PGE2 then decreased at 20 h. Collagenolytic activity of follicular tissue increased at 20 h and was maximal at 24 h (during the time of follicular rupture). An inhibitor of synthesis of P4 (isoxazol) or PGs (indomethacin) was injected into the follicular antrum at 8 h. Isoxazol did not prevent the initial rise in PGs, but inhibited synthesis of PGF2 alpha at 16 h and therafter. Isoxazol negated the decline in PGE2 and increase in collagenolysis. Indomethacin did not influence synthesis of P4; however, it suppressed collagenolytic activity of follicular tissue. Ovaries with treated follicles were left in situ and observed for an ovulation point at 30 h. Isoxazol or indomethacin was a potent inhibitor of ovulation. The blockade of ovulation by isoxazol was reversed by systemic administration of P4 or PGF2 alpha, but not by PGE2. Reversal of the blockade by indomethacin was accomplished with PGE2 or PGF2 alpha. Collagenolytic activity of follicular tissue was likewise restored by such treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Nucleotide sequence of the yeast cell division cycle start genes CDC28, CDC36, CDC37, and CDC39, and a structural analysis of the predicted products

The nucleotide sequences of the yeast cell division cycle start genes CDC36, CDC37, and CDC39 are presented. An open reading frame corresponding in size and mapped position to the mRNA for each gene was revealed. These sequences, as well as that of the CDC28 gene, were analyzed for the presence of consensus sequences postulated to be transcriptional or translational signals, or to be involved in mRNA processing. In addition, the predicted protein products of the four genes were subjected to a number of structural and statistical analyses including codon usage bias analysis, secondary structure analysis and hydropathicity analysis.

Cold potassium cardioplegia versus topical hypothermia and intermittent aortic occlusion for myocardial protection during coronary artery surgery: a randomized clinical study

The effect of two different myocardial preservation techniques on perioperative myocardial necrosis during coronary artery bypass surgery was assessed by serial myocardial creatine kinase determinations in 100 consecutive patients operated on by the same surgeon. Topical hypothermia with cold potassium cardioplegia was used randomly in 50 patients (group 1), and topical hypothermia with local interruption of the coronary circulation was used in the other 50 patients (group 2). Myocardial creatine kinase was measured by column chromatography every 6 hours for 36 hours after surgery. There was no significant difference between the two groups in terms of age, sex, functional class, extent of coronary artery disease, number of bypassed arteries, ejection fraction, or cardiopulmonary bypass time. Myocardial creatine kinase release (mean +/- standard error of the mean) was 193 +/- 33 IU/L X hours in group 1 patients operated on with cardioplegia and 210 +/- 31 IU/L X hours in group 2 patients operated on with topical hypothermia (p greater than 0.5). Myocardial creatine kinase peaks were 9.2 +/- 1.9 IU/L and 10.0 +/- 1.6 IU/L, respectively (p greater than 0.5). Perioperative myocardial infarction, as defined by serum enzyme activity and electrocardiographic criteria, occurred in 4 patients in group 1 and 3 patients in group 2. Thus, the addition of cardioplegia to topical hypothermia, although perhaps offering technical advantages, does not appear to improve myocardial protection over topical hypothermia with local interruption of the coronary circulation during coronary artery bypass surgery.

Regulation of CDC9, the Saccharomyces cerevisiae gene that encodes DNA ligase

We have cloned CDC9, the structural gene for Saccharomyces cerevisiae DNA ligase, and investigated its transcriptional regulation both as a function of cell cycle stage and after UV irradiation. The steady-state level of DNA ligase mRNA increases at least fourfold in late G1, after the completion of start but before S phase. This high level of CDC9 mRNA then decays with an apparent half-life of ca. 20 min and remains at a low basal level throughout the rest of the cell cycle. The accumulation of CDC9 mRNA in late G1 is dependent upon the completion of start but not the CDC7 and CDC8 functions. Exposure of cells to UV light elicits an eightfold increase in DNA ligase mRNA levels.

A relationship between the yeast cell cycle genes CDC4 and CDC36 and the ets sequence of oncogenic virus E26

We report here significant primary sequence homology among the predicted translational products of three genes: CDC4 , CDC36 and ets. CDC4 and CDC36 are Saccharomyces cerevisiae cell division cycle genes, while ets is a transformation-specific sequence of avian erythroblastosis virus E26. The deduced primary structures of the three gene products were compared by computer to a large data base of known and predicted protein sequences. The search revealed 22.0-25.5% identity over regions of 140-206 codons, respectively between the different pairwise combinations. For these particular sequences, these identity scores fall 3.4-4.0 standard deviations above the empirically-determined mean values of fortuitous similarity. S. cerevisiae calls require CDC36 and CDC4 in order to complete two early events in the cell cycle: execution of start ( CDC36 ) and spindle pole body separation ( CDC4 ). In virus E26, the ets sequence is linked in frame with delta gag and mybE in the tripartite structure 5'-delta gag- mybE -ets-3', comprising the E26 transforming oncogene. The homologies described here suggest that the biochemical functions or regulation of the CDC4 , CDC36 and ets products may be related.

Isolation and transcriptional characterization of three genes which function at start, the controlling event of the Saccharomyces cerevisiae cell division cycle: CDC36, CDC37, and CDC39

The genes CDC36, CDC37, and CDC39, thought to function in the cell division control process in Saccharomyces cerevisiae, were isolated from a recombinant plasmid library prepared by partial digestion of S. cerevisiae genomic DNA with Sau3A and insertion into the S. cerevisiae-Escherichia coli shuttle vector YRp7. In each case, S. cerevisiae DNA sequences were identified which could complement mutant alleles of the gene in question and which could direct integration of a plasmid at the chromosomal location known to correspond to that gene. Complementing DNA segments were subcloned to remove extraneous coding regions. The coding regions corresponding to CDC36, CDC37, and CDC39 were then identified and localized by R-loop analysis. The estimated sizes of the three coding regions were 615, 1,400, and 2,700 base pairs, respectively. Transcriptional orientation of the coding regions was established by using M13 vectors to prepare strand-specific probes followed by hybridization to blots of electrophoresed S. cerevisiae mRNA. The intracellular steady-state abundance of the mRNA species corresponding to the genes was estimated by comparing hybridization signals on RNA blots to that of a previously determined standard, the cell cycle start gene CDC28. The quantities calculated for the three mRNA species were low, ranging from 1.5 +/- 1 copies per haploid cell for the CDC36 mRNA to 3.1 +/- 1.5 and 4.6 +/- 2 copies per haploid cell for the CDC37 and CDC39 mRNAs, respectively. The CDC28 mRNA had been previously estimated at 7.0 +/- 2 copies per cell.

Predictors of perioperative myocardial infarction in coronary artery operation

Postoperative graft patency and thirteen perioperative variables were evaluated as potential risk factors for perioperative myocardial infarction (MI) in 102 consecutive patients undergoing coronary artery bypass grafting. Also, the incidence of perioperative MI and the amount of CK-MB released in the postoperative period were compared in three groups of patients selected according to the myocardial preservation technique employed: (1) topical hypothermia with and (2) without aortic cross-clamping and (3) cardioplegia. A perioperative MI as detected by electrocardiogram, enzymes, and myocardial scintigraphy with technetium 99 developed in 15 patients. Most important predictors of perioperative MI were found to be (1) left main and triple-vessel coronary artery disease, (2) a left ventricular end-diastolic pressure greater than or equal to 15 mm Hg, (3) a decreased ejection fraction (p < 0.05), and (4) cardiopulmonary bypass time > 120 minutes (p < 0.01). The incidence of perioperative MI was 50% in patients with three or more risk factors and 7% in those with less than three risk factors (p < 0.001). Graft patency was similar in patients with or without perioperative MI. Differing myocardial preservation techniques did not influence CK-MB release or the incidence of perioperative MI. Thus, the severity of ischemic heart disease and the length of the cardiopulmonary bypass time were important predictors of perioperative MI while graft patency and myocardial preservation technique did not appear to be related to its incidence in this study.