Time Required for Planned and Unplanned Episodes of Care in Septic and Aseptic Hip and Knee Revision Surgery

Background: Surgical reimbursement rates are established by the Centers for Medicare and Medicaid Services (CMS). Studies have indicated that revision hip (rTHA) and knee (rTKA) arthroplasties require significantly more work effort, but are reimbursed less than primary procedures. This study quantified planned and unplanned work performed for revision surgeries by the surgeon and/or the surgeon’s team during the episode of care “reimbursement window.” Quantification of time was performed separately for aseptic and septic (two-stage) revisions and compared to allowed reimbursement amounts. Methods: All unilateral rTHA and rTKA procedures performed over a 10-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. Results: Calculations demonstrated average per patient work for aseptic rTKA exceeded the reimbursable amount by 31 minutes. Calculated average minutes of work per patient required for aseptic rTHA fell within the number of minutes approved for reimbursement. Average per patient work for septic rTKA and rTHA exceeded the reimbursable amounts by 331 and 166 minutes, respectively, equating to 2.8 to 5.5 hours of uncompensated time. Conclusion: Revision hip and knee procedures are substantially more complex than primary procedures, with many surgeons referring patients to out-of-network care. Financially dis-incentivizing surgeons to care for these patients reduces patient access to care when high quality care is needed the most, especially infection cases susceptible to high sepsis and mortality rates. Study findings will be applied to advocacy efforts for appropriate legislative reform.

Nontuberculous Mycobacteria under Scrutiny in the Geneva Area (2015–2020)

<b><i>Background:</i></b> Nontuberculous mycobacteria (NTM) are increasingly identified in industrialized countries, and their role as pathogens is more frequently recognized. The relative prevalence of NTM strains shows an important geographical variability. Thus, establishing the local relative prevalence of NTM strains is relevant and useful for clinicians. <b><i>Methods:</i></b> Retrospective analysis (2015–2020) of a comprehensive database was conducted including all results of cultures for mycobacteria in a University Hospital (Geneva, Switzerland), covering a population of approximately 500,000 inhabitants. All NTM culture-positive patients were included in the analyses. Patients’ characteristics, NTM strains, and time to culture positivity were reported. <b><i>Results:</i></b> Among 38,065 samples analyzed during the study period, 411 were culture-positive for NTM, representing 236 strains, and 231 episodes of care which occurred in 222 patients. Patients in whom NTM were identified were predominantly female (55%), with a median age of 62 years, and a low BMI (median: 22.6 kg/m²). The <i>Mycobacterium avium</i> complex (MAC) was the most frequently identified group (37% of strains) followed by <i>Mycobacterium gordonae</i> (25%) and <i>Mycobacterium xenopi</i> (12%) among the slowly growing mycobacteria (SGM), while the <i>Mycobacterium chelonae/abscessus</i> group (11%) were the most frequently identified rapidly growing mycobacteria (RGM). Only 19% of all patients were treated, mostly for pulmonary infections: the MAC was the most frequently treated NTM (<i>n</i> = 19, 43% of cases in patients treated) followed by RGM (<i>n</i> = 15, 34%) and <i>M. xenopi</i> (<i>n</i> = 6, 14%). Among those treated, 23% were immunosuppressed, 12% had pulmonary comorbidities, and 5% systemic comorbidities. Cultures became positive after a median of 41 days (IQR: 23; 68) for SGM and 28 days (14; 35) for RGM. <b><i>Conclusions:</i></b> In Western Switzerland, <i>M. avium</i> and <i>M. gordonae</i> were the most prevalent NTM identified. Positive cultures for NTM led to a specific treatment in 19% of subjects. Patients with a positive culture for NTM were mostly female, with a median age of 62 years, a low BMI, and a low prevalence of immunosuppression or associated severe comorbidities.

Social Workers in Primary Care Increase Access to Palliative Care

Clinical trials show that palliative care improves patient experiences and reduces costs, and use of palliative care and hospice care have been increasing over the past three decades. In the Veterans Administration health care system (VA), Veterans may receive palliative care concurrently with other treatments. However, many barriers exist to the use of palliative care, such as patients’ misperceptions. Social workers in primary care teams may increase use of this valuable service by establishing trust between patient and care team, educating patients and caregivers, and coordinating services. Leveraging a national social-work-staffing program as a natural experiment, we evaluated the effect of hiring one or more social workers to the primary-care team on use of palliative or hospice care among Veterans with a recent hospital stay. Our data included 91,675 episodes of care between 2016 and 2018. 1.45 percent of episodes were followed by use of palliative care or hospice within 30 days. The addition of one or more social workers through the staffing program was associated with an increase of 0.53 percentage points (p&lt;0.001) in the probability of any palliative or hospice care, i.e., a more than 30% increase relative to the mean. Policy makers and health system leaders who seek to improve patient experience and reduce costs through increased access to palliative and hospice care could consider social work staffing as a policy tool to achieve those aims.

Demographic, Comorbidity, and Episode of Care Trends in Primary Hip Arthroplasty: 2008 to 2018

Background While previous studies have provided insight into time-trends in age and comorbidities of total hip arthroplasty (THA) patients, there is limited recent literature from within the past decade. The implication of these findings is relevant due to the projected THA volume increase and continued emphasis on healthcare system cost-containment policies. Therefore, the purpose of this study was to identify trends in THA patient demographics, comorbidities, and episode of care from 2008 to 2018. Methods The National Surgical Quality Improvement Program (NSQIP) was queried to identify patient demographics, comorbidities, and episodes of care outcomes in patients undergoing primary THA from 2008 to 2018 (n = 216,524). Trends were analyzed using analysis of variances for continuous variables, while categorical variables were analyzed using chi-squared or Monte Carlo tests, where applicable. Results From 2008 to 2018, there were no clinically significant differences in age and body mass index (BMI) in patients with BMI over 40 kg/m2. However, modifiable comorbidities including patients with hypertension (60.2% in 2008, 54.3 in 2018%, p < 0.001) and anemia (19% in 2008, 11.2%, in 2016, p < 0.001) improved. Functional status and the overall morbidity probability have improved with a decrease in hospital lengths of stay (4.0 ± 2.8 days in 2008, 2.1 ± 2.2 days in 2018, p < 0.001), 30-day readmissions (4.2% in 2009, 3.3% in 2018, p < 0.001), and significant increase in home-discharges (70.1% in 2008, 87.3% in 2018, p < 0.001). Conclusion Patient overall health status improved from 2008 to 2018. While conjectural, our findings may be a reflection of a global shift toward value-based comprehensive care centering on patient optimization prior to arthroplasty, quality-of-care, and curtailing costs by mitigating perioperative adverse events.This study's level of evidence is III.

Management of surgical patients on opioid replacement therapy: An audit of current practice

Patients on opioid replacement therapy hospitalised with acute pain represent a clinical challenge and have poorer perioperative outcomes. There is limited evidence relating to acute pain management of this complex cohort. The primary objectives of this retrospective audit was to establish the number of patients who are admitted on opioid replacement therapy with an acute pain condition under surgical services and evaluate the management of these patients to determine consistency of pain management practices. Secondarily, we aimed to evaluate the documentation of opioid replacement therapy in clinical notes to determine adherence to operational protocols and record clinically relevant outcomes including infection or postoperative complication rates. Forty-four episodes of care for buprenorphine patients and 19 episodes of care for methadone patients were included. There was significant variability in inpatient opioid prescribing, including practice of dose modification, and there was high utilisation of additional opioids, although agent choice varied. Multimodal analgesia was utilised, especially following acute pain service review. There was an 11% readmission rate for complications of the initial presentation. Documentation at transitions of care was poor. There is a need for further clinical studies into specific acute pain management strategies, and their effect on clinically relevant outcomes, to guide consistent management practices.

Taking advanced clinical practice to the streets: an evaluation of the benefits and challenges in homeless health care

Homelessness in the UK continues to rise. People who are homeless are more likely to have poor health and die early, and face multiple barriers to accessing health care. Ten years have passed since the Marmot review recommended action on these disparities. In the context of significant health inequalities, advanced clinical practitioners (ACPs) offer a different approach to homeless health care, providing complete episodes of care in complex situations and leading in integrating multiple agencies, service development and strategic advocacy. ACPs can use their expertise in this specialty to deliver education that raises awareness and reduces prejudice. Their research skills can identify gaps and expand the evidence base to improve practice at local and national levels. However, ACPs must promote their own roles, work closely with people with lived experience and be supported by their employers to embrace all four pillars of advanced clinical practice for the full benefits to be realised.

An ensemble model for predicting therapeutic response to unfractionated heparin therapy (Preprint)

BACKGROUND Unfractionated heparin (UFH), is an anticoagulant drug considered a high-risk medication in that an excessive dose can cause bleeding, while an insufficient dose can lead to a recurrent embolic event. Following initiation of intravenous (IV) UFH, the therapeutic response is monitored using a measure of blood clotting time known as the activated partial thromboplastin time (aPTT). Clinicians iteratively adjust the dose of UFH to a target aPTT range, with the usual therapeutic target range between 60 to 100 seconds. OBJECTIVE The aim of this study was to develop and validate a ML algorithm to predict, aPTT within 12 hours after a specified bolus and maintenance dose of UFH. METHODS This was a retrospective cohort study of 3273 episodes of care from January 2017 to August 2020 using data collected from electronic health records (EHR) of five hospitals in Queensland, Australia. Data from four hospitals were used to build and test ensemble models using cross validation, while the data from the fifth hospital was used for external validation. Modelling was performed using H2O Driverless AI® an automated ML tool, and 17 different experiments were conducted in an iterative process to optimise model accuracy. RESULTS In predicting aPTT, the best performing experiment produced an ensemble with 4x LightGBM models with a root mean square error (RMSE) of 31.35. This dataset was re-purposed as a multi-classification task (sub-therapeutic, therapeutic, and supra-therapeutic aPTT result) and achieved a 59.9% accuracy and area under the receiver operating characteristic curve (AUC) of 0.735. External validation yielded similar results: RMSE of 30.52 +/- 1.29 for the prediction model, and accuracy of 56.8% +/- 3.15 and AUC of 0.724 for the multi-classification model. CONCLUSIONS According to our knowledge, this is the first study of ML applied to IV UFH dosing that has been developed and externally validated in a multisite adult general medical inpatient setting. We present the processes of data collection, preparation, and feature engineering for purposes of replication.