scholarly journals Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study

BMJ ◽  
2021 ◽  
pp. n1747
Author(s):  
Ben J Marafino ◽  
Gabriel J Escobar ◽  
Michael T Baiocchi ◽  
Vincent X Liu ◽  
Colleen C Plimier ◽  
...  
Keyword(s):  
Observational Study ◽  
Confidence Interval ◽  
Health System ◽  
Hospital Discharge ◽  
Regression Discontinuity ◽  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Post Discharge ◽  
Medium Risk ◽  
Predicted Risk

Abstract Objectives To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. Design Observational study. Setting 21 hospitals operated by Kaiser Permanente Northern California. Participants 1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge. Intervention Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data. Main outcome measures Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge. Results Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval −2.5%, −3.1% to −2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction −2.7%, −3.2% to −2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (−0.7% −1.4% to −0.0%) was significant and suggested benefit in this subgroup of patients. Conclusions In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting.

Abstract P4: Does the Expected Reduction in Restenosis from Drug-Eluting Stents Predict Actual Use? An Assessment of Treatment-Risk Paradox Using the C-Statistic

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Robert W Yeh ◽  
Sharon-Lise T Normand ◽  
Laura Mauri ◽  
Robert E Wolf ◽  
David J Cohen ◽  
...  
Keyword(s):  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Target Vessel Revascularization ◽  
Treatment Risk ◽  
C Statistic ◽  
Actual Use ◽  
Drug Eluting ◽  
Poor Outcomes ◽  
The Relationship ◽  
Predicted Risk

Background: Beneficial treatments are often least prescribed to patients at highest risk for poor outcomes. Quantitative assessments of “treatment-risk paradox” have relied on comparisons across risk strata defined by single variables or arbitrary categories of predicted risk. We examined whether DES were preferentially used in patients at highest risk for target vessel revascularization (TVR) after PCI using a novel quantitative method. Methods: We used a validated model to predict TVR at 1 year for all PCI hospitalizations in MA between 10/04 and 9/07. For each patient, we calculated predicted absolute risk reduction (ARR) in TVR assuming treatment with DES (vs. BMS). Using logistic regression, we assessed the association between predicted ARR and observed stent treatment for the entire population and each of 21 hospitals, and calculated the c-statistics for each as a measure of the extent to which predicted benefit discriminated observed DES use. Results: A total of 21933 (80.9%) PCIs with DES and 5174 (19.1%) PCIs with BMS were included. The predicted ARR in TVR associated with PCI ranged from 1.2% to 15.9%. Overall, predicted benefit from DES poorly discriminated receipt of DES (c-statistic 0.545, 95% CI 0.537 - 0.554). Of 22 hospitals, 15 had c-statistics with CIs that crossed 0.5, implying no relationship between predicted benefit of DES and stent selection. (Figure) Conclusions: We observed a minimal relationship between predicted benefit from DES and actual DES use. The c-statistic and ROC curve may be a useful metrics to assess the relationship between predicted benefit and observed receipt of therapies, and identify potential areas for quality improvement.

Use of pre-operative calcium and vitamin D supplementation to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy: a systematic review

2021 ◽  
pp. 1-6
Author(s):  
A S Khatiwada ◽  
A S Harris
Keyword(s):  
Systematic Review ◽  
Vitamin D ◽  
Clinical Trials ◽  
Total Thyroidectomy ◽  
Risk Reduction ◽  
Operative Treatment ◽  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Vitamin D Supplementation ◽  
Absolute Reduction

Abstract Objective This systematic review aimed to establish the evidence behind the use of pre-operative calcium, vitamin D or both calcium and vitamin D to prevent post-operative hypocalcaemia in patients undergoing thyroidectomy. Method This review included prospective clinical trials on adult human patients that were published in English and which studied the effects of pre-operative supplementation with calcium, vitamin D or both calcium and vitamin D on the rate of post-operative hypocalcaemia following total thyroidectomy. Results Seven out of the nine trials included reported statistically significantly reduced rates of post-operative laboratory hypocalcaemia (absolute risk reduction, 13–59 per cent) and symptomatic hypocalcaemia (absolute reduction, 11–40 per cent) following pre-operative supplementation. Conclusion Pre-operative treatment with calcium, vitamin D or both calcium and vitamin D reduces the risk of post-operative hypocalcaemia and should be considered in patients undergoing total thyroidectomy.

scholarly journals OP0240 EPIDEMIOLOGY, PREDICTORS OF MORTALITY AND ROLE OF PROPHYLAXIS FOR PNEUMOCYSTITIS JIROVECI PNEUMONIA AMONG RHEUMATIC PATIENTS: A TERRITORY-WIDE STUDY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 147-147
Author(s):  
C. W. S. Chan ◽  
H. Y. Chung ◽  
W. Y. Yeung ◽  
C. S. Lau ◽  
P. H. LI
Keyword(s):  
Lupus Erythematosus ◽  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Number Needed To Treat ◽  
Healthcare Database ◽  
Pneumocystis Jiroveci ◽  
Predictors Of Mortality ◽  
Prednisolone Dose ◽  
Rheumatic Patients

Background:Pneumocystis jiroveci pneumonia (PJP) is an opportunistic infection affecting immunocompromised individuals. Due to its high mortality, PJP prophylaxis is commonly recommended for many immunocompromising conditions. However, evidence regarding the burden and role of prophylaxis in PJP among rheumatic patients remains limited. There is lack of consensus for when and for whom to initiate prophylaxis. Delineating the epidemiology, predictors of mortality and efficacy of prophylaxis in PJP among rheumatic patients is urgently needed.Objectives:To delineate the epidemiology of PJP, identify predictors of mortality and evaluate the usefulness of prophylaxis in rheumatology patients.Methods:We performed a big-data cohort study based on the territory-wide healthcare database of the Hong Kong Hospital Authority. All patients with a diagnosis of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), immune-mediated myositis (IMM), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), or spondyloarthritis (SpA) between 2015-2019 were included. PJP were identified based on physician diagnosis and/or positive microbiological results from deep respiratory tract specimens. Prophylaxis was defined as prescription of a prophylactic dose of co-trimoxazole for at least 2 weeks and/or inhaled pentamidine. Prevalence of PJP, prophylaxis and mortality among rheumatic patients were calculated. Demographics, blood parameters and immunosuppressants use was also collected for multivariate analysis. Number needed to treat (NNT) analysis was performed based on absolute risk reduction of PJP in patients with and without prior PJP prophylaxis.Results:A total of 21,587 unique rheumatic patients were analysed (54% RA, 25% SLE, 13% SpA, 5% IMM, 2% AAV and 1% SSc). Between 2015-2019, 1141 (5.3%) patients were prescribed PJP prophylaxis and 48 (0.2%) developed PJP. None of those patients who developed PJP had received prophylaxis prior to infection. The risk of PJP was highest among SSc (1.8%), AAV (1.4%) and IMM (0.7%) patients, with NNT of SSc 36, AAV 48 and IMM 114. Within these disease entities, the majority of PJP occurred at prednisolone dose of 15mg/day (P15) or above (100% in SSc and IIM, 66.7% in AAV). Overall, PJP was associated with a mortality-rate of 39.6%. Glucocorticoid dose (daily prednisolone dose equivalent 29.1±23.5mg vs 11.4±7.2mg, P<0.01) and lymphopenia (0.44x109/L vs 0.90x109/L, P= 0.04) at PJP diagnosis were associated with PJP mortality in rheumatic patients.Conclusion:PJP is an uncommon but important infection in rheumatic patients associated with significant mortality. PJP prophylaxis is effective and should be considered in patients with SSc, AAV and IMM, especially in those receiving a steroid dose above P15.Disclosure of Interests:None declared

scholarly journals Multidisciplinary Unit Improves Pregnancy Outcomes in Women with Rheumatic Diseases and Hereditary Thrombophilias: An Observational Study

2021 ◽  
Vol 10 (7) ◽  
pp. 1487
Author(s):  
Isabel Añón-Oñate ◽  
Rafael Cáliz-Cáliz ◽  
Carmen Rosa-Garrido ◽  
María José Pérez-Galán ◽  
Susana Quirosa-Flores ◽  
...  
Keyword(s):  
High Risk ◽  
Observational Study ◽  
Medical Care ◽  
Pregnant Women ◽  
Rheumatic Diseases ◽  
Absolute Risk ◽  
University Hospital ◽  
Obstetric Outcomes ◽  
Number Needed To Treat ◽  
Foetal Death

Rheumatic diseases (RD) and hereditary thrombophilias (HT) can be associated with high-risk pregnancies. This study describes obstetric outcomes after receiving medical care at a multidisciplinary consultation (MC) and compares adverse neonatal outcomes (ANOs) before and after medical care at an MC. This study is a retrospective observational study among pregnant women with RD and HT treated at an MC of a university hospital (southern Spain) from 2012 to 2018. Absolute risk reduction (ARR) and number needed to treat (NNT) were calculated. A total of 198 pregnancies were registered in 143 women (112 with RD, 31 with HT), with 191 (96.5%) pregnancies without ANOs and seven (3.5%) pregnancies with some ANOs (five miscarriages and two foetal deaths). Results previous to the MC showed 60.8% of women had more than one miscarriage, with 4.2% experiencing foetal death. MC reduced the ANO rate by AAR = 60.1% (95%CI: 51.6−68.7%). The NNT to avoid one miscarriage was 1.74 (95%CI: 1.5–2.1) and to avoid one foetal death NNT = 35.75 (95CI%: 15.2–90.9). A total of 84.8% of newborns and 93.2% of women did not experience any complication. As a conclusion, the follow-up of RD or HT pregnant women in the MC drastically reduced the risk of ANOs in this population with a previous high risk.

scholarly journals Amblyopia screening effectiveness at 3–4 years old: a cohort study

2021 ◽  
Vol 6 (1) ◽  
pp. e000599
Author(s):  
Sandra Guimaraes ◽  
Andreia Soares ◽  
Cristina Freitas ◽  
Pedro Barros ◽  
Ricardo Dourado Leite ◽  
...  
Keyword(s):  
Risk Reduction ◽  
Treatment Effectiveness ◽  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Number Needed To Screen ◽  
History Of ◽  
Disease Study ◽  
New Diagnosis ◽  
Screening Effectiveness ◽  
Timely Referral

ObjectiveTo study the effectiveness of amblyopia screening at ages 3–4.Methods and AnalysisFrom a population with no previous screening, a cohort of 2300 children with 3–4 years old attending school (91% of children this age attend school in Portugal), were submitted to a complete ophthalmological evaluation. Amblyopia was diagnosed, treated and followed. Amblyopia prevalence, treatment effectiveness, absolute risk reduction (ARR), number needed to screen (NNS) and relative risk reduction (RRR) were estimated.ResultsPast/present history of amblyopia was higher than 3.1%–4.2%, depending on amblyopia definition normatives. Screening at age 3–4, had estimated ARR=2.09% (95% CI 1.50% to 2.68%) with a reduced risk of amblyopia in adulthood of 87% (RRR). NNS was 47.8 (95% CI 37.3 to 66.7). Treatment effectiveness of new diagnosis was 88% (83% if we include children already followed). 91% of new amblyopia diagnoses were refractive (of which 100% surpassed amblyopia Multi-Ethnic Pediatric Eye Disease Study criteria after treatment), while most strabismic amblyopias were already treated or undertreatment. Only 30% of children with refractive amblyopia risk factors that were not followed by an ophthalmologist, ended up having amblyopia at age 3–4. Eye patch was needed equally in new-diagnosis versus treated-earlier refractive amblyopia.ConclusionsScreening amblyopia in a whole-population setting at age 3–4 is highly effective. For each 48 children screened at age 3–4, one amblyopia is estimated to be prevented in the future (NNS). Screening earlier may lead to overdiagnosis and overtreatments: Treating all new diagnosis before age 3–4 would have a maximal difference in ARR of 0.3%, with the possible burden of as much as 70% children being unnecessary treated before age 3–4.Involving primary care, with policies for timely referral of suspicious/high-risk preverbal children, plus whole screening at age 3–4 seems a rational/effective way of controlling amblyopia.

scholarly journals Validity of the LACE index for identifying frequent early readmissions after hospital discharge in children

2021 ◽  
Author(s):  
Thang S Han ◽  
David Fluck ◽  
Christopher H Fry
Keyword(s):  
At Risk ◽  
Confidence Interval ◽  
Hospital Discharge ◽  
Odds Ratio ◽  
Hospital Readmissions ◽  
Index Score ◽  
Children At Risk ◽  
Increased Risk ◽  
Scoring Tool ◽  
Event Rates

AbstractThe LACE index scoring tool has been designed to predict hospital readmissions in adults. We aimed to evaluate the ability of the LACE index to identify children at risk of frequent readmissions. We analysed data from alive-discharge episodes (1 April 2017 to 31 March 2019) for 6546 males and 5875 females from birth to 18 years. The LACE index predicted frequent all-cause readmissions within 28 days of hospital discharge with high accuracy: the area under the curve = 86.9% (95% confidence interval = 84.3–89.5%, p < 0.001). Two-graph receiver operating characteristic curve analysis revealed the LACE index cutoff to be 4.3, where sensitivity equals specificity, to predict frequent readmissions. Compared with those with a LACE index score = 0–4 (event rates, 0.3%), those with a score > 4 (event rates, 3.7%) were at increased risk of frequent readmissions: age- and sex-adjusted odds ratio = 12.4 (95% confidence interval = 8.0–19.2, p < 0.001) and death within 30 days of discharge: OR = 5.0 (95% CI = 1.5–16.7). The ORs for frequent readmissions were between 6 and 14 for children of different age categories (neonate, infant, young child and adolescent), except for patients in the child category (6–12 years) where odds ratio was 2.8.Conclusion: The LACE index can be used in healthcare services to identify children at risk of frequent readmissions. Focus should be directed at individuals with a LACE index score above 4 to help reduce risk of readmissions. What is Known:• The LACE index scoring tool has been widely used to predict hospital readmissions in adults. What is New:• Compared with children with a LACE index score of 0–4 (event rates, 0.3%), those with a score > 4 are at increased risk of frequent readmissions by 14-fold.• The cutoff of a LACE index of 4 may be a useful level to identify children at increased risk of frequent readmissions.

Innovative Technique to Reduce Incidence of Frey's Syndrome after Parotid Surgery

2011 ◽  
Vol 77 (3) ◽  
pp. 351-354 ◽  
Author(s):  
Neeraj Singh ◽  
Monica Kohli ◽  
Harjeet Kohli
Keyword(s):  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Control Group ◽  
Regenerated Cellulose ◽  
P Value ◽  
Frey’S Syndrome ◽  
Exact Test ◽  
Parotid Surgery ◽  
Frey's Syndrome ◽  
Aberrant Regeneration

Frey's syndrome was first described by Lucia Frey, a Polish neurologist in 1923. It is well accepted that it involves injury to the branches of the auriculotemporal nerve with subsequent aberrant regeneration. Due to this abnormal communication, the skin glands and vessels are always stimulated at the same time as eating and mastication, which results in symptoms such as flushing and sweating. The incidence of Frey's syndrome in the literature has been variously described from 6 to 96 per cent. We analyzed the chart of 18 patients who had parotidectomy from March 2002 to December 2009. All procedures were performed by a single surgeon at the same facility. A total of 16 superficial and three total parotidectomies were done; one patient had bilateral parotidectomy. Oxidized regenerated cellulose (Interceed) was used after 10 surgeries (study group) and no adjuvant was used after nine surgeries (control group). All of the surgeries were done using similar technique. All the patients were followed-up with for a period of about 6 months postoperatively. The absolute risk reduction associated with the placement of an Interceed was 11 per cent. The small number of cases (n = 19) and an empty cell limits statistical analysis (a Fisher's exact test revealed a P value of 0.44). Clearly the low number of procedures restricted the power to test these differences. The development of Frey's syndrome is a very disabling but under-reported complication. The placement of a temporary barrier like Interceed may help in the prevention of Frey's syndrome without increasing any complications.

Estimated effect of secondary screening for hip dislocation

2020 ◽  
Vol 105 (12) ◽  
pp. 1175-1179
Author(s):  
Daniel Wenger ◽  
Carl Johan Tiderius ◽  
Henrik Düppe
Keyword(s):  
Birth Cohort ◽  
Absolute Risk ◽  
Hip Dislocation ◽  
Absolute Risk Reduction ◽  
Age At Diagnosis ◽  
Hip Instability ◽  
Primary Screening ◽  
Surrogate Variable ◽  
Secondary Screening ◽  
Child Healthcare

ObjectivesTo quantify the effect of secondary screening for hip dislocations.DesignRetrospective analysis of hospital files from participants in a prospectively collected nationwide registry.SettingChild healthcare centres and orthopaedic departments in Sweden.ParticipantsOf 126 children with hip dislocation diagnosed later than 14 days age in the 2000–2009 birth cohort, 101 had complete data and were included in the study.InterventionsThe entire birth cohort was subject to clinical screening for hip instability at 6–8 weeks, 6 months and 10–12 months age. Children diagnosed through this screening were compared with children presenting due to symptoms, which was used as a surrogate variable representing a situation without secondary screening.Main outcome measuresAge at diagnosis and disease severity of late presenting hip dislocations.ResultsChildren diagnosed through secondary screening were 11 months younger (median: 47 weeks) compared with those presenting with symptoms (p<0.001). Children diagnosed through secondary screening had 11% risk of having a high (severe) dislocation, compared with 38% for those diagnosed due to symptoms; absolute risk reduction 27% (95% CI: 9.7% to 45%), relative risk 0.28 (95% CI: 0.11 to 0.70). Children presenting due to symptoms had OR 5.1 (95% CI: 1.7 to 15) of having a high dislocation, and OR 11 (95% CI: 4.1 to 31) of presenting at age 1 year or older, compared with the secondary screening group. The secondary screening was able to identify half of the children (55%, 95% CI: 45% to 66%) not diagnosed through primary screening.ConclusionsSecondary screening at child healthcare centres may have substantially lowered the age at diagnosis in half of all children with late presenting hip dislocation not diagnosed through primary screening, with the risk of having a high dislocation decreased almost to one-quarter in such cases.

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