Implementation of the Reengineered Discharge Process and Transitional Care Management at a Rural Critical Access Hospital

Healthcare in the United States is changing from a fee-for-service to a value based healthcare delivery system. One area of national focus is reducing 30-day hospital readmissions by providing high-quality transitions-of-care. Patients leaving the hospital without proper assessment of home care needs, patient education, and coordination of care run into barriers managing health conditions, which contributes to hospital readmissions. Poor transitions-of-care contribute to deterioration of health leading to acute care utilization and hospital readmissions, which is costly for healthcare organizations, insurance payers, and individuals. In 2017, the value based healthcare structure will be decreasing reimbursement to hospitals that have 30-day hospital readmissions higher than the national average. Providing high-quality transitions-of-care is a way to bring value to a health care delivery system. The Agency for Health Research and Quality and Centers for Medicaid and Medicare Services have significant evidence that implementing the Reengineered Discharge process and utilizing the Transitional Care Management program reduces 30-day hospital readmissions and acute care utilization through the provision of high-quality transitions-of-care. This quality improvement project standardizes all hospital discharges by incorporating the Reengineered Discharge process and includes eligible Medicare recipients in the Transitional Care Management program. This project increased the number of patients who received followup appointments, follow-up phone calls, and patients included in Transitional Care Management. Follow-up appointments for inpatient status increased by 22.5% and follow-up phone calls increased by 16.7%, enabling billing for seventeen Transitional Care Management patients

Adding Patient-Reported Outcomes to Medicare's Oncology Value-Based Payment Model

On November 1,2019, the Centers for Medicare & Medicaid Services (CMS) Innovation Center released details of a proposed alternative payment model for medical oncology care, called Oncology Care First (OCF), for public comment. The OCF model will succeed the Oncology Care Model (OCM), which will expire at the end of 2020. When it started in 2016, the OCM,which was voluntary, was important in oncology due to its emphasis on value-based care transformation

Application of 50 MHz doppler radar wind profiler to launch operations at Kennedy Space Center and Cape Canaveral Air Station

This paper presents a case study where a significant wind shift, not detected by jimspheres, was detected by the 50 MHz DRWP (Doppler Radar Wind Profiler) and evaluated to be acceptable prior to the launch of a Shuttle. This case study illustrates the importance of frequent upper air wind measurements for detecting significant rapidly changing features as well as for providing confidence that the features really exist and are not due to instrumentation error. Had the release of the jimsphere been timed such that it would have detected the entire wind shift, there would not have been sufficient time to release another jimsphere to confirm the existence of the feature prior to the scheduled launch. We found that using a temporal median filter on the one minute spectral estimates coupled with a constraining window about a first guess velocity effectively removes nearly all spurious signals from the velocity profile generated by NASA's 50 MHz DRWP while boosting the temporal resolution to as high as one profile every 3 minutes. The higher temporal resolution of the 50 MHz DRWP using the signal processing algorithm described in this paper ensures the detection of rapidly changing features as well as provides the confidence that the features are genuine. Further benefit is gained when the profiles generated by the DRWP are examined in relation to the profiles measured by jimspheres and/or rawinsondes. The redundancy offered by using two independent measurements can dispel or confirm any suspicion regarding instrumentation error or malfunction and wind profiles can be examined in light of their respective instruments' strengths and weaknesses

Effects of bone marrow‐derived mesenchymal stromal cells on gene expression in human alveolar type II cells exposed to TNF‐α, IL‐1β, and IFN‐γ

The acute respiratory distress syndrome (ARDS) is common in critically ill patients and has a high mortality rate. Mesenchymal stromal cells (MSCs) have demonstrated therapeutic potential in animal models of ARDS, and their benefits occur in part through interactions with alveolar type II (ATII) cells. However, the effects that MSCs have on human ATII cells have not been well studied. Using previously published microarray data, we performed genome‐wide differential gene expression analyses of human ATII cells that were (1) unstimulated, (2) exposed to proinflammatory cytokines (CytoMix), or (3) exposed to proinflammatory cytokines plus MSCs. Findings were validated by qPCR. Alveolar type II cells differentially expressed hundreds of genes when exposed either to proinflammatory cytokines or to proinflammatory cytokines plus MSCs. Stimulation with proinflammatory cytokines increased expression of inflammatory genes and downregulated genes related to surfactant function and alveolar fluid clearance. Some of these changes, including expression of some cytokines and genes related to surfactant, were reversed by exposure to MSCs. In addition, MSCs induced upregulation of other potentially beneficial genes, such as those related to extracellular matrix remodeling. We confirmed several of these gene expression changes by qPCR. Thus, ATII cells downregulate genes associated with surfactant and alveolar fluid clearance when exposed to inflammatory cytokines, and mesenchymal stromal cells partially reverse many of these gene expression changes.Mesenchymal stromal cells (MSCs) have therapeutic potential for the acute respiratory distress syndrome, and their benefits occur in part through interactions with alveolar type II (ATII) cells. We performed genome‐wide differential gene expression analyses of human ATII cells that were (1) unstimulated, (2) exposed to proinflammatory cytokines (CytoMix), or (3) exposed to CytoMix plus MSCs. Stimulation with CytoMix increased expression of inflammatory genes and downregulated genes related to surfactant function and alveolar fluid clearance, and several gene expression changes were reversed by exposure to MSCs.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/145579/1/phy213831_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/145579/2/phy213831.pd

High-dimensional analysis reveals distinct endotypes in patients with idiopathic inflammatory myopathies

The idiopathic inflammatory myopathies (IIM) are a rare clinically heterogeneous group of conditions affecting the skin, muscle, joint, and lung in various combinations. While myositis specific autoantibodies are well described, we postulate that broader immune endotypes exist in IIM spanning B cell, T cell, and monocyte compartments. This study aims to identify immune endotypes through detailed immunophenotyping of peripheral blood mononuclear cells (PBMCs) in IIM patients compared to healthy controls. We collected PBMCs from 17 patients with a clinical diagnosis of inflammatory myositis and characterized the B, T, and myeloid cell subsets using mass cytometry by time of flight (CyTOF). Data were analyzed using a combination of the dimensionality reduction algorithm t-distributed stochastic neighbor embedding (t-SNE), cluster identification, characterization, and regression (CITRUS), and marker enrichment modeling (MEM); supervised biaxial gating validated populations identified by these methods to be differentially abundant between groups. Using these approaches, we identified shared immunologic features across all IIM patients, despite different clinical features, as well as two distinct immune endotypes. All IIM patients had decreased surface expression of RP105/CD180 on B cells and a reduction in circulating CD3+CXCR3+ subsets relative to healthy controls. One IIM endotype featured CXCR4 upregulation across all cellular compartments. The second endotype was hallmarked by an increased frequency of CD19+CD21loCD11c+ and CD3+CD4+PD1+ subsets. The experimental and analytical methods we describe here are broadly applicable to studying other immune-mediated diseases (e.g., autoimmunity, immunodeficiency) or protective immune responses (e.g., infection, vaccination)

Network-Targeted Approach and Postoperative Resting-State Functional Magnetic Resonance Imaging Are Associated with Seizure Outcome

Objective Postoperative resting‐state functional magnetic resonance imaging (MRI) in children with intractable epilepsy has not been quantified in relation to seizure outcome. Therefore, its value as a biomarker for epileptogenic pathology is not well understood. Methods In a sample of children with intractable epilepsy who underwent prospective resting‐state seizure onset zone (SOZ)‐targeted epilepsy surgery, postoperative resting‐state functional MRI (rs‐fMRI) was performed 6 to 12 months later. Graded normalization of the postoperative resting‐state SOZ was compared to seizure outcomes, patient, surgery, and anatomical MRI characteristics. Results A total of 64 cases were evaluated. Network‐targeted surgery, followed by postoperative rs‐fMRI normalization was significantly (p < 0.001) correlated with seizure reduction, with a Spearman rank correlation coefficient of 0.83. Of 39 cases with postoperative rs‐fMRI SOZ normalization, 38 (97%) became completely seizure free. In contrast, of the 25 cases without complete rs‐fMRI SOZ normalization, only 3 (5%) became seizure free. The accuracy of rs‐fMRI as a biomarker predicting seizure freedom is 94%, with 96% sensitivity and 93% specificity. Interpretation Among seizure localization techniques in pediatric epilepsy, network‐targeted surgery, followed by postoperative rs‐fMRI normalization, has high correlation with seizure freedom. This study shows that rs‐fMRI SOZ can be used as a biomarker of the epileptogenic zone, and postoperative rs‐fMRI normalization is a biomarker for SOZ quiescence

CD19 + CD21lo/neg cells are increased in systemic sclerosis-associated interstitial lung disease

Interstitial lung disease (ILD) represents a significant cause of morbidity and mortality in systemic sclerosis (SSc). The purpose of this study was to examine recirculating lymphocytes from SSc patients for potential biomarkers of interstitial lung disease (ILD). Peripheral blood mononuclear cells (PBMCs) were isolated from patients with SSc and healthy controls enrolled in the Vanderbilt University Myositis and Scleroderma Treatment Initiative Center cohort between 9/2017-6/2019. Clinical phenotyping was performed by chart abstraction. Immunophenotyping was performed using both mass cytometry and fluorescence cytometry combined with t-distributed stochastic neighbor embedding analysis and traditional biaxial gating. This study included 34 patients with SSc-ILD, 14 patients without SSc-ILD, and 25 healthy controls. CD2

Topologically-Driven Linear Magnetoresistance in Helimagnetic FeP

The helimagnet FeP is part of a family of binary pnictide materials with the MnP-type structure which share a nonsymmorphic crystal symmetry that preserves generic band structure characteristics through changes in elemental composition. It shows many similarities, including in its magnetic order, to isostructural CrAs and MnP, two compounds that are driven to superconductivity under applied pressure. Here we present a series of high magnetic field experiments on high quality single crystals of FeP, showing that the resistance not only increases without saturation by up to several hundred times its zero field value by 35 T, but that it also exhibits an anomalously linear field dependence over the entire field range when the field is aligned precisely along the crystallographic c-axis. A close comparison of quantum oscillation frequencies to electronic structure calculations links this orientation to a semi-Dirac point in the band structure which disperses linearly in a single direction in the plane perpendicular to field, a symmetry-protected feature of this entire material family. We show that the two striking features of MR-large amplitude and linear field dependence-arise separately in this system, with the latter likely due to a combination of ordered magnetism and topological band structure.Comment: 10 pages, 6 figure