Hotspotting medically complex at-risk patients in an urban primary care residency clinic

Context: It has been established that 5% of the patients incur 50% of the health care cost. Hot spotting is the collaborative care approach put into place in the hopes of improving outcomes and decreasing healthcare costs. Objective: Create a more formalized plan for managing medically complex patients within one family medicine residency clinic over one year. Study Design: Prospective enrollment, retrospective review, quality improvement. Quarterly interdisciplinary team meetings were conducted throughout the year to discuss patients in order to analyze and address each patient’s social situation and barriers. At least one home visit was also conducted and more frequent contact was established with each patient. Setting: Milwaukee County, WI, USA. Patients: Twenty medically at risk patients (mean age 62.4 years, 70% female). Results: The average Charlson score for the patients was 6.2 (median 6; Note, a score of 6 equates to 10 year mortality risk of 98%). Analysis of characteristics of the 20 patients revealed 80% prevalence of mental illness and communication problems; 70% were over-medicated. After initiating the pilot, total ED visits decreased 20.0% (95 vs 76) and total admissions decreased 35.5% (31 vs 20) at Aurora hospitals. Surveys determined that patients, clinic staff, and physicians all were very satisfied with the intervention. Overall, 94% of provider respondents felt more patients would benefit from being involved. Total direct cost savings 6 months pre- and post-intervention revealed $187,000 savings for 17 patients ($11,000 per patient) and a 9:1 return on investment. Conclusions: The impact of this project was profound. Given the ease at which it was incorporated into the practice, as well as the promising results of decreased ER visits and hospital admissions, this pilot successfully managed complex patients. We believe this concept has large potential to provide further benefit in the future and is worth duplicating

One-year mortality in type 2 MI: Patient characteristics from a large clinical series

Background: Type 2 MI is caused by an imbalance in oxygen supply/demand. Little is known about the patient characteristics associated with Type 2 MI. Objective: This study aimed to define patient characteristics of Type 2 MI. Methods: We retrospectively studied patients older than 18 years presented to our health care facilities between 9/2011-12/2015. All patients determined to have Type 2 MI (i.e., if the patient had an elevated troponin greater than or equal to 0.05 ng/mL or diagnosis of demand ischemia) were included. We excluded those with troponin greater than 20.0 ng/mL, ST-elevation MI diagnosis, cardiogenic shock, or non-ST-elevation MI with percutaneous coronary intervention, stent placement, or coronary artery bypass surgery. Hospice discharges were also excluded. Cox proportional hazards model, Chi-squared and Fishers exact tests were used for statistical analysis for one-year mortality. Hazard ratios (HR) and associated 95% confidence intervals (CI) were also computed. Results: A total of 21,139 patients [mean age 71+/- 16 years, females 10,565(49.9%)] fulfilled the study cohort. Univariate analysis showed that one-year mortality (28.5%) was high and associated with older age and White race (P’s\u3c0.0001). A history of diabetes (P=0.037), aortic aneurysm (P=0.0008), congestive heart failure, atrial fibrillation, anemia, chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD; P’s\u3c0.0001) were also associated with one-year mortality. One-year death rate was lower in patients with known history of coronary artery disease (CAD; P’s\u3c0.0001). Multivariate analysis showed that anemia (P=\u3c0.0001; HR=1.29, CI[1.22- 1.38]), COPD (P=\u3c0.0001; HR=1.26, CI[1.16-1.37]) ,CKD (P=\u3c0.0001; HR=1.16, CI[1.08- 1.24]), and diabetes (P=0.012; HR=1.08 CI[1.02-1.15]) were significantly associated with oneyear mortality. Additionally, a five year increase in age increases the risk of one-year mortality (HR=1.15, CI[1.14-1.16]). Conclusion: Patients with Type 2 MI have several common characteristics which increases their likelihood of one-year mortality and a history of CAD is somewhat protective