Precision Health Analytics With Predictive Analytics and Implementation Research: JACC State-of-the-Art Review

Emerging data science techniques of predictive analytics expand the quality and quantity of complex data relevant to human health and provide opportunities for understanding and control of conditions such as heart, lung, blood, and sleep disorders. To realize these opportunities, the information sources, the data science tools that use the information, and the application of resulting analytics to health and health care issues will require implementation research methods to define benefits, harms, reach, and sustainability; and to understand related resource utilization implications to inform policymakers. This JACC State-of-the-Art Review is based on a workshop convened by the National Heart, Lung, and Blood Institute to explore predictive analytics in the context of implementation science. It highlights precision medicine and precision public health as complementary and compelling applications of predictive analytics, and addresses future research and training endeavors that might further foster the application of predictive analytics in clinical medicine and public health.

Zimbabwe's hospital referral system: does it work?

BACKGROUND

Anecdotal evidence has suggested inefficiency in the pyramidal health care referral system established in Zimbabwe in 1980, as part of its primary health care (PHC) model.

AIM

To assess the functioning of the pyramidal referral system in two rural districts surrounding Harare, Zimbabwe, with regard to two common indicator conditions: pneumonia in children and malaria in adults.

METHODS

For a three-month period, all complete inpatient records with discharge diagnoses of pneumonia or malaria from three hospitals representing different levels of care were analyzed (n = 227). Data were collected on demographic and patient care variables. The appropriateness of admissions and referrals was determined by an assessment of the severity of illness and 'intensiveness' of care required. Data were analyzed for differences among the three hospitals and between the two indicator conditions. Per night inpatient bed costs for each hospital were also calculated.

RESULTS

For pneumonia in children, 56.8% of patients admitted at the secondary level, 53.8% of patients at the tertiary level and 57.8% of patients at the quaternary level were of mild severity. For malaria in adults, 74.0% of patients seen at the secondary level, 81.5% of patients at the tertiary level and 54.3% at the quaternary level were of mild severity. For pneumonia, were no differences in severity between the three hospitals whereas for malaria significant case-mix differences among the hospitals were found. Most patients attending the highest level referral facility were inappropriate admissions who could have been treated at a lower level of care. The majority of patients at all the hospitals studied had used that hospital as their first or second point of contact with the health services. There were large variations in the inpatient per night bed costs between the three hospitals.

CONCLUSIONS

Using the indicator diseases of pneumonia in children and malaria in adults, this study concluded that this network did not meet design expectations as the central level referral hospital cared for a similar case-mix of patients as the district level, but at six times the cost. The appropriateness of admissions and referrals could be improved by developing or strengthening intermediate level facilities, by changing mechanisms of access to specialist facilities and by training health professionals in community settings.

Clinical and laboratory considerations in the use of a new all-ceramic restorative system

Ceramic systems are continually under development in an effort to refine their clinical application. An all-ceramic full-coverage crown system (Procera, Nobel Biocare, Westmont, IL) that utilizes computer technology and industrial presses to fabricate precise copings has recently been introduced. Using this system, aluminous porcelain is baked over a high-strength, high-purity aluminum oxide coping to fabricate a functional, biocompatible, and aesthetic restoration. This article presents a discussion of the clinical and laboratory considerations that are involved in the utilization of this all-ceramic system.

Adhesion receptors on bone marrow stromal cells: in vivo expression of vascular cell adhesion molecule-1 by reticular cells and sinusoidal endothelium in normal and gamma-irradiated mice

Cell adhesion molecules (CAMs) play a key role in interactions between stromal and hematopoietic cells in bone marrow (BM) and in cell traffic through vascular endothelium. To examine the identity of CAMs involved in these processes in mouse BM, we have investigated the in vivo expression of vascular cell adhesion molecule-1 (VCAM-1) and its counter-receptor, very late antigen-4 (VLA-4). Radioiodinated monoclonal antibodies (MoAbs) detecting VLA-4 and VCAM-1 were injected intravenously. Antibody binding was detected in BM by light and electron microscope radioautography. VCAM-1 labeling was restricted to stromal reticular cells and endothelial cells lining BM sinusoids. VCAM-1+ reticular cells formed patchy concentrations, especially in subosteal regions, associated with lymphoid, granulocytic, and erythroid cells. After gamma-irradiation to deplete hematopoietic cells, reticular cells and endothelial cells all showed VCAM-1 labeling in apparently increased intensity. VLA-4 labeling was shown by undifferentiated blast cells and lymphohematopoietic cells both in BM cell suspensions and in vivo, especially at reticular cell contact points. The results demonstrate that VCAM-1 is expressed in vivo by certain BM reticular cells, suggesting that the molecule mediates adhesion to multiple lineages of lymphohematopoietic cells. The finding that VCAM-1 is also expressed constitutively by BM sinusoidal endothelium, unlike its inductive expression by endothelia elsewhere, suggests that VCAM-1 and VLA-4 may be involved in regulating the normal cell traffic between BM and the blood stream.

Paediatric pneumonia in Zimbabwe: management and pharmaceutical costs of inpatient care

Acute respiratory infection exacts a heavy toll on the children of Zimbabwe. During 1986-7 significant resources were committed to manage this condition that accounted for 35 per cent of outpatient visits. Moreover, pneumonia or acute lower respiratory infection (ALRI) represented the greatest proportion of paediatric hospital inpatient discharge diagnoses (32 per cent) and was responsible for 33 per cent of under 5 deaths in Harare. Case management and pharmaceutical cost patterns for paediatric ALRI inpatients are compared for representative rural district and provincial hospitals and an urban central hospital in Harare. The case-mix of patients was similar at all three hospital levels. Significantly, mildly ill patients between the ages of 7 months and 5 years were uniformly over-treated based on management protocols recommended both in the Essential Drug List for Zimbabwe and by the World Health Organization (WHO). The resulting excessive expenditure was Z$26000 (1Z$ = 0.59U$$ in 1986) for this category of patient in 1986. Reasons for the lack of compliance with WHO management protocols are explored.

Systemic acyclovir in pregnancy: a case report

Disseminated herpes simplex infection in pregnancy presents serious risk to mother and fetus. Although an uncommon problem, the high maternal and fetal mortality and morbidity accompanying disseminated herpes infection warrants aggressive new treatment. Specific antiviral chemotherapy is now possible for selected cases. The present report describes the use of acyclovir during the third trimester for disseminated herpes simplex infection. The treatment protocol used and pregnancy outcome are described for this case. Acyclovir therapy and potential toxicities are described.