The Revolving Door: A Report on U.S. Hospital Readmissions

The U.S. health care system suffers from a chronic malady -- the revolving door syndrome at its hospitals. It is so bad that the federal government says one in five elderly patients is back in the hospital within 30 days of leaving.Some return trips are predictable elements of a treatment plan. Others are unplanned but difficult to prevent: patients go home, new and unexpected problems arise, and they require an immediate trip back to the hospital.But many of these readmissions can and should be prevented. They are the result of a fragmented system of care that too often leaves discharged patients to their own devices, unable to follow instructions they didn't understand, and not taking medications or getting the necessary follow-up care.The federal government has pegged the cost of readmissions for Medicare patients alone at $26 billion annually, and says more than$17 billion of it pays for return trips that need not happen if patients get the right care. This is one reason the Centers for Medicare & Medicaid Services has identified avoidable readmissions as one of the leading problems facing the U.S. health care system and now penalizes hospitals with high rates of readmissions for their heart failure, heart attack, and pneumonia patients. This report is being released in conjunction with the Robert Wood John Foundation's Care About Your Care initiative, which is devoted to improving care transitions when people leave the hospital. It looks at the issue of readmissions in two ways: by the numbers and through the eyes of the people who live them

Trends and Variation in End-of-Life Care for Medicare Beneficiaries With Severe Chronic Illness

Provides an updated analysis of regional and hospital variations in end-of-life care for Medicare beneficiaries with chronic illnesses, including percentage of hospital deaths, days in intensive care units, and physician labor per patient

Characterization of Host-Cell Line Specific Glycosylation Profiles of Early Transmitted/Founder HIV-1 gp120 Envelope Proteins

Glycosylation plays an essential role in regulating protein function by modulating biological, structural, and therapeutic properties. However, due to its inherent heterogeneity and diversity, the comprehensive analysis of protein glycosylation remains a challenge. As part of our continuing effort in the analysis of glycosylation profiles of recombinant HIV-1 envelope-based immunogens, we evaluated and compared the host-cell specific glycosylation pattern of recombinant HIV-1 surface glycoprotein, gp120, derived from clade C transmitted/founder virus 1086.C expressed in Chinese hamster ovary (CHO) and human embryonic kidney containing T antigen (293T) cell lines. We used an integrated glycopeptide-based mass mapping workflow that includes a partial deglycosylation step described in our previous study1 with the inclusion of the fragmentation technique, electron transfer dissociation (ETD), to complement collision induced dissociation (CID). The inclusion of ETD facilitated the analysis by providing additional validation for glycopeptide identification and expanding the identified glycopeptides to include coverage of O-linked glycosylation. The site-specific glycosylation analysis shows that the transmitted/founder 1086.C gp120 expressed in CHO and 293T displayed distinct similarities and differences. For N-linked glycosylation, two sites (N386 and N392), in the V4 region were populated with high mannose glycans in the CHO cell-derived 1086.C gp120, while these sites had a mixture of high mannose and processed glycans in the 293T cell-derived 1086.C gp120. Compositional analysis of O-linked glycans revealed that 293T cell-derived 1086.C gp120 consisted of cores 1, 2, and 4 type O-linked glycans while CHO cell-derived 1086.C exclusively consisted of core 1 type O-linked glycans. Overall, glycosylation site occupancy of the CHO and 293T cell-derived 1086.C gp120 show high degree of similarity except for one site at N88 in the C1 region. This site was partially occupied in 293T-gp120 but fully occupied in CHO-gp120. Site-specific glycopeptide analysis of transmitted/founder 1086.C gp120 expressed in CHO cells revealed the presence of phosphorylated glycans while 293T cell produced 1086.C gp120 glycans were not phosphorylated. While the influence of phosphorylated glycans on immunogenicity is unclear, distinguishing host-cell specific variations in glycosylation profiles provides insights into the similarity (or difference) in recombinant vaccine products. While these differences had minimal effect on envelope antigenicity, they may be important in considering immunogenicity and functional capacities of recombinant envelope proteins produced in different expression systems

Integrating Patient-reported Symptoms in the Arthritis Care Record

Background For knee and hip arthritis patients, self-assessed pain and physical function are central to treatment decisions as well as to clinical and outcomes research. Both paper and electronic health records capture the clinician’s summary of the patient symptoms. Brief patient-reported arthritis symptom assessments have been broadly tested and validated in clinical research, yet have not been integrated into routine office practice. The introduction of electronic health records offers an opportunity for patient direct-entry and real-time scores of standardized symptom assessments to be included in the routine health record. Purpose To both support patient-centered health care in arthritis care and to track aggregate outcomes for longitudinal research, a comprehensive arthritis care record system was designed and implemented with the goal of integrating standardized symptom assessments and clinical metrics in an individual patient health record. Trend pain and function metrics over time, Provide real-time data to patients and clinicians to inform treatment decisions, and, Track aggregate outcomes for quality assessment and research. Study Design The data collection and management system was implemented in the Arthritis and Total Joint Center (TJC) ambulatory clinic at UMass Medical Center. The host system allows development and delivery of custom web-based surveys and serves as a database archive system with interfaces to hospital information services (HIS) and a data storage location. The survey data are divided into 21 tables representing clinical categories (e.g., pain, function, clinical diagnoses) with 259 measures, and 66 among them are used for QA reports. The patient-entered survey data are merged with the clinical data in a structured format, providing comprehensive longitudinal records for individual patients. In addition, real-time symptom trend reports are produced using query, search and analysis functions. System Use The core system was established in 2007, fully operational in 2008, and by June 2010, over 1,000,000 clinical measures had been collected from over 30,000 patients visiting the Arthritis and Total Joint Center (TJC). Among patient measures, around 400,000 measures (28,500 surveys) are related to patient self-assessed symptoms. Conclusions The system implemented in our clinic is a successful model for collecting and integrating patient symptom data with clinical data as part of a patient health record. This template is the foundation for a newly funded national research registry for comparative effectiveness in total joint replacement surgery (FORCE-TJR)

Characterization of Glycosylation Profiles of HIV-1 Transmitted/Founder Envelopes by Mass Spectrometry

This is the published version, also available here: http://dx.doi.org/10.1128/JVI.05053-11.The analysis of HIV-1 envelope carbohydrates is critical to understanding their roles in HIV-1 transmission as well as in binding of envelope to HIV-1 antibodies. However, direct analysis of protein glycosylation by glycopeptide-based mass mapping approaches involves structural simplification of proteins with the use of a protease followed by an isolation and/or enrichment step before mass analysis. The successful completion of glycosylation analysis is still a major analytical challenge due to the complexity of samples, wide dynamic range of glycopeptide concentrations, and glycosylation heterogeneity. Here, we use a novel experimental workflow that includes an up-front complete or partial enzymatic deglycosylation step before trypsin digestion to characterize the glycosylation patterns and maximize the glycosylation coverage of two recombinant HIV-1 transmitted/founder envelope oligomers derived from clade B and C viruses isolated from acute infection and expressed in 293T cells. Our results show that both transmitted/founder Envs had similar degrees of glycosylation site occupancy as well as similar glycan profiles. Compared to 293T-derived recombinant Envs from viruses isolated from chronic HIV-1, transmitted/founder Envs displayed marked differences in their glycosylation site occupancies and in their amounts of complex glycans. Our analysis reveals that the glycosylation patterns of transmitted/founder Envs from two different clades (B and C) are more similar to each other than they are to the glycosylation patterns of chronic HIV-1 Envs derived from their own clades

Health System Characteristics and Rates of Readmission After Acute Myocardial Infarction in the United States

Background: Interventions to reduce early readmissions have focused on patient characteristics and the importance of early follow‐up; however, less is known about the characteristics of health systems, including quality, capacity, and intensity, and their influence on readmission rates in the United States. Therefore, we examined the association of hospital patterns of medical care with rates of 30‐day readmission. Methods and Results: Medicare beneficiaries hospitalized for an AMI (n=188 611) between 2008 and 2009 in 1088 hospitals in the United States were included in our cohort. We tested the association between hospital patterns of medical care quality (discharge planning care quality), capacity (hospital size measured as the number of beds, hospital‐level Medicare all medical admission rates, supply of primary care physicians and cardiologists), and intensity (measures of care during the last 6 months of life) on CMS risk‐adjusted rates of 30‐day readmission using Poisson multilevel mixed‐effects models adjusting for patient‐ and hospital‐level covariates. There were 38 350 readmissions at 30‐days (20.3%) AMI discharges. Controlling for patient characteristics, measures of hospital care associated with higher rates of readmission included higher hospital‐level rates for all medical admissions, per capita primary care physicians and cardiologists, and last 6 months of life care intensity measures including increased number of hospital days, number of ICU days, number of physician visits, and 10 or more different physicians seen during the last 6 months of life. Better discharge quality and larger hospitals were associated with lower rates of readmission. Conclusions: In addition to quality of care, high 30‐day readmission rates are associated with hospital‐level measures of capacity and intensity. Efforts to reduce readmission rates may need to address these broader patterns of medical care

A Web-Based Treatment Decision Support Tool for Patients With Advanced Knee Arthritis: Evaluation of User Interface and Content Design

BACKGROUND: Data-driven surgical decisions will ensure proper use and timing of surgical care. We developed a Web-based patient-centered treatment decision and assessment tool to guide treatment decisions among patients with advanced knee osteoarthritis who are considering total knee replacement surgery. OBJECTIVE: The aim of this study was to examine user experience and acceptance of the Web-based treatment decision support tool among older adults. METHODS: User-centered formative and summative evaluations were conducted for the tool. A sample of 28 patients who were considering total knee replacement participated in the study. Participants\u27 responses to the user interface design, the clarity of information, as well as usefulness, satisfaction, and acceptance of the tool were collected through qualitative (ie, individual patient interviews) and quantitative (ie, standardized Computer System Usability Questionnaire) methods. RESULTS: Participants were older adults with a mean age of 63 (SD 11) years. Three-quarters of them had no technical questions using the tool. User interface design recommendations included larger fonts, bigger buttons, less colors, simpler navigation without extra next page click, less mouse movement, and clearer illustrations with simple graphs. Color-coded bar charts and outcome-specific graphs with positive action were easiest for them to understand the outcomes data. Questionnaire data revealed high satisfaction with the tool usefulness and interface quality, and also showed ease of use of the tool, regardless of age or educational status. CONCLUSIONS: We evaluated the usability of a patient-centered decision support tool designed for advanced knee arthritis patients to facilitate their knee osteoarthritis treatment decision making. The lessons learned can inform other decision support tools to improve interface and content design for older patients\u27 use

GlycoPep Grader: A web-based utility for assigning the composition of N-linked glycopeptides

GlycoPep Grader (GPG) is a freely-available software tool designed to accelerate the process of accurately determining glycopeptide composition from tandem mass spectrometric data. GPG relies on the identification of unique dissociation patterns shown for high mannose, hybrid, and complex N-linked glycoprotein types, including patterns specific to those structures containing fucose or sialic acid residues. The novel GPG scoring algorithm scores potential candidate compositions of the same nominal mass against MS/MS data through evaluation of the Y1 ion and other peptide-containing product ions, across multiple charge states, when applicable. In addition to evaluating the peptide portions of a given glycopeptide, the GPG algorithm predicts and scores product ions that result from unique neutral losses of terminal glycans. GPG has been applied to a variety of glycoproteins, including RNase B, asialofetuin and transferrin, and the HIV envelope glycoprotein, CON-S gp140 CFI. The GPG software is implemented predominantly in PostgreSQL, with PHP as the presentation tier, and is publically accessible online. Thus far, the algorithm has identified the correct compositional assignment from multiple candidate N-glycopeptides in all tests performed