The Impact of Expanded Tele-Mental Health on Quality-Of-Care Indicators: A Three-Pronged Regression Analysis at Los Angeles County’s Department of Mental Health

Background: The use of Tele-Mental Health (TMH) skyrocketed after the COVID-19 pandemic led to the announcement of a public health emergency in March 2020. This rise coincided with soaring rates of mental health issues and increasing demand for accessible and sustainable treatment, all while meeting physical distancing requirements. TMH use is theorized to improve timely access to care and provide opportunities to improve quality of care indicators in individuals and at the health systems level. Research Question: How has the widespread adoption of Tele-Mental Health changed quality of care (QoC) indicators among patients of LA County Department of Mental Health’s (LAC DMH) Directly Operated (DO) clinics? Methods: The study design for this analysis is a multivariate quasi-experimental study with a pseudo-control. A three-pronged approach to the analysis was used to tackle the research question and two QoC indicators are defined as the binary “Timely” variable and the continuous “Appointment Adherence” variable. All the models adjusted for covariates (demographic variables and the ratio of patients to providers) and mediators (the Request Type, which determines the timely standards of care). A “Pandemic Time” variable referred to if the data point took place before March 19, 2020, which referred to the date that the Safer-at-Home Order (SHO) was announced, or after. The first prong, approach A, used a logistic regression for the Timely variable and an OLS regression for Appointment Adherence; it compared users of TMH to those receiving in-person care and included the pandemic time variable. Approach B did the same but accounted for crowding effects over time by adding an offset variable for the ratio of appointment requests to providers. An ANOVA for the first two approaches determined the effect size of the variables and those that had an effect size over 0.01 were used to build a parsimonious model for Approach C. Approach C used Interrupted Time Series models to compare the actual changes in QoC indicators from March 2017 to February 2021 with the expansion of TMH taking place post-SHO (March 2020-February 2021) to a pseudo-control for the whole health system. Approach C transformed the “Timely” and “TMH” variables to be continuous by transforming them to the percent of the total patients that received timely care and the percent of services delivered via TMH. Results: Approach A found that TMH use was significantly associated (p=0.00) with a 15% reduced probability of receiving a timely appointment compared to those that received in-person care, though the probability of receiving a timely appointment increased 10% post-SHO compared to pre-SHO (p=0.00). Approach A also found that TMH use was significantly associated with a 2.5% increase in Appointment Adherence (p=0.00) compared to those receiving in-person care, but that post-SHO there was a 4% decrease in Appointment Adherence as compared to pre-SHO (p=0.00). Approach B found that TMH use was significantly associated (p=0.00) with a 6% decrease in the probability to receive a timely appointment when accounting for the crowding effect; TMH use was not significantly associated with Appointment Adherence. Approach C used Interrupted Time Series regression to find that there was no significant association between TMH use and receiving a timely appointment and that the fluctuations in timely care both exceeded and fell short of the pseudo-control. TMH adoption did however have a significant relationship at a 10% level (p=0.09) with appointment adherence, in which every additional percent of TMH adoption by DMH was associated with a 7% increase in appointment adherence compared to the pseudo-control. Conclusion: TMH use, timely access to care, and Appointment Adherence all increased post-SHO. DMH’s adoption to TMH is associated with an increased likelihood of Appointment Adherence compared to if DMH kept TMH use at pre-SHO levels. Request Types with shorter timely standards are more likely to receive a timely appointment and to adhere to appointment plans when the health system had adopted TMH. However, there was no significant association exists between the adoption of TMH and Timely care within the health system. Among individuals that used TMH, there was a decreased likelihood to receive Timely care as compared to those receiving in-person care, though the likelihood of receiving timely appointments increase post-SHO. Individuals that used TMH were more likely than those that received in-person care to adhere to their appointment schedules. Future research should examine the impact of TMH use on QoC indicators over a longer time-period. Additionally, TMH should be evaluated as a promising intervention to reduce disparities in care, especially when adjusting for language and racial concordance, and to improve cost-effectiveness through redistribution of resources

Stevens-Johnson Syndrome

This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of Stevens-Johnson Syndrome

Adequacy of Cancer Screening in Adult Women with Congenital Heart Disease

Adults with congenital heart disease (ACHD) face noncardiac healthcare challenges as the population ages. We assessed whether women with ACHD have comparable cancer screening rates to non-ACHD women in a cardiac practice and to the general population. We performed a retrospective review of 175 adult women seen in a cardiac care center in 2009–2011. Data on Pap tests, mammography, and colonoscopies, were collected through electronic medical records and primary care provider records. Adequate documentation was available for 100 individuals with ACHD and 40 comparator cardiac patients. The adequacy of screening was determined using guidelines set forth by the American Cancer Society in 2010. Compared with the national average, ACHD patients had significantly lower rates of Pap tests (60% versus 83%, P < 0.001) and mammography (48% versus 72%, P < 0.001). Compared with non-ACHD women in the same practice, ACHD patients had consistently lower rates of mammography (48% versus 81%, P = 0.02) and colonoscopies (54% versus 82%, P = 0.23). As the population of ACHD individuals ages, attention to cancer screening becomes increasingly important but may be overlooked in this population. Primary care physicians and cardiologists should collaborate to ensure appropriate cancer screening for this growing population

Thousands of small, novel genes predicted in global phage genomes

Small genes (40,000 small-gene families in ∼2.3 million phage genome contigs. We find that small genes in phage genomes are approximately 3-fold more prevalent than in host prokaryotic genomes. Our approach enriches for small genes that are translated in microbiomes, suggesting the small genes identified are coding. More than 9,000 families encode potentially secreted or transmembrane proteins, more than 5,000 families encode predicted anti-CRISPR proteins, and more than 500 families encode predicted antimicrobial proteins. By combining homology and genomic-neighborhood analyses, we reveal substantial novelty and diversity within phage biology, including small phage genes found in multiple host phyla, small genes encoding proteins that play essential roles in host infection, and small genes that share genomic neighborhoods and whose encoded proteins may share related functions

Elimination of Transcoarctation Pressure Gradients Has No Impact on Left Ventricular Function or Aortic Shear Stress After Intervention in Patients With Mild Coarctation

Objectives: This study sought to investigate the impact of transcatheter intervention on left ventricular function and aortic hemodynamics in patients with mild coarctation of the aorta (COA). Background: The optimal method and timing of transcatheter intervention for COA remains unclear, especially when the severity of COA is mild (peak-to-peak transcoarctation pressure gradient  < 20 mm Hg). Debate rages regarding the risk/benefit ratio of intervention versus long-term effects of persistent minimal gradient in this heterogeneous population with differing blood pressures, ventricular function, and peripheral perfusion. Methods: We developed a unique computational fluid dynamics and lumped parameter modeling framework based on patient-specific hemodynamic input parameters and validated it against patient-specific clinical outcomes (before and after intervention). We used clinically measured hemodynamic metrics and imaging of the aorta and the left ventricle in 34 patients with mild COA to make these correlations. Results: Despite dramatic reduction in the transcoarctation pressure gradient (catheter and Doppler echocardiography pressure gradients reduced by 75% and 47.3%, respectively), there was only modest effect on aortic flow and no significant impact on aortic shear stress (the maximum time-averaged wall shear stress in descending aorta was reduced 5.1%). In no patient did transcatheter intervention improve left ventricular function (e.g., stroke work and normalized stroke work were reduced by only 4.48% and 3.9%, respectively). Conclusions: Transcatheter intervention that successfully relieves mild COA pressure gradients does not translate to decreased myocardial strain. The effects of the intervention were determined to the greatest degree by ventricular–vascular coupling hemodynamics and provide a novel valuable mechanism to evaluate patients with COA that may influence clinical practice. Key Words: aortic hemodynamics, left ventricle function, mild coarctation, peak-to-peak pressure gradient, transcatheter interventionNational Institute of Mental Health (U.S.) (R01 GM 49039)American Heart Association (Postdoctoral Fellowship 16POST26420039

Diversity of resistance mechanisms in carbapenem-resistant Enterobacteriaceae at a health care system in Northern California, from 2013 to 2016

The mechanism of resistance in carbapenem-resistant Enterobacteriaceae (CRE) has therapeutic implications. We comprehensively characterized emerging mechanisms of resistance in CRE between 2013 and 2016 at a health system in Northern California. A total of 38.7% (24/62) of CRE isolates were carbapenemase gene-positive, comprising 25.0% (6/24) blaOXA-48 like, 20.8% (5/24) blaKPC, 20.8% (5/24) blaNDM, 20.8% (5/24) blaSME, 8.3% (2/24) blaIMP, and 4.2% (1/24) blaVIM. Between carbapenemases and porin loss, the resistance mechanism was identified in 95.2% (59/62) of CRE isolates. Isolates expressing blaKPC were 100% susceptible to ceftazidime–avibactam, meropenem–vaborbactam, and imipenem–relebactam; blaOXA-48 like–positive isolates were 100% susceptible to ceftazidime–avibactam; and metallo β-lactamase–positive isolates were nearly all nonsusceptible to above antibiotics. Carbapenemase gene-negative CRE were 100% (38/38), 92.1% (35/38), 89.5% (34/38), and 31.6% (12/38) susceptible to ceftazidime–avibactam, meropenem–vaborbactam, imipenem–relebactam, and ceftolozane–tazobactam, respectively. None of the CRE strains were identical by whole genome sequencing. At this health system, CRE were mediated by diverse mechanisms with predictable susceptibility to newer β-lactamase inhibitors

A Multicenter, Phase 2, Randomized, Placebo-Controlled, Double-Blind, Parallel-Group, Dose-Finding Trial of the Oral Factor XIa Inhibitor Asundexian to Prevent Adverse Cardiovascular Outcomes Following Acute Myocardial Infarction

Background: Oral factor XIa (FXIa) inhibitors may modulate coagulation to prevent thromboembolic events without significantly increasing bleeding. We explored the pharmacodynamics, safety, and efficacy of the oral FXIa inhibitor asundexian for secondary prevention after acute myocardial infarction (MI)

Medication Complications in Extracorporeal Membrane Oxygenation.

The need for extracorporeal membrane oxygenation (ECMO) therapy is a marker of disease severity for which multiple medications are required. The therapy causes physiologic changes that impact drug pharmacokinetics. These changes can lead to exposure-driven decreases in efficacy or increased incidence of side effects. The pharmacokinetic changes are drug specific and largely undefined for most drugs. We review available drug dosing data and provide guidance for use in the ECMO patient population

GRFS and CRFS in alternative donor hematopoietic cell transplantation for pediatric patients with acute leukemia.

We report graft-versus-host disease (GVHD)-free relapse-free survival (GRFS) (a composite end point of survival without grade III-IV acute GVHD [aGVHD], systemic therapy-requiring chronic GVHD [cGVHD], or relapse) and cGVHD-free relapse-free survival (CRFS) among pediatric patients with acute leukemia (n = 1613) who underwent transplantation with 1 antigen-mismatched (7/8) bone marrow (BM; n = 172) or umbilical cord blood (UCB; n = 1441). Multivariate analysis was performed using Cox proportional hazards models. To account for multiple testing, P \u3c .01 for the donor/graft variable was considered statistically significant. Clinical characteristics were similar between UCB and 7/8 BM recipients, because most had acute lymphoblastic leukemia (62%), 64% received total body irradiation-based conditioning, and 60% received anti-thymocyte globulin or alemtuzumab. Methotrexate-based GVHD prophylaxis was more common with 7/8 BM (79%) than with UCB (15%), in which mycophenolate mofetil was commonly used. The univariate estimates of GRFS and CRFS were 22% (95% confidence interval [CI], 16-29) and 27% (95% CI, 20-34), respectively, with 7/8 BM and 33% (95% CI, 31-36) and 38% (95% CI, 35-40), respectively, with UCB (P \u3c .001). In multivariate analysis, 7/8 BM vs UCB had similar GRFS (hazard ratio [HR], 1.12; 95% CI, 0.87-1.45; P = .39), CRFS (HR, 1.06; 95% CI, 0.82-1.38; P = .66), overall survival (HR, 1.07; 95% CI, 0.80-1.44; P = .66), and relapse (HR, 1.44; 95% CI, 1.03-2.02; P = .03). However, the 7/8 BM group had a significantly higher risk for grade III-IV aGVHD (HR, 1.70; 95% CI, 1.16-2.48; P = .006) compared with the UCB group. UCB and 7/8 BM groups had similar outcomes, as measured by GRFS and CRFS. However, given the higher risk for grade III-IV aGVHD, UCB might be preferred for patients lacking matched donors. © 2019 American Society of Hematology. All rights reserved