Association between hospital private equity acquisition and outcomes of acute medical conditions among Medicare beneficiaries

Importance: As private equity (PE) acquisitions of short-term acute care hospitals (ACHs) continue, their impact on the care of medically vulnerable older adults remains largely unexplored. Objective: To investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions. Design, Setting, and Participants: This cross-sectional study used a generalized difference-in-differences approach to compare 21 091 222 patients admitted to PE-acquired vs non-PE-acquired short-term ACHs between January 1, 2001, and December 31, 2018, at least 3 years before to 3 years after PE acquisition. The analysis was conducted between December 28, 2020, and February 1, 2022. Differences were estimated using both facility and hospital service area fixed effects. To assess the robustness of findings, regressions were reestimated after including fixed effects of patient county of origin to account for geographic differences in underlying health risks. Two subset analyses were also conducted: (1) an analysis including only hospitals in hospital referral regions with at least 1 PE acquisition and (2) an analysis stratified by participation in the Hospital Corporation of America 2006 acquisition. The study included Medicare beneficiaries 66 years and older who were hospitalized with 1 of 5 acute medical conditions: acute myocardial infarction (AMI), acute stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and pneumonia. Exposures: Acquisition of hospitals by PE firms. Main Outcomes and Measures: Comorbidity burden (measured by Elixhauser comorbidity score), hospital length of stay, in-hospital mortality, 30-day mortality, 30-day readmission, and 30-day episode payments. Results: Among 21 091 222 total Medicare beneficiaries admitted to ACHs between 2001 and 2018, 20 431 486 patients received care at non-PE-acquired hospitals, and 659 736 received care at PE-acquired hospitals. Across all admissions, the mean (SD) age was 79.45 (7.95) years; 11 727 439 patients (55.6%) were male, and 4 550 012 patients (21.6%) had dual insurance; 2 996 560 (14.2%) patients were members of racial or ethnic minority groups, including 2 085 128 [9.9%] Black and 371 648 [1.8%] Hispanic; 18 094 662 patients (85.8%) were White. Overall, 3 083 760 patients (14.6%) were hospitalized with AMI, 2 835 777 (13.4%) with acute stroke, 3 674 477 (17.4%) with chronic obstructive pulmonary disease exacerbation, 5 868 034 (27.8%) with congestive heart failure exacerbation, and 5 629 174 (26.7%) with pneumonia. Comorbidity burden decreased slightly among patients admitted with acute stroke (difference, -0.04 SDs; 95% CI, -0.004 to -0.07 SDs) at acquired hospitals compared with nonacquired hospitals but was unchanged across the other 4 conditions. Among patients with AMI, a greater decrease in in-hospital mortality was observed in PE-acquired hospitals compared with non-PE-acquired hospitals (difference, -1.14 percentage points, 95% CI, -1.86 to -0.42 percentage points). In addition, a greater decrease in 30-day mortality (difference, -1.41 percentage points; 95% CI, -2.26 to -0.56 percentage points) was found at acquired vs nonacquired hospitals. However, 30-day spending and readmission rates remained unchanged across all conditions. The extent and directionality of estimates were preserved across all robustness assessments and subset analyses. Conclusions and Relevance: In this cross-sectional study using a difference-in-differences approach, PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI

Xenogeneic Mesh Provides Safe and Durable Long-Term Outcomes in Abdominal Wall Reconstruction of High-Risk Centers for Disease Control and Prevention Class III and IV Defects

Objective:. Evaluate long-term outcomes of abdominal wall reconstruction (AWR) using xenogeneic mesh in patients with Centers for Disease Control and Prevention (CDC) class III/IV defects. We hypothesized that AWR with xenogeneic mesh results in acceptable outcomes. Background:. Optimal mesh selection in AWR of CDC class III/IV defects is controversial. Outcomes using xenogeneic mesh are lacking. Methods:. We conducted a retrospective cohort study of patients who underwent AWR using xenogeneic mesh in CDC class III/IV defects from March 2005 to June 2019. Primary outcome was hernia recurrence (HR). Secondary outcomes were surgical site occurrence (SSO) and surgical site infection (SSI). Results:. Of consecutive 725 AWRs, we identified 101 patients who met study criteria. Sixty-eight patients had class III defects, while 33 had class IV defects. Patients had a mean age of 61.3 ± 11.1 years, mean body mass index of 31.8 ± 7.3 kg/m2, and mean follow-up time of 41.9 ± 26.3 months. Patients had HR rate of 21%, SSO rate of 49%, and SSI rate of 24. Class IV defects were predictive of SSOs (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.11–7.42; P = 0.029) but not HR (hazard ratio, 1.60; 95% CI, 0.59–4.34; P = 0.355) or SSIs (OR, 2.62; 95% CI, 0.85–8.10; P = 0.094). Conclusions:. Patients with class IV defects have a higher risk of SSOs, but not HR or SSIs, compared with patients with class III defects. Despite the high level of defect contamination, AWR with xenogeneic mesh demonstrated acceptable HR, SSO, and SSI rates. Therefore, safe and durable long-term outcomes are achievable in single-stage AWR using xenogeneic mesh for CDC class III/IV defects

Management of symptomatic patients with textured implants

Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance.SUMMARY: Proper management of symptomatic textured implant patients is critical to identify and treat associated oncologic disease. Textured surface breast implants were first introduced more than 50 years ago in an effort to decrease high rates of capsular contracture and implant malposition observed with first-generation smooth surface breast implants. Textured implants were dominant over smooth devices in the United States in the late 1990s, but they fell out of favor for newer-generation smooth implants, while texture remained the dominant selling implants worldwide until recently. A class I device recall by the US Food and Drug Administration in 2019 precipitated a removal of the highest selling implant worldwide, Allergan Biocell, due to a disproportionately increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Operative strategies, such as bacterial control at the time of textured implant insertion, have not been credibly shown to affect or prevent the future development of BIA-ALCL. BIA-ALCL patients require complete surgical excision of their disease, whereas textured implant patients who are otherwise asymptomatic do not require surgical removal. For suspicious cases, diagnostic testing with CD30 immunohistochemistry should be performed before any surgical intervention. Capsules are evaluated with 12 strategic regional biopsies in a standardized approach. If surgeons are revising or exchanging textured implants, they may reasonably consider a total capsulectomy, though this is not advocated by the Food and Drug Administration or national societies, and has not been shown to mitigate future risk of BIA-ALCL. The purpose of this article is to review data on and outcomes for textured surface implants, disease-associated risk, and the management strategy for revisionary surgery and device surveillance

What are the implications of implementation science for medical education?

© 2015 David W. Price et al. Background: Derived from multiple disciplines and established in industries outside of medicine, Implementation Science (IS) seeks to move evidence-based approaches into widespread use to enable improved outcomes to be realized as quickly as possible by as many as possible. Methods: This review highlights selected IS theories and models, chosen based on the experience of the authors, that could be used to plan and deliver medical education activities to help learners better implement and sustain new knowledge and skills in their work settings. Results: IS models, theories and approaches can help medical educators promote and determine their success in achieving desired learner outcomes. We discuss the importance of incorporating IS into the training of individuals, teams, and organizations, and employing IS across the medical education continuum. Challenges and specific strategies for the application of IS in educational settings are also discussed. Conclusions: Utilizing IS in medical education can help us better achieve changes in competence, performance, and patient outcomes. IS should be incorporated into curricula across disciplines and across the continuum of medical education to facilitate implementation of learning. Educators should start by selecting, applying, and evaluating the teaching and patient care impact one or two IS strategies in their work

Minute dosages of ανβ3-targeted fumagillin nanoparticles impair Vx-2 tumor angiogenesis and development in rabbits

Fumagillin suppresses angiogenesis in cancer models and clinical trials, but it is associated with neurotoxicity at systemic doses. In this study, ανβ3-targeted fumagillin nanoparticles were used to suppress the neovasculature and inhibit Vx-2 adenocarcinoma development using minute drug doses. Tumor-bearing rabbits were treated on days 6, 9, and 12 postimplantation with ανβ3-targeted fumagillin nanoparticles (30 μg/kg), ανβ3-targeted nanoparticles without drug, nontargeted fumagillin nanoparticles (30 μg/kg) or saline. On day 16, MRI was performed with ανβ3-targeted paramagnetic nanoparticles to quantify tumor size and assess neovascularity. Tumor volume was reduced among rabbits receiving ανβ3-targeted fumagillin nanoparticles (470±120 mm3) compared with the three control groups: nontargeted fumagillin nanoparticles (1370±300 mm3, P<0.05), ανβ3-targeted nanoparticles without drug (1080±180 mm3, P<0.05) and saline (980±80 mm3, P<0.05). MR molecular imaging of control rabbits (no fumagillin) revealed a predominant peripheral distribution of neovascularity representing 7.2% of the tumor rim volume, which decreased to 2.8% (P<0.05) with ανβ3-targeted fumagillin nanoparticle treatment. Microscopically, the tumor parenchyma tended to show T-cell infiltration after targeted fumagillin treatment, which was not appreciated in control animals. These results suggest that ανβ3-targeted fumagillin nanoparticles could provide a safe and effective means to deliver MetAP2 inhibitors alone or in combination with cytotoxic or immunotherapy.—Winter, P. M., Schmieder, A. H., Caruthers, S. D., Keene, J. L., Zhang, H., Wickline, S. A., Lanza, G. M. Minute dosages of ανβ3-targeted fumagillin nanoparticles impair Vx-2 tumor angiogenesis and development in rabbits

αvβ3-Targeted nanotherapy suppresses inflammatory arthritis in mice

The purpose of this study was to assess whether an alternative treatment approach that targets angiogenesis, delivered through ligand-targeted nanotherapy, would ameliorate inflammatory arthritis. Arthritis was induced using the K/BxN mouse model of inflammatory arthritis. After arthritis was clearly established, mice received three consecutive daily doses of αvβ3-targeted fumagillin nanoparticles. Control groups received no treatment or αvβ3-targeted nanoparticles without drugs. Disease score and paw thickness were measured daily. Mice that received αvβ3-targeted fumagillin nanoparticles showed a significantly lower disease activity score (mean score of 1.4±0.4; P<0.001) and change in ankle thickness (mean increase of 0.17±0.05 mm; P<0.001) 7 d after arthritis induction, whereas the group that received αvβ3-targeted nanoparticles without drugs exhibited a mean arthritic score of 9.0 ± 0.3 and mean change in ankle thickness of 1.01 ± 0.09 mm. Meanwhile, the group that received no treatment showed a mean arthritic score of 9.8 ± 0.5 and mean change in ankle thickness of 1.05 ± 0.10 mm. Synovial tissues from animals treated with targeted fumagillin nanoparticles also showed significant decrease in inflammation and angiogenesis and preserved proteoglycan integrity. Ligand-targeted nanotherapy to deliver antiangiogenic agents may represent an effective way to treat inflammatory arthritis.—Zhou, H.-F., Chan, H. W., Wickline, S. A., Lanza, G. M., Pham, C. T. N. αvβ3-Targeted nanotherapy suppresses inflammatory arthritis in mice