Effects of Patient-Centered Medical Home model on primary care

The Patient-Centered Medical Home (PCMH) model has been touted as one of the most promising reform efforts of the largely inefficient U.S. healthcare system. In comparison to the current primary care system, the PCMH is a care delivery model that is based on the principles of care-coordination, enhanced access, and team-based collaboration as a means of providing comprehensive, patient-centered medical care. The current literature contains a limited number of review articles synthesizing the data of numerous PCMH outcome studies. Even a smaller number draws definitive conclusions as to whether PCMH is a viable model upon which to reform the US healthcare system. This literature review will examine the available results of PCMH studies in light of their ability to 1) decrease the overall cost of healthcare 2) increase the efficiency of the continuity of care and 3) to increase positive patient outcomes through proactive patient care. Additionally, these results will be examined in regard to their longevity as a viable model of reform and specifically as it compares to the current US healthcare system. This review will determine whether there is statistical evidence that the Patient-Centered Medical Home is a successful model to decrease healthcare costs, increase healthcare efficiency as well as increasing positive patient outcomes. In addition, this review hopes to point to ways in which the model could be improved in order to more completely achieve the goals listed above

Risks to biodiversity and coastal livelihoods from artisanal elasmobranch fisheries in a Least Developed Country: The Gambia (West Africa)

Developing nations in tropical regions harbour rich biological resources on which humans depend for food, income and employment, yet data to aid their management is often lacking. In West Africa, the diversity and fisheries of elasmobranchs are poorly documented, despite them being known to be economically important and vulnerable to overexploitation. Rapid qualitative surveys of fish processing and landing sites in The Gambia from 2010-2018 revealed valuable new data on species composition, biology, relative abundance, fisheries and utilisation by humans. Diversity and abundance was dominated by batoids, with a major component comprising a large guitarfish (Glaucostegus cemiculus) that was apparently targeted, and a small whipray (Fontitrygon margaritella). Nearly all taxa recorded are classified by the IUCN Red List as Critically Endangered (angel sharks Squatina spp.), Endangered, Data Deficient, or Not Evaluated; several were endemic, of exceptional evolutionary distinctness, cryptic, possibly undescribed, and rare (including stingray Hypanus rudis not apparently recorded since description in 1870). Significant threats to biodiversity, coastal livelihoods and possibly food security are identified based on the apparent importance of elasmobranch fisheries and processing; the known inability of key taxa to withstand intensive fisheries; ‘fishing down the food web’ by intensive utilisation of F. margaritella; and the absence or rarity of previously common elasmobranch species that may be severely depleted in the region. This study provides data that may act as a starting point to aid sustainability accreditation of local fin-fisheries, and demonstrates the value of inexpensive and low-resolution data collection in developing countries

The Pandemic Leadership Model: A Study of Medical Student Values During COVID-19

Background: Leadership training in medical school continues to grow. Little information exists to guide leadership program development. Concurrently, the COVID-19 pandemic provides a real-world crucible of leadership, allowing insight into qualities and characteristics medical students value. We aim to determine what students value in leadership during a pandemic and the implicit framework students use. Methods: We conducted a cross-sectional, qualitative study using a five-item novel survey instrument developed by a consensus group of experts from family medicine, leadership development, medical education, and survey research to elicit student perceptions of effective and ineffective leadership qualities and examples during the COVID-19 pandemic at the University of Michigan Medical School. We used thematic analysis to identify overarching themes to build a model of leadership integrated with existing theory. Results: 162 students participated across all years of medical school. We identified themes of Communication, Other-Orientation, Personal Characteristics, Decisive Action, and Use of Information. These five themes were then built into the model of Pandemic Leadership within the context of complexity leadership theory and collective leadership theory. This model represents qualities and characteristics students value in good leaders during a crisis. Conclusion: This study is unique in its focus on student perceptions of leadership qualities during a real-world laboratory for leadership. We hope that this information, along with the pandemic leadership model, can serve as the first step toward relevant leadership training programs in medical education. Leadership training programs in medical education would likely benefit from grounding in the student values identified by this study

Impact of Degree of Commissural Opening After Percutaneous Mitral Commissurotomy on Long-Term Outcome

ObjectivesWe sought to evaluate the prognostic value of the degree of commissural opening (CO) on outcome.BackgroundCommissural opening is the main mechanism by which the mitral valve area (MVA) increases after percutaneous mitral commissurotomy (PMC) but its impact on long-term outcome has never been evaluated.MethodsOf 1,024 consecutive patients with severe MS who underwent PMC, degree of CO was prospectively evaluated in 875 patients (age 48 ± 13 years, female 83%, New York Heart Association (NYHA) functional class III/IV 75%) with good immediate PMC results (MVA ≥1.5 cm2 and no mitral regurgitation >2/4). These 875 patients were divided into 3 groups: both commissures only partially opened or not split (Group 1, n = 189), 1 commissure completely split (Group 2; n = 459), and both commissures completely split (Group 3; n = 227). During a follow-up of 55 ± 28 months, following clinical end points were collected: death, cardiovascular death, need for mitral valve surgery or repeat dilation, and NYHA functional class.ResultsBefore PMC, patients in Group 1 were older, more often in NYHA functional class III/IV, but MVA and mean gradient were not different (p ≥ 0.50). Immediately after PMC, there were significant differences between groups with regard to mean gradient (Group 1, 5.1 ± 2.1 mm Hg; Group 2, 4.5 ± 1.7 mm Hg; Group 3, 4.0 ± 1.6 mm Hg; p < 0.0001) and MVA (Group 1, 1.8 ± 0.2 cm2; Group 2, 1.9 ± 0.2 cm2; Group 3, 2.1 ± 0.3 cm2; p < 0.0001). The 10-year rate of good functional results (survival without need for mitral surgery or repeat dilation and NYHA functional class I or II at last follow-up) was significantly higher in Group 3 (76 ± 5%) than in Groups 1 and 2 (39 ± 8% and 57 ± 11%, respectively; p < 0.0001). In multivariable analysis, either the degree of CO or the MVA was an independent predictor of good late functional results (p < 0.05).ConclusionsComplete CO is associated with larger MVA, smaller gradients, and functional improvement. The degree of CO provides important prognostic information and thus should be systematically evaluated during and after PMC and considered as a complementary measure of the procedural success in addition to the MVA, not always easy to assess

Contemporary Management of Severe Symptomatic Aortic Stenosis

There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS).This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey.Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention.A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age-adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001).A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians

Thrombolysis with tissue plasminogen activator in acute myocardial infarction: no additional benefit from immediate percutaneous coronary angioplasty

A randomised trial of 367 patients with acute myocardial infarction was performed to determine whether an invasive strategy combining thrombolysis with recombinant tissue-type plasminogen activator (rTPA), heparin, and acetylsalicylic acid, and immediate percutaneous transluminal coronary angioplasty (PTCA) would be superior to a noninvasive strategy with the same medical treatment but without immediate angiography and PTCA. Intravenous infusion of 100 mg rTPA was started within 5 h after onset of symptoms (median 156 min). Angiography was performed 6-165 min later in 180 out of 183 patients allocated to the invasive strategy; 184 patients were allocated to the non-invasive strategy. Immediate PTCA reduced the percentage stenosis of the infarc

Costs and cost-effectiveness of cervical cancer screening strategies in women living with HIV in Burkina Faso: The HPV in Africa Research Partnership (HARP) study.

INTRODUCTION: This study estimated the costs and incremental cost per case detected of screening strategies for high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) attending HIV clinics in Burkina Faso. METHODS: The direct healthcare provider costs of screening tests (visual inspection with acetic acid (VIA), VIA combined visual inspection with Lugol's iodine (VIA/VILI), cytology and a rapid HPV DNA test (careHPV)) and confirmatory tests (colposcopy, directed biopsy and systematic four-quadrant (4Q) biopsy) were collected alongside the HPV in Africa Research Partnership (HARP) study. A model was developed for a hypothetical cohort of 1000 WLHIV using data on CIN2+ prevalence and the sensitivity of the screening tests. Costs are reported in USD (2019). RESULTS: The study enrolled 554 WLHIV with median age 36 years (inter-quartile range, 31-41) and CIN2+ prevalence of 5.8%. The average cost per screening test ranged from US$3.2 for VIA to US$24.8 for cytology. Compared to VIA alone, the incremental cost per CIN2+ case detected was US$48 for VIA/VILI and US$814 for careHPV. Despite higher costs, careHPV was more sensitive for CIN2+ cases detected compared to VIA/VILI (97% and 56%, respectively). The cost of colposcopy was US$6.6 per person while directed biopsy was US$33.0 and 4Q biopsy was US$48.0. CONCLUSION: Depending on the willingness to pay for the detection of a case of cervical cancer, decision makers in Burkina Faso can consider a variety of cervical cancer screening strategies for WLHIV. While careHPV is more costly, it has the potential to be cost-effective depending on the willingness to pay threshold. Future research should explore the lifetime costs and benefits of cervical cancer screening to enable comparisons with interventions for other diseases