Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study

Background

For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients' needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients' full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs.

Methods

In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey.

Discussion

Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs.

Adverse outcomes of SARS-CoV-2 infection with delta and omicron variants in vaccinated versus unvaccinated US veterans: retrospective cohort study

OBJECTIVES

To determine the association between covid-19 vaccination types and doses with adverse outcomes of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection during the periods of delta (B.1.617.2) and omicron (B.1.1.529) variant predominance.

DESIGN

Retrospective cohort.

SETTING

US Veterans Affairs healthcare system.

PARTICIPANTS

Adults (≥18 years) who are affiliated to Veterans Affairs with a first documented SARS-CoV-2 infection during the periods of delta (1 July-30 November 2021) or omicron (1 January-30 June 2022) variant predominance. The combined cohorts had a mean age of 59.4 (standard deviation 16.3) and 87% were male.

INTERVENTIONS

Covid-19 vaccination with mRNA vaccines (BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna)) and adenovirus vector vaccine (Ad26.COV2.S (Janssen/Johnson & Johnson)).

MAIN OUTCOME MEASURES

Stay in hospital, intensive care unit admission, use of ventilation, and mortality measured 30 days after a positive test result for SARS-CoV-2.

RESULTS

In the delta period, 95 336 patients had infections with 47.6% having at least one vaccine dose, compared with 184 653 patients in the omicron period, with 72.6% vaccinated. After adjustment for patient demographic and clinical characteristics, in the delta period, two doses of the mRNA vaccines were associated with lower odds of hospital admission (adjusted odds ratio 0.41 (95% confidence interval 0.39 to 0.43)), intensive care unit admission (0.33 (0.31 to 0.36)), ventilation (0.27 (0.24 to 0.30)), and death (0.21 (0.19 to 0.23)), compared with no vaccination. In the omicron period, receipt of two mRNA doses were associated with lower odds of hospital admission (0.60 (0.57 to 0.63)), intensive care unit admission (0.57 (0.53 to 0.62)), ventilation (0.59 (0.51 to 0.67)), and death (0.43 (0.39 to 0.48)). Additionally, a third mRNA dose was associated with lower odds of all outcomes compared with two doses: hospital admission (0.65 (0.63 to 0.69)), intensive care unit admission (0.65 (0.59 to 0.70)), ventilation (0.70 (0.61 to 0.80)), and death (0.51 (0.46 to 0.57)). The Ad26.COV2.S vaccination was associated with better outcomes relative to no vaccination, but higher odds of hospital stay and intensive care unit admission than with two mRNA doses. BNT162b2 was generally associated with worse outcomes than mRNA-1273 (adjusted odds ratios between 0.97 and 1.42).

CONCLUSIONS

In veterans with recent healthcare use and high occurrence of multimorbidity, vaccination was robustly associated with lower odds of 30 day morbidity and mortality compared with no vaccination among patients infected with covid-19. The vaccination type and number of doses had a significant association with outcomes.

Diagnostic usefulness of spiroergometry and risk factors of long -COVID in patients with normal left ventricular ejection fraction

Background

Recent evidence has shown that patients with acute SARS-CoV-2 infection might present symptoms of infection a long time after a recovery.

Purpose

To investigate the risk factors and assess the utility of spiroergometry parameters in differential diagnosing patients presenting the symptoms (dyspnea, fatique, pain in chest, muscle pain, cognitive impairment, taste and smell disturbances) persisting for a few months after recovery from COVID 19 (symptoms of long COVID).

Methods and results

The 146 patients (pts) with normal left ventricular ejection fraction and without respiratory diseases, hospitalised in Cardiology Department recovering from COVID-19 at three to six months after confirmed diagnosis were included. The clinical examination, laboratory results, echocardiography using Vivid E95–GE Healthcare, non-invasive body mass analysis using Body Composition Analyzer (Tanita Pro), spiroergometry using The MetaSoft® Studio application were analyzed. The subjects were divided into the two following groups: group demonstrating long COVID symptoms (i.e. suffering from one of the following dyspnea, fatique, pain in chest, muscle pain, cognitive impairment, taste or smell disturbances) [N=44 pts] and the group without long COVID symptoms [N=102 pts]. Pts with long COVID symptoms presented significantly higher age (58 versus [vs] 44 years; p<0.0001), higher metabolic age (53 vs 45 years; p=0.01), higher left atrial diameter (37 vs 35 mm; p=0.04), higher left ventricular mass index (LVMI) (83 vs 74 g/m2, p=0.03), higher E/E' (7.3 vs 6; p<0.001) compared to control group. In CPET long COVID pts presented lower forced vital capacity (FVC) (3.6 vs 4.3 L; p=0.009), lower maximal oxygen consumption measured during incremental exercise indexed per kilogram (VO2max) (21 vs 23 ml/min/kg; p=0.04), lower respiratory exchange ratio (RER) (1.0 vs 1.1; p=0.04); lower forced expiratory volume in one second (FEV1) (2.9 vs 3.25 L; p=0,03); higher ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FVC) (106 vs 100%; p=0.0002) – Figure 1, there were no significant changes in electrocardiogram between groups. The laboratory results pointed that pts with long COVID symptoms had also lower rate of red blood cells (RBC) (4,4 vs 4,6 mln; p=0.01); higher level of glucose (92 vs 90 mg%; p=0.02); lower glomerular filtration rate (GFR) estimate by Modification of Diet in Renal Disease (MDRD) (88 vs 95; p=0.02); higher level of hypersensitive cardiac Troponin T (hsTnT) (6.1 vs 3.9 ng/L; p=0.03). The parameters significant in univariate analyses were included to the multivariate model. The results of multiple logistic regression were as follows: age (OR 4.6, 95% CI: 1.7–11.5; p=0.001) and LVMI (OR 2.5, 95% CI: 1.0–6.6; p=0.04).

Conclusions

Persistent symptoms in long COVID can mimic those of cardiovascular disease. Spiroergometric parameters are useful in making a proper diagnosis.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Polish Mother's Memorial Hospital Research Institute

Factors of persistent limited exercise tolerance in patients after COVID-19 with normal left ventricular ejection fraction

Background

Exercise intolerance de novo is one of the most common reported symptoms in patients (pts) recovering from COVID-19.

Purpose

The present study determines etiological and pathophysiological factors influencing the mechanism of exercise intolerance in the COVID-19 survivors. Therefore, the factors affecting percent predicted oxygen uptake at peak exercise VO2 (%VO2pred) in pts after COVID-19 with normal left ventricular ejection fraction were assessed.

Methods and results

The 120 consecutive patients from the Department of Cardiology recovering from COVID-19 at three to six months after confirmed diagnosis were included. The clinical examinations, laboratory test results, echocardiography using Vivid E95 – GE Healthcare, non-invasive body mass analysis using Body Composition Analyzer (Tanita Pro), and spiroergometry using The MetaSoft® Studio application were analysed. The subjects were divided into the two following groups: study i.e. pts with worse oxygen uptake (%VO2pred <80%; N=47) and control including these cases with %VO2pred ≥80% (N=73) – Table 1. Pts with %VO2pred <80% presented significantly lower global peak systolic strain (GLPS) [p=0.03], tricuspid annular plane systolic excursion (TAPSE) [p=0.002] and late diastolic filling velocity (A) [p=0.004] compared to controls – Figure 1. The male gender (p=0.007) and the percent of total body water content (TBW %) (p=0.02) were significantly higher in study in comparison to the control group. The results of multiple logistic regression model independently associated with %VO2pred were as follows: A (OR 0.4, 95% CI: 0.17–0.95; p=0.03) and gender (OR 2.52, 95% CI: 1.07–5.91; p=0.03).

Conclusions

Males have over twice risk of persistent limited exercise tolerance after COVID-19 infection than females. The lower late diastolic filling velocity, tricuspid annular plane systolic excursion, worse global peak systolic strain, and hydration status are connected with limited exercise tolerance after COVID-19 in patients with normal left ventricular ejection fraction.

Funding Acknowledgement

Type of funding sources: None.

Post-COVID-19 cardiovascular complications and their association with clinical characteristics, symptoms and comorbidities – the LATE-COVID study

Background

Among many complications of coronavirus disease 2019 (COVID-19) there is a wide range of cardiovascular (CV) problems ranging from mild to severe ones. Even asymptomatic patients and those with mild course of COVID-19 may develop severe CV complications. Factors leading to such state have not been extensively studied so far.

Purpose

We aimed to assess which factors were linked to the severe complications of COVID-19.

Methods

We included 200 consecutive patients admitted to the Department of Cardiology and Adult Congenital Heart Diseases of the Polish Mother's Memorial Research Institute (PMMHRI) due to post-Covid cardiovascular complications. SARS-CoV2 infection was confirmed with real-life PCR testing. Laboratory tests, 24-hour ECG monitoring and echocardiography were performed in all patients from the investigated group. For the purposes of our study severe complications were defined as: myocarditis, a decrease of ejection fraction >10% from the pre-disease value, thromboembolic complications, angina pectoris requiring myocardial revascularization and the new onset of atrial fibrillation of supraventricular tachycardia. Some patients presented more than one of the above. Statistical analysis was performed using the software Statistica v.13 (TIBCO Software Inc., Palo Alto, CA, USA). Data were presented as mean ±SD or median (25th-75th percentile) for continuous variables and as proportions for categorical variables. Comparisons between groups were performed using Student's t-test for independent variables and the Mann-Whitney U test or χ2 test with Yates's correction, as appropriate. For all calculations p-values <0.05 were considered statistically significant.

Results

Finally, we included 200 consecutive patients (aged 54±16 years, 76 males – 38%), hospitalized for COVID-19 complications after a median 3 (2–6) months following the acute phase of infection. On admission patients presented with dyspnea (23%), impairment of exercise tolerance (47%), chest pain (32%), increase in blood pressure (29%), palpitations (25%), weight loss (13%), brain fog (6%), general malaise (11%), headache (5%), limb pain (13%), swelling (14%). Severe complications of COVID-19 were diagnosed in 31 patients (16%).Taking into consideration symptoms, the presence of severe COVID-19 complications was significantly associated with dyspnoea and deterioration of exercise tolerance. In comparison to patients with mild complications, severe ones were linked to age (the older patients, the higher risk), previous history of heart failure and diabetes mellitus. We did not observe statistically significant differences in severity of complications depending on smoking status (Tables 1 and 2).

Conclusions

Previous history of heart failure and diabetes mellitus as well as symptoms (dyspnoea and deterioration of exercise tolerance) along with older age are related to more severe complications following COVID-19.

Funding Acknowledgement

Type of funding sources: None.

The relationship of dehydration and body mass index with the occurrence of atrial fibrillation in heart failure patients

Background/Introduction

Heart failure (HF) and atrial fibrillation (AF) are two conditions that are likely to dominate the next years of cardiovascular (CV) care. These diseases frequently coexist and they can beget one another due to similar risk factors and similar pathophysiology.

Purpose

The aim of the study was to assess the relationship of dehydration, body mass index (BMI) and other indices with the occurrence of AF in HF patients.

Methods

The study included 113 patients [median age 64 years; 57.52% male] hospitalized due to HF. Baseline demographics, body mass analysis, echocardiographic results, key cardiopulmonary exercise test (CPET) parameters, six minute walk distance (6MWD) and Kansas City Cardiomyopathy Questionnaire (KCCQ) score were assessed.

Results

Of all patients, 23 (20.35%) had AF, and 90 (79.65%) had sinus rhythm (SR). Patients with AF were older (med. 66 vs 64 years; p=0.039), with higher BMI (32.02 vs. 28.51 kg/m2; p=0.017) and percentage of fat content (37.0 vs. 27.9%, p=0.014). They were more dehydrated, with a lower percentage of total body water (TBW%) (45.7 vs 50.0%; p=0.022). Clinically, patients with AF had more often higher New York Heart Association (NYHA) class (III vs II; p<0.001), shorter 6MWD (median 292.35 vs 378.4 m; p=0.001) and a lower KCCQ overall summary score (52.60 vs 73.96 points; p=0.002). Patients with AF had significantly lower exercise capacity as measured by peak oxygen consumption (peak VO2) (0.92 vs 1.26 mL/min, p=0.016), peak VO2/kg (11 vs. 15 mL/kg/min; p<0.001), and percentage of predicted VO2max (pp-peak VO2) (62.5 vs 70.0; p=0.010). We also found VE/VCO2 (med.33.85 vs 32.20; p=0.049) to be higher and peak oxygen pulse (8.5 vs 11 mL/beat; p=0.038) to be lower in patients with AF than in patients without AF. In a multiple logistic regression model higher BMI (OR 1.23 per unit increase, p<0.001) and higher left atrial volume index (LAVI) (OR 1.07 per unit increase, p=0.03), lower tricuspid annular plane systolic excursion (TAPSE) (OR 0.74 per unit increase, p=0.03) and lower TBW% in body mass analysis (OR 0.90 per unit increase, p=0.03) were independently related to AF in patients with HF.

Conclusions

Increased volume of left atrium and right ventricular systolic dysfunction are well-known predictors of AF occurrence in patients with HF, but hydration status and increased body mass also seem to be important factors of AF in HF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Hydration status, BMI and troponin as factors of an impaired exercise tolerance in women over 40 with arterial hypertension

Purpose

The aim was to identify factors influencing maximal oxygen uptake (VO2max) and early identification of hypertensive women at risk of heart failure (HF).

Methods

The 185 consecutive females with controlled hypertension were divided according VO2max quartiles. The patients underwent echocardiography, non-invasive body mass analysis, spiroergometry and hemodynamic parameters. Regression analyses determined predictors of the lowest VO2max (quartile 1: VO2max <17 ml/kg/min).

Results

Females with the worst oxygen consumption had significantly higher level of high sensitive cardiac Troponin T (hs-cTnT) [p=0.001], higher values of the left atrial (LA) volume, late diastolic mitral annulus velocity (A'), ratio of peak velocity of early diastolic transmitral flow to peak velocity of early diastolic mitral annular motion (E/E') [p=0.0003, p=0.02, p=0.04; respectively] and lower E' [p=0.001] compared to controls. Women with the worst exercise capacity had higher body mass index (BMI) and fat content (kg and %) [p<0.0001], higher fat free mass (FFM) (kg) [p<0.0001], higher total body water content (TBW) [p=0.0002] as well as extracellular body water content (ECW) [p<0.0001] and intracellular body water content (ICW) [p=0.005], ECW/TBW x 100% [p<0.0001] and metabolic age [p<0.0001] compared to counterparts. In a multiple logistic regression model independently associated with VO2max were: ECW/TBW x 100% (OR 4.45, 95% CI: 1.77–11.21; p=0.002) Figure 1, BMI (OR 7.11, 95% CI: 2.01–25.11; p=0.002) Figure 2 and hs-cTnT level (OR 2.69, 95% CI: 1.23–5.91; p=0.013).

Conclusions

High-sensitivity cardiac troponin may serve as early biomarker of heart failure in hypertensive women. Hydration status should be considered in overall hypertensive women care. There is an importance of body mass compartments analysis in early identification of hypertensive females at risk of heart failure.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Project is financed by the Polish National Agency for Academic Exchange under the Foreign Promotion Programme. Figure 1Figure 2

Degree for weakly upper semicontinuous perturbations of quasi-m-accretive operators

In the paper, we provide the construction of a coincidence degree being a homotopy invariant detecting the existence of solutions of equations or inclusions of the form Ax ∈ F(x), x ∈ U, where [Formula: see text] is an m-accretive operator in a Banach space E, [Formula: see text] is a weakly upper semicontinuous set-valued map constrained to an open subset U of a closed set K ⊂ E. Two different approaches are presented. The theory is applied to show the existence of non-trivial positive solutions of some nonlinear second-order partial differential equations with discontinuities. This article is part of the theme issue 'Topological degree and fixed point theories in differential and difference equations'.

P1311 A rare case of asymptomatic cyst in interatrial septum longterm observation

Background

Incidental findings in echocardiography performed from other indications are not always able to explain the patient condition as well as the observed pathology. However, review of literature, helps to find the most possible explanation. We present a case study of a patient with our proposal of possible diagnosis.

Case report

28-year old female with hypothyroidism and no other concomitant diseases presented with easy fatigue. Exercise stress test was clinically and ECG negative with 12,8 METs. Transthoracic echocardiography showed normal size of heart structures with preserved systolic and diastolic function of both left and right chamber. The only abnormality was a cystic structure of 44x31x34 cm in interatrial septum which was protruding to both left and right atrium and was not affecting the blood flow with normal gradients. We did not find any signs of inflammation nor infiltration to the heart walls. There was no flow inside the cyst with the use of colour Doppler. The structure had homogenous echolucency with very thin walls and a septum inside. As we did not find any connection between the cyst and the atriums we considered it as not harmful in terms of a risk of embolization. Patient was hemodynamically stable, there was no history of neurological dysfunctions nor atrioventricular conduction disturbances. Taking into account possible diagnoses for that patient we decided to schedule the patient for follow-ups. Ten years observation period confirmed that that our approach was proper. Serial echocardiographic studies showed no change in the cyst. In this year we performed multimodality imaging with CT and MRI, which showed the same views as echocardiography.

Discussion

The most possible diagnose for our patient is a bronchogenic cyst, a very rare congenital bronchopulmonary malformation of the foregut that is usually found incidentally with mostly asymptomatic benign course. Also the localization of the cyst confirms that diagnosis. Nevertheless the final diagnosis would be possible only in histopathological study.

The differential diagnosis should include a cystic myxoma and echinococcosis. However the structure is not polycystic and seems to have homogenous echolucency. We ruled out the blood cyst because of the lack of typical localization and connection to valves.

As long as the patient remains asymptomatic surgical resection remains controversial.

P253 Patient after correction of Taussig-Bing anomaly with severe neoaortic regurgitation and after sudden cardiac arrest

The Taussig –Bing anomaly is a rare congenital heart malformation that was first described in 1949 by Helen B. Taussig and Richard J. Bing. It is characterized by the presence of a large subpulmonic ventricular septal defect (VSD) and, usually, side-by-side great vessels that arise entirely from the right ventricle. Unlike TGA with VSD, this anomaly is characterized by the presence of a bilateral conus and the absence of aortomitral continuity. Increased pulmonary blood flow leads to early onset of pulmonary vascular disease, hence repair in the early infancy period is recommended. VSD closure combined with arterial switch is currently the preferred procedure. Lecompte introduced a new surgical technique that includes extensive resection of the conal septum and direct reimplantation of the pulmonary trunk on the superior margin of the right ventricular infundibulotomy.

We present case of 18-year-old male patient with Taussig-Bing anomaly after pulmonary artery binding and closure of ductus arteriosus when one year old and after anatomical Jatene correction with modified Lacompte procedure at the age of two years. The patient was admitted to our Department in October 2018 after episode of sudden cardiac arrest in the mechanism of ventricular fibrillation. Echocardiographic examination revealed preserved systolic function of both ventricles (LVEF 62%, TAPSE 25 mm, RV S’ 13cm/s) without contractility disturbances. The enlarged and hypertrophic left ventricle consists of the primary cavity connecting by VSD (size 39 mm) with a fragment of the right ventricle separated from the rest of the right ventricle by a patch with Gore-Tex acting as a ventricular septum - without any leakage features (Figure 1A and 1B). We noticed also enlarged left atrium, increased diameter of neoaorty bulb (50 mm), severe neoaortic regurgitation (AV max: 1,85 m/s, ERO-70, VC-8mm, PHT 327 ms) (Figure 1C), moderate mitral regurgitation (type I according Carpentier) (Figure1D). On 8.01.2019 a subcutaneous ICD Boston Scientific Emblem with a subcutaneous defibrillation electrode was implanted. In performed spiroergometry decreased peak oxygen consumption (2,24 ml/min/kg), the study was stopped because of fatique, assessed expiratory exchange ratio, and episode of nsVT. After decision of Heart Team the patient is qualified for surgical treatment of valve defects.

Abstract P253 Figure 1

P1452 A rare case of embolic blindness in an adult patient with univentricular heart after fontan operation

Background

Thromboembolic complications following Fontan procedure are one of the major causes of mortality and morbidity among patients with univentricular heart. We may classify thromboembolic complications into two groups: systemic- and nonsystemic. We present a case of a patient with a manifestation of both.

Case report

24-year old female, foreign student was admitted to Ophthalmology Department due to sudden blindness of the left eye. Performed studies revealed embolus in the left central retinal artery. Because the patient had the history of congenital heart defect she was referred to our department. Analysis of medical documentation showed that the patient has combined congenital heart defect including right ventricle hypoplasia, tricuspid atresia, pulmonic stenosis, ventricular septal defect, atrial septal defect and persistent ductus arteriosus. She had a history of two surgeries: modified left-side Blalock-Tausing connection (in 4th month of life) and total cavo-pulmonary connection with the closure of Blalock-Tausing and excision of interatrial septum (in 2,5 year of life). On admission she presented with left-eye blindness. She had no dyspnoea or palpitations. However she reported very severe migraines from a few days preceding the admission to hospital. Echocardiography revealed tricuspid atresia, hypoplastic right ventricle, preserved systolic and diastolic function of left ventricle, atrial septal defect with no restriction. We observed enlarged diameter of vena cava inferior with no respirophasic variations and massive thrombus in inside with very low flow. The connection between inferior vena cava and right pulmonary artery was working properly with no visible fenestration. We also observed a winding vessel between ascending aorta and truncus pulmonalis/pulmonary artery with continuous flow of blood from left to right side. Computer tomography confirmed the diagnosis of massive thrombosis of vena cava inferior. Patient had anticoagulation started. Two days later we the flow in inferior vena cava returned – we did not observe any thrombus. Patient was referred to catheterization and had chronic anticoagulation initiated.

Three months follow-up revealed no changes in clinical condition of a patient.

Discussion

The palliative Fontan operation predispose to the increased risk of thromboembolic complication. Despite the risk factors of such complications have been identified, there are no guidelines about prophylactic anticoagulation in that group of patients. As a result, chronic anticoagulation is initiated in patients who have other indications e.g. atrial fibrillation. It seems that it would be beneficial to define the group of patients after Fontan procedure with indications to chronic anticoagulation therapy despite arrhythmias.

Expression III: patients' expectations and preferences regarding physician-patient relationship and clinical management-results of the international NOGGO/ENGOT-ov4-GCIG study in 1830 ovarian cancer patients from European countries

Backround

The primary aim of this study was to investigate information needs and treatment preferences of patients with ovarian cancer, focusing especially on physician-patient relationship and treatment.

Patients and methods

A questionnaire was developed based on the experiences of the national German survey 'Expression II', and was provided to patients with ovarian cancer either at initial diagnosis or with recurrent disease via Internet (online-version) or as print-out-version.

Results

From December 2009 to October 2012, a total of 1830 patients with ovarian cancer from eight European countries (Austria, Belgium, France, Germany, Italy, Poland, Romania, Spain) participated, 902 (49.3%) after initial diagnosis and 731 (39.9%) with recurrent ovarian cancer. The median age was 58 years (range 17-89). Nearly all patients (96.2%) had experienced upfront surgery followed by first-line chemotherapy (91.8%). The majority of patients were satisfied with the completeness and comprehensibility of the explanation about the diagnosis and treatment options. The three most important aspects, identified by patients to improve the treatment for ovarian cancer included: 'the therapy should not induce alopecia' (42%), 'there must be more done to counter fatigue' (34.5%) and 'the therapy should be more effective' (29.7%). Out of 659 (36%) patients, who were offered participation in a clinical trial, 476 (26%) were included.

Conclusion

This study underlines the high need of patients with ovarian cancer for all details concerning treatment options irrespective of their cultural background, the stage of disease and the patient's age. Increased information requirements regarding potential side effects and treatment alternatives were recorded. Besides the need for more effective therapy, alopecia and fatigue are the most important side effects of concern to patients.

Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study

OBJECTIVE

To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality.

DATA SOURCE

Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010.

DESIGN

Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012.

DATA COLLECTION

Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013.

FINDINGS

In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP < 160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics.

CONCLUSIONS

Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

[Metameric macular and papular skin mastocytosis]

BACKGROUND

Mastocytosis is characterised by the presence of abnormal quantities of mastocytes in one or more organs. Although it occurs in systemic forms of mastocytosis, isolated skin involvement is the predominant presentation, particularly in children, in the form of more or less extensive though non-systematic lesions. Herein, we report a case of maculopapular cutaneous mastocytosis that is unusual in terms of its metameric topography.

PATIENTS AND METHODS

A 16-year-old youth presented with an erythematous maculopapular rash of 18 months' duration and involving pruritic inflammatory episodes strictly localised in segment T8 to the left. The skin biopsy showed a significant increase in the number of dermal mastocytes (CD117+). No KIT mutations were found in the skin lesions nor in the unimpaired skin of the opposite side. Further investigations ruled out systemic mastocytis.

DISCUSSION

Herein, we report a case of cutaneous mastocytosis that is unusual in terms of its metameric disposition. There have been only two previous reports of segmental cutaneous mastocytis. The two pathological hypotheses involved precessional dermatitis that renders the skin surface susceptible to homing, and somatic mosaicism (type 1) with local mastocyte proliferation.

Comparing Survival Following Hip Fracture Repair in VHA and Non-VHA Facilities

INTRODUCTION

Although postsurgical outcomes are similar between Veterans Health Administration (VHA) and non-VHA hospitals for many procedures, no studies have compared 30-day and 1-year survival following hip fracture repair. Therefore, this study compared survival of veterans aged 65 years and older treated in VHA hospitals with a propensity-matched cohort of Medicare beneficiaries in non-VHA hospitals.

MATERIALS AND METHODS

Retrospective cohort study of 1894 hip fracture repair patients in VHA or non-VHA hospitals between 2003 and 2005. Current Procedural Terminology codes identified 3542 male patients aged >65 years who had hip fracture repair between 2003 and 2005 in the Veterans Affairs' National Surgical Quality Improvement Program database. The Medicare comparison sample was drawn from 2003 to 2005 Medicare Part A inpatient hospital claims files. To create comparable VHA and Medicare cohorts, patients were propensity score matched on age, admission source (community vs. nursing home), repair type, comorbidity index, race, year, and region. Thirty-day and 1-year survival after surgery were compared between cohorts after further adjustment for selected comorbidities, year of surgery, and pre- and postsurgical length of hospital stay using logistic regression.

RESULTS

Odds of survival were significantly better in the Medicare than the VHA cohort at 30 days (1.68, 95% CI 1.15-2.44) and 1 year (1.35, 95% CI 1.08-1.69).

CONCLUSION

Medicare beneficiaries with hip fracture repair in non-VHA hospitals had better survival than veterans in VHA hospitals. Whether this is driven by unobserved patient characteristics or systematic care differences is unknown.

The role of peroxisome-proliferator-activating receptor gamma agonists: rosiglitazone and 15-deoxy-delta12,14-prostaglandin J2 in chronic experimental cyclosporine A-induced nephrotoxicity

Cyclosporine A(CsA) is an immunosuppressor frequently used in the transplant surgery and in the treatment of autoimmune diseases. The therapeutic benefits of CsA are often limited by it's main side effect-nephrotoxicity. Mechanisms of chronic CsA- induced renal damage include: activation of renin-angiotensin-aldosterone system, upregulation of transforming growth factor beta (TGF-β), oxidative stress. This study was undertaken to investigate the protective effect of the peroxisome-proliferator-activated receptors gamma (PPARs-γ) agonists: rosiglitazone and 15-deoxy-Δ12,14-prostaglandin J2 (PGDJ2), against CsA-induced kidney injury in male Wistar rats. CsA was administered subcutaneously at a dose of 15 mg/kg/day for 28 days. Both PPAR-γ agonists were given for 28 days 0.5 hour before the administration of CsA. Rosiglitazone was administered orally at a dose of 8 mg/kg/day and PGDJ2 was given intraperitoneally at a dose of 30 μg/kg/day. CsA induced renal failure was evidenced by increased serum levels of urea, uric acid and creatinine. Serum concentrations of GSH and GSSG, lipid peroxidation products as well as NAD+/NADH, NADP+/NADPH and ADP/ATP ratios showed, that CsA induced oxidative stress and evoked an imbalanced red-ox state in the kidney. Light and electron microscope studies showed degenerative changes within renal tubules with damage to their mitochondria, interstitial fibrosis and arteriolopathy. Immunohistochemical expression of profibrotic TGF-β was assessed. The biochemical and morphological changes induced by CsA were limited by administration of both rosiglitazone and PGDJ2. Ultrastructural examination of renal tubular epithelial cells showed marked improvement within mitochondria. Our results indicate that both PPAR-γ agonists used in the experiment may play an important role in protecting against CsA-induced damage in the kidney.

Tumor necrosis factor-α inhibitor treatment and the risk of incident cardiovascular events in patients with early rheumatoid arthritis: a nested case-control study

OBJECTIVE

To compare the risk of cardiovascular (CV) events between use of tumor necrosis factor-α inhibitors (TNFi) and nonbiologic disease-modifying antirheumatic drugs (DMARD) in patients with early rheumatoid arthritis (RA).

METHODS

A nested case-control study was conducted using data from Truven's MarketScan commercial and Medicare claims database for patients with early RA who started treatment with either a TNFi or a nonbiologic DMARD between January 1, 2008, and December 31, 2010. Date of CV event diagnosis for cases was defined as the event date, and 12 age-matched and sex-matched controls were sampled using incidence density sampling. Drug exposure was defined into the following mutually exclusive categories hierarchically: (1) current use of TNFi (with or without nonbiologics), (2) past use of TNFi (with or without nonbiologics), (3) current use of nonbiologics only, and (4) past use of nonbiologics only. Current use was defined as any use in the period 90 days prior to the event date. Conditional logistic regression models were used to derive incidence rate ratios (IRR).

RESULTS

From the cohort of patients with early RA, 279 cases of incident CV events and 3348 matched controls were identified. The adjusted risk of CV events was not significantly different between current TNFi users and current nonbiologic users (IRR 0.92, 95% CI 0.59-1.44). However, past users of nonbiologics showed significantly higher risk compared to current nonbiologic users (IRR 1.47, 95% CI 1.04-2.08).

CONCLUSION

No differences in the CV risk were found between current TNFi and current nonbiologic DMARD treatment in patients with early RA.

Adherence to antipsychotics and cardiometabolic medication: association with health care utilization and costs

OBJECTIVE

This study examined the association between adherence to antipsychotic and cardiometabolic medication and annual use of health care services and expenditures.

METHODS

MarketScan Medicaid files from 2004 to 2008 were used to evaluate annual cross-sections of patients with schizophrenia and diabetes, hypertension, or hyperlipidemia. Annual adherence to antipsychotic and cardiometabolic medication was defined as a score of at least 80% on proportion of days covered. Logistic regression was used to examine the association between antipsychotic adherence and adherence to cardiometabolic medications. Count data models and generalized linear models estimated health care utilization and health care expenditures, respectively, for outpatient, emergency, inpatient, and overall health services.

RESULTS

A total of 87,015 unique patients with schizophrenia received at least one antipsychotic medication. The overall prevalence of any comorbid cardiometabolic condition was 42.9% in 2004 and increased to 52.5% in 2008. Adherence to cardiometabolic medications was significantly greater among patients who were adherent to antipsychotic medications (adjusted odds ratio=6.9). Adjusted annual expenditures for emergency and inpatient care were higher for patients who were nonadherent to either antipsychotics or cardiometabolic medications than for patients who were adherent to antipsychotic and cardiometabolic medications. They were highest for patients who were nonadherent to both groups of medications. Outpatient, medication, and overall expenditures were lower for patients who were nonadherent to antipsychotic medications, regardless of cardiometabolic medication adherence.

CONCLUSIONS

Among Medicaid patients with schizophrenia, cardiometabolic conditions are common, and adherence to antipsychotics and adherence to cardiometabolic medications are strongly related. Interventions that can improve medication adherence to treatment of both schizophrenia and comorbid cardiometabolic conditions may reduce emergency visits and hospitalizations.

Challenges in merging Medicaid and Medicare databases to obtain healthcare costs for dual-eligible beneficiaries: using diabetes as an example

Dual-eligible Medicaid-Medicare beneficiaries represent a group of people who are in the lowest income bracket in the US, have numerous co-morbidities and place a heavy financial burden on the US healthcare system. As cost-effectiveness analyses are used to inform national policy decisions and to determine the value of implemented chronic disease control programmes, it is imperative that complete and valid determination of healthcare utilization and costs can be obtained from existing state and federal databases. Differences and inconsistencies between the Medicaid and Medicare databases have presented significant challenges when extracting accurate data for dual-eligible beneficiaries. To describe the challenges inherent in merging Medicaid and Medicare claims databases and to present a protocol that would allow successful linkage between these two disparate databases. Healthcare claims and costs were extracted from both Medicaid and Medicare databases for King County, Seattle, WA, USA. Three Medicaid files were linked to eight Medicare files for unique dual-eligible beneficiaries with type 2 diabetes mellitus. Although major differences were identified in how variables and claims were defined in each database, our method enabled us to link these two different databases to compile a complete and accurate assessment of healthcare use and costs for dual-eligible beneficiaries with a costly chronic condition. For example, of the 1759 dual-eligible beneficiaries with diabetes, the average cost of healthcare was USD 15,981 per capita, with an average of 76 claims per person per year. The resulting merged database provides a virtually complete documentation of both utilization and costs of medical care for a population who receives coverage from two different programmes. By identifying differences and implementing our linkage protocol, the merged database serves as a foundation for a broad array of analyses on healthcare use and costs for effectiveness research.

Disability and health care costs in the Medicare population

OBJECTIVE

To determine the effect of activity limitations on health care expenditures.

DESIGN

Cross-sectional.

SETTING

National survey.

PARTICIPANTS

Data from the 1997 Medicare Current Beneficiary Survey (n=9298), a nationally representative sample of community-dwelling Medicare beneficiaries who were older than 64 years of age.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The impact of patient disability on health care costs (inpatient, outpatient, skilled nursing facility, home health, medications). Activity limitations were determined by patient assessment of restrictions in activities of daily living (ADLs).

RESULTS

Over 20% (n=6,500,000) of the entire Medicare population had at least 1 health-related activity limitation. Total median health care costs per year (interquartile range [IQR]) increased as the number of these limitation increased (0 ADLs: $1934 [IQR, $801-$4761]; 1-2 ADLs: $4540 [IQR, $1744-$12,937]; 3-4 ADLs: $7589 [IQR, $2580-$23,149]; 5-6 ADLs: $14,399 [IQR, $5425-$33,014]). After adjusting for confounding characteristics including the impact of comorbid illnesses, Medicare enrollees incurred higher health care costs as their number of activity limitations increased (0 ADLs: cost ratio=1.0; 1-2 ADLs: cost ratio=1.4 [95% confidence interval (CI), 1.2-1.6]; 3-4 ADLs: cost ratio=1.6 [95% CI, 1.3-2.0]; 5-6 ADLs: cost ratio=2.3 [95% CI, 1.7-3.2]). The cost increases were because of an increase in the frequency of all events (eg, hospital admissions, outpatient visits) rather than an increase in the intensity or cost of those events. In addition, with increasing activity limitations, there was a significant increase in the proportional impact of home health costs such that, for those with 5 or 6 limitations, home health costs exceeded the cost of outpatient visits.

CONCLUSIONS

Activity limitation is an independent risk factor for increased health care costs and appears to be more than just a proxy for chronic illness.

Footwear used by individuals with diabetes and a history of foot ulcer

OBJECTIVE

To describe footwear preferences of people with diabetes and a history of foot ulcer from two large western Washington State healthcare organizations.

METHODS

As part of a clinical trial of footwear, self-reported information on footwear preferences, use, and cost were obtained from persons with diabetes and a prior healed foot ulcer for the year before their study enrollment. All participants' shoes were allocated into optimal, adequate, and dangerous categories based on design, structural and safety features, and materials.

RESULTS

The 309 males and 91 females in this study averaged 62 years of age. At baseline, men owned an average of 6 (+3) pairs of shoes, with an average purchase price of $56, while women owned an average of 8 (+5) pairs, with an average purchase price of $42. Women spent an average of 51% of their time in shoes in dangerous shoes compared to men who spent 27% of their time. Men and women spent nearly 30% of their time while out of bed in slippers, stockings, and barefoot.

CONCLUSIONS

People with a history of diabetes and foot ulcers needed several styles of safe and attractive shoes for regular activities. Healthcare professionals can provide patients with information on good footwear choices to help them select adequate shoes while avoiding dangerous shoes. This approach is more realistic than trying to move all people with prior foot risk factors or ulcers into uniformly optimal footwear, since recent evidence does not support this practice.

A demand-side view of risk adjustment

This paper analyzes the efficient allocation of consumers to health plans. Specifically, we address the question of why employers that offer multiple health plans often make larger contributions to the premiums of the high-cost plans. Our perspective is that the subsidy for high-cost plans represents a form of demand-side risk adjustment that improves efficiency. Without such subsidies (and in the absence of formal risk adjustment), too few employees would choose the high-cost plans preferred by high-risk workers. We test the theory by estimating a model of the employer premium subsidy, using data from a survey of large public employers in 1994. Our empirical analysis shows that employers are more likely to subsidize high-cost plans when the benefits of risk adjustment are greater. The findings suggest that the premium subsidy can accomplish some of the benefits of formal risk adjustment.

[Side effects during dobutamine stress echocardiography in patients with aortic stenosis]

The purpose of the study was to assess the safety of the dobutamine stress echocardiography (DASE) in patients with aortic stenosis (AS). 161 patients (mean age 59 +/- 13 years) with AS were prospectively studied with DASE. There were 58 female and 103 male. Dobutamine was given in stepwise increasing doses from 5 to 40 ug/kg/min. Mean maximal dose achieved was 31.4 ug/kg/min. The test was positive in 40 (24.8%) patients. Significant coronary artery disease was present in 60 (37.3%) patients. DASE resulted in significant increase in transvalvular mean gradient from 29.3 +/- 12.5 mmHg at rest to 46.3 +/- 19.3 mmHg at peak dose. There was no significant increase in valve area. There were no death, myocardial infarction or episodes of sustained ventricular tachycardia as a result of DASE. The test was terminated when following conditions were revealed: target heart rate (39.1%), left ventricular asynergy (25.5%), maximal established dose achieved (8.1%), side effects (27.3%). The most common side effects with the need of test cessation were arrhythmias (9.9%) and hypotension (9.9%). The most side effects were usually well tolerated without need of medical treatment. We conclude that DASE may be safely performed in patients with AS. Side effects are more common than in patients with coronary disease, but are usually well tolerated without need of medical treatment.

Disenrollment from Medicare HMOs

BACKGROUND

Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare.

OBJECTIVES

To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries.

DESIGN

Cross-sectional analysis of 1994 Medicare data.

PARTICIPANTS AND METHODS

Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment.

RESULTS

The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries.

CONCLUSIONS

On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

Selection experiences in Medicare HMOs: pre-enrollment expenditures

Using 1993 and 1994 data, the authors examine whether beneficiaries who enroll in a Medicare health maintenance organization (HMO), including those enrolling for only a short period of time, have lower expenditures than continuous fee-for-service (FFS) beneficiaries the year prior to enrollment. We also test whether biased selection varies by the level of HMO market penetration and the rate of market-share growth. We find favorable selection associated with enrollment into Medicare HMOs, which declines as market share increases but does not disappear. Among short-term enrollees, we find unfavorable selection, however, selection bias was not sensitive to market characteristics.

The relationship of patient satisfaction with care and clinical outcomes

OBJECTIVES

The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status).

METHODS

A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis.

RESULTS

Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores.

CONCLUSIONS

Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.