Category: Nevin Manimala

R I Med J (2013). 2024 Nov 1;107(11):10-13.

ABSTRACT

Functional neurological disorder (FND) is a common diagnosis of varied neuropsychiatric symptoms presenting to pediatric healthcare settings, including primary, urgent and subspecialty care. A key diagnostic shift appearing in the DSM-V is that FND is no longer a diagnosis of exclusion; rather, a rule-in diagnosis based on suggestive elements of symptom presentation. This article reviews diagnostic criteria, clarifying features, risks, and prognostic factors. This is the first in a series of six articles on FND and will introduce an FND case that will be examined in each subsequent article in the context of their more specific subject matter.

PMID:39467190

AORN J. 2024 Nov;120(5):e1-e9. doi: 10.1002/aorn.14236.

ABSTRACT

The use of a surgical safety checklist can help prevent sentinel events; however, a lack of adherence to the checklist can result in inadequate preoperative patient readiness and negative outcomes. The purpose of this quality improvement project was to address preoperative concerns that prevent patient readiness in a military hospital. To change practice, the project involved the use of an evidence-based practice model and Kurt Lewin’s change theory. The primary investigator provided an educational initiative on the required checklist for perioperative personnel and collected data on key elements (ie, consent completion, laboratory test results, antibiotic availability, checklist completion) for 30 days after the initiative. Consent completion rates were 100% both before and after the intervention. Statistical analysis (chi-square [χ²]) showed significant improvement for the remaining three elements. The results were the most significant for laboratory test results (χ² ₁ = 33.496, P < .00001).

PMID:39467188 | DOI:10.1002/aorn.14236

Am J Manag Care. 2024 Oct;30(10):504-509. doi: 10.37765/ajmc.2024.89619.

ABSTRACT

OBJECTIVE: To describe the results of a program developed to manage institutional postacute care (IPAC) (postacute skilled nursing, inpatient rehabilitation facility, and long-term acute care) in a CMS Bundled Payments for Care Improvement (BPCI) project for coronary artery bypass graft (CABG) surgery.

STUDY DESIGN: We compared pre- and postutilization patterns during a 3-year period by evaluating risk-adjusted national, state, and other BPCI participant comparisons using a difference-in-differences (DID) analysis in a large urban community tertiary center with a CABG surgery program. Included in the analysis were all Medicare patients receiving CABG surgery at the institution (n = 504), across the nation (n = 213,423), and at other BPCI institutions (n = 4939).

METHODS: The intervention included (1) use of a standardized tool for evaluation and prognostication of patient placement, (2) programmatic changes to manage patient functional recovery, and (3) patient and family engagement in postacute placement and functional recovery plan.

RESULTS: Physical therapist/occupational therapist time with patients who had undergone CABG surgery increased by more than 179% between the pre- and postintervention periods. This was associated with a 41.2% and 51.6% decline in IPAC use at the institution on an observed basis and adjusted basis, respectively. DID comparison demonstrated a 14.40% (95% CI, -19.30% to -9.60%) greater reduction at the target hospital than at other participating BPCI hospitals.

CONCLUSIONS: A strong association exists between a focused patient functional recovery program and IPAC use reduction after CABG surgery. Using a structured approach to clinical analytics and hypothesis testing of redesign efforts when managing postacute care populations removes waste from care delivery.

PMID:39467180 | DOI:10.37765/ajmc.2024.89619

Am J Manag Care. 2024 Oct;30(10):494-499. doi: 10.37765/ajmc.2024.89618.

ABSTRACT

OBJECTIVE: Prior authorization is used to ensure providers treat patients with medically accepted treatments. Our objective was to evaluate prior authorization decisions in cancer care by race/ethnicity for commercially insured patients.

STUDY DESIGN: Retrospective study of 18,041 patients diagnosed with cancer between January 1, 2017, and April 1, 2020.

METHODS: Using commercial longitudinal data from a large national insurer, we described the racial and ethnic composition in terms of prior authorization process outcomes for individuals diagnosed with cancer. We then used linear regression models to evaluate whether disparities by race or ethnicity emerged in prior authorization process outcomes.

RESULTS: The self-identified composition of the sample was 85% White, 3% Asian, 10% Black, and 1% Hispanic; 64% were female, and the mean age was 53 years. The average prior authorization denial rate was 10%, and the denial rate specifically due to no medical necessity was 5%. Hispanic patients had the highest prior authorization denial rate (12%), and Black patients had the lowest prior authorization denial rate (8%). Regressions results did not identify racial or ethnic disparities in prior authorization outcomes for Black and Hispanic patients compared with White patients. We observed that Asian patients had lower rates of prior authorization denials compared with White patients.

CONCLUSIONS: We observed no differences in the prior authorization process for Black and Hispanic patients with cancer and higher rates of prior authorization approvals for Asian patients compared with White patients.

PMID:39467179 | DOI:10.37765/ajmc.2024.89618

Am J Manag Care. 2024 Oct;30(10):482-487. doi: 10.37765/ajmc.2024.89617.

ABSTRACT

OBJECTIVES: To assess the congruence between patient assignment and established patients as well as their association with Healthcare Effectiveness Data and Information Set (HEDIS) quality performance.

STUDY DESIGN: A retrospective cross-sectional analysis from January 2020 to February 2022.

METHODS: The study setting is a fully integrated health care delivery system in Phoenix, Arizona. The study population includes Medicaid patients who received primary care services or were assigned to a primary care physician (PCP) at the study setting by 5 Medicaid managed care organizations (MCOs). We identified 4 possible relationships between the established patients (2 primary care visits) and the assigned patients (assigned by the MCO to the study setting): true-positive, false-positive, true-negative, and false-negative classifications. Precision and recall measures were used to assess congruence (or incongruence). Outcome measures were HEDIS quality metrics.

RESULTS: A total of 100,030 Medicaid enrollees (adults and children) were established and/or assigned to the study setting from 5 separate payers. Only 15% were congruently established and assigned to the physician (true-positive). The overall precision was 21%, and the overall recall was 37%. The HEDIS quality performance was significantly higher (P < .05) for established patients for 5 of 6 metrics compared with patients who were not established.

CONCLUSIONS: The vast majority of assigned patients were not treated by the assigned PCP, yet better patient outcomes were seen with an established patient. As the health system rapidly adopts value-based payments, more rigorous methodologies are essential to identify physician-patient relationships.

PMID:39467178 | DOI:10.37765/ajmc.2024.89617

Elife. 2024 Oct 28;13:e78738. doi: 10.7554/eLife.78738.

ABSTRACT

FOXP3⁺ regulatory T cells (Treg cells) are key for immune homeostasis. Here, we reveal that nuclear receptor corepressor 1 (NCOR1) controls naïve and effector Treg cell states. Upon NCOR1 deletion in T cells, effector Treg cell frequencies were elevated in mice and in in vitro-generated human Treg cells. NCOR1-deficient Treg cells failed to protect mice from severe weight loss and intestinal inflammation associated with CD4⁺ T cell transfer colitis, indicating impaired suppressive function. NCOR1 controls the transcriptional integrity of Treg cells, since effector gene signatures were already upregulated in naïve NCOR1-deficient Treg cells while effector NCOR1-deficient Treg cells failed to repress genes associated with naïve Treg cells. Moreover, genes related to cholesterol homeostasis including targets of liver X receptor (LXR) were dysregulated in NCOR1-deficient Treg cells. However, genetic ablation of LXRβ in T cells did not revert the effects of NCOR1 deficiency, indicating that NCOR1 controls naïve and effector Treg cell subset composition independent from its ability to repress LXRβ-induced gene expression. Thus, our study reveals that NCOR1 maintains naïve and effector Treg cell states via regulating their transcriptional integrity. We also reveal a critical role for this epigenetic regulator in supporting the suppressive functions of Treg cells in vivo.

PMID:39466314 | DOI:10.7554/eLife.78738

J Med Internet Res. 2024 Oct 28;26:e59791. doi: 10.2196/59791.

ABSTRACT

BACKGROUND: Health information technology (health IT) has revolutionized health care in the United States through interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and electronic patient access to health information.

OBJECTIVE: This study aims to examine progress in health IT adoption and its alignment with the Office of the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP’s) mission to enhance health care through data access and exchange.

METHODS: This study leverages data on end users of health IT to capture trends in engagement in interoperable clinical care data exchange (ability to find, send, receive, and integrate information from outside organizations), e-prescribing, electronic public health reporting, and capabilities to enable patient access to electronic health information. Data were primarily sourced from the American Hospital Association Annual Survey IT Supplement (2008 to 2023), Surescripts e-prescribing use data (2008 to 2023), the National Cancer Institute’s Health Information National Trends Survey (2014 to 2022), and the National Center for Health Statistics’ National Electronic Health Records Survey (2009 to 2023).

RESULTS: Since 2009, there has been a 10-fold increase in electronic health record (EHR) use among hospitals and a 5-fold increase among physicians. This enabled the interoperable exchange of electronic health information, e- prescribing, electronic public health data exchange, and the means for patients and their caregivers to access crucial personal health information digitally. As of 2023, 70% of hospitals are interoperable, with many providers integrated within EHR systems. Nearly all pharmacies and 92% of prescribers possess e-prescribing capabilities, an 85%-point increase since 2008. In 2013, 40% of hospitals and one-third of physicians allowed patients to view their online medical records. Patient access has improved, with 97% of hospitals and 65% of physicians possessing EHRs that enable patients to access their online medical records. As of 2022, three-fourths of individuals report being offered access to patient portals, and over half (57%) report engaging with their health information through their patient portal. Electronic public health reporting has also seen an increase, with most hospitals and physicians actively engaged in key reporting types.

CONCLUSIONS: Federal incentives have contributed to the widespread adoption of EHRs and broad digitization in health care, while efforts to promote interoperability have encouraged collaboration across health care entities. As a result, interoperable clinical care data exchange, e-prescribing, electronic public health reporting, and patient access to health information have grown substantially over the past quarter century and have been shown to improve health care outcomes. However, interoperability hurdles, usability issues, data security concerns, and inequitable patient access persist. Addressing these issues will require collaborative efforts among stakeholders to promote data standardization, implement governance structures, and establish robust health information exchange networks.

PMID:39466303 | DOI:10.2196/59791

J Pediatr Orthop. 2024 Nov-Dec 01;44(10):586-591. doi: 10.1097/BPO.0000000000002806. Epub 2024 Oct 9.

ABSTRACT

BACKGROUND: Magnetic controlled growth rods (MCGR) are the most common type of implant used for operative treatment of patients with early-onset scoliosis (EOS). Rods can have either a 7-cm actuator, allowing 2.8 cm of potential expansion, or a 9-cm actuator which allows 4.8 cm potential expansion. We hypothesized that the rate of unplanned return to the operating room (UPROR) will be increased when the 9-cm actuator is implanted in smaller patients. In addition, we aimed to identify a cutoff for spine length between planned upper and lower instrumented MCGR levels that best differentiated between patients having a high versus low risk of UPROR.

METHODS: We identified 167 patients from a prospectively collected registry of EOS patients who began MCGR treatment at 9 years of age or younger, with greater than 1 year of follow-up, and had adequate radiographs. Demographic, clinical, and surgical characteristics were analyzed for 7-cm and 9-cm actuator patients. Chi-square tests and Student t tests were used to test for differences between the 2 actuator rod groups. A predictive model for UPROR within 2 years was developed based on variables significantly predictive of UPROR.

RESULTS: The average follow-up was 2.6 years (range, 1 to 5 y) in both the 7 cm (n=74) and 9 cm (n=93) groups. Twenty-five complications in 14 patients led to UPROR within 2 years of MCGR insertion, 8% incidence (95% CI, 4%-13%). Device-related complications (n=15) were the most common reason for UPROR, followed by wound complications (n=4), pain-related complications (n=3), junctional kyphosis (n=2), and incarcerated umbilical hernia (n=1). After adjusting for age, spine height, number of spine anchors, sex, and diagnosis, there was no significant difference in UPROR rates between groups. Fewer proximal anchors, smaller T1-S1 height, and more caudal mid-point of primary coronal curvature were significantly associated with UPROR in the predictive model.

CONCLUSION: MCGR actuator size is not a significant factor in predicted UPROR. Smaller height, fewer anchors, and caudal apex increased UPROR risk.

LEVEL OF EVIDENCE: This is a retrospective, multicenter comparative cohort study (Level III therapeutic).

PMID:39466293 | DOI:10.1097/BPO.0000000000002806

J Pediatr Orthop. 2024 Nov-Dec 01;44(10):e871-e875. doi: 10.1097/BPO.0000000000002793. Epub 2024 Oct 9.

ABSTRACT

BACKGROUND: Supracondylar humerus (SCH) fractures are common and present with associated nerve injuries in 11% to 42% of cases. Historically, SCH fractures with neurological compromise warranted urgent surgical intervention. A recent study showed that treatment delay is acceptable in patients with isolated anterior interosseous nerve (AIN) injury. Though indications for urgent treatment are relaxing, no studies have evaluated the need for urgent surgical treatment for other nerve injuries associated with SCH fractures. The aim of this study was to determine if the timing of surgical intervention is related to the timing of neurological recovery in SCH fractures associated with any nerve injury.

METHODS: A retrospective review of 64 patients with surgically managed SCH fractures and concomitant neurological deficit on presentation was conducted at a single level 1 pediatric trauma hospital from 1997 to 2022. The relationship between the time to surgical intervention and the time to partial and complete nerve recovery was analyzed using linear regression.

RESULTS: Sixty-four patients with an average age of 6.9±2.0 years and an average time to surgery of 9.8±5.6 hours were analyzed. Sixty-two patients (97%) were followed to partial neurological recovery and 36 (56%) were followed to full neurological recovery. Neurological deficit included median [n=41 (64%)], radial [n=22 (34%)], and ulnar [n=15 (23%)]. Ten patients (16%) had isolated AIN injury. The average time to partial neurological recovery was 20±23 days and the time to full recovery was 93±83 days. There was a statistically significant relationship between time to partial neurological recovery and time to surgical intervention (P=0.02). There was no relationship between time to full neurological recovery and time to surgery (P=0.8).

CONCLUSION: Earlier time to surgical intervention in pediatric SCH fractures with isolated nerve injury was associated with earlier partial recovery but not full neurological recovery. Prioritizing urgent surgery in these patients did not improve their ultimate neurological recovery.

LEVEL OF EVIDENCE: Therapeutic level III.

PMID:39466291 | DOI:10.1097/BPO.0000000000002793

JAMA Neurol. 2024 Oct 28. doi: 10.1001/jamaneurol.2024.3659. Online ahead of print.

ABSTRACT

IMPORTANCE: Clinical trials have suggested that prehospital management in a mobile stroke unit (MSU) improves functional outcomes in patients with acute ischemic stroke who are potentially eligible for intravenous thrombolysis, but there is a paucity of real-world evidence from routine clinical practice on this topic.

OBJECTIVE: To determine the association between prehospital management in an MSU vs standard emergency medical services (EMS) management and the level of global disability at hospital discharge.

DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective, observational, cohort study that included consecutive patients with a final diagnosis of ischemic stroke who received either prehospital management in an MSU or standard EMS management between August 1, 2018, and January 31, 2023. Follow-up ended at hospital discharge. The primary analytic cohort included those who were potentially eligible for IV thrombolysis. A separate, overlapping cohort including all patients regardless of diagnosis was also analyzed. Patient data were obtained from the American Heart Association’s Get With The Guidelines-Stroke (GWTG-Stroke) Program, a nationwide, multicenter quality assurance registry. This analysis was completed in May 2024.

EXPOSURE: Prehospital management in an MSU (vs standard EMS management).

MAIN OUTCOMES AND MEASURES: The primary efficacy end point was the utility-weighted modified Rankin Scale (UW-mRS) score. The secondary efficacy end point was independent ambulation status. The coprimary safety end points were symptomatic intracranial hemorrhage (sICH) and in-hospital mortality.

RESULTS: Of 19 433 patients (median [IQR] age, 73 [62-83] years; 9867 female [50.8%]) treated at 106 hospitals, 1237 (6.4%) received prehospital management in an MSU. Prehospital management in an MSU was associated with a better score on the UW-mRS at discharge (adjusted mean difference, 0.03; 95% CI, 0.01-0.05) and a higher likelihood of independent ambulation at discharge (53.3% [468 of 878 patients] vs 48.3% [5868 of 12 148 patients]; adjusted risk ratio [aRR], 1.08; 95% CI, 1.03-1.13). There was no statistically significant difference in sICH (5.2% [57 of 1094] vs 4.2% [545 of 13 014]; aRR, 1.30; 95% CI, 0.94-1.75]) or in-hospital mortality (5.7% [70 of 1237] vs 6.2% [1121 of 18 196]; aRR, 1.03; 95% CI, 0.78-1.27) between the 2 groups.

CONCLUSIONS AND RELEVANCE: Among patients with acute ischemic stroke potentially eligible for intravenous thrombolysis, prehospital management in an MSU compared with standard EMS management was associated with a significantly lower level of global disability at hospital discharge. These findings support policy efforts to expand access to prehospital MSU management.

PMID:39466286 | DOI:10.1001/jamaneurol.2024.3659