Association of Patient and Visit Characteristics With Rate and Timing of Urologic Procedures for Patients Discharged From the Emergency Department With Renal Colic

Importance: Little is known about the timing of urologic interventions in patients with renal colic discharged from the emergency department. Understanding patients\u27 likelihood of a subsequent urologic intervention could inform decision-making in this population. Objectives: To examine the rate and timing of urologic procedures performed after an emergency department visit for renal colic and the factors associated with receipt of an intervention. Design, Setting, and Participants: This retrospective cohort study used the Massachusetts All Payers Claims Database to identify patients 18 to 64 years of age who were seen in a Massachusetts emergency department for renal colic from January 1, 2011, to October 31, 2014, Patients were identified via International Classification of Diseases, Ninth Revision codes, and all medical care was linked, enabling identification of subsequent health care use. Data analysis was performed from January 1, 2017, to December 31, 2018. Main Outcomes and Measures: The main outcome was receipt of urologic procedure within 60 days. Secondary outcomes included rates of return emergency department visit and urologic and primary care follow-up. Results: A total of 66218 unique index visits by 55314 patients (mean [SD] age, 42.6 [12.4] years; 33 590 [50.7%] female; 25 411 [38.4%] Medicaid insured) were included in the study. A total of 5851 patients (8.8%) had visits resulting in admission at the index encounter, and 1774 (2.7%) had visits resulting in a urologic procedure during that admission. Of the 60367 patient visits resulting in discharge from the emergency department, 3018 (5.0%) led to a urologic procedure within 7 days, 4407 (7.3%) within 14 days, 5916 (9.8%) within 28 days, and 7667 (12.7%) within 60 days. A total of 3226 visits (5.3%) led to a subsequent emergency department visit within 7 days and 6792 (11.3%) within 60 days. For the entire cohort (admitted and discharged patients), 39 189 (59.2%) had contact with a urologist or primary care practitioner within 60 days. Having Medicaid-only insurance was associated with lower rates of urologic procedures (odds ratio, 0.70; 95% CI, 0.66-0.74) and urologic follow-up (5.6% vs 8.8%; P \u3c .001) and higher rates of primary care follow-up (59.2% vs 47.2%; P \u3c .001) compared with patients with all other insurance types. Conclusions and Relevance: In this cohort study, most adult patients younger than 65 years who were discharged from the emergency department with a diagnosis of renal colic did not undergo a procedure or see a urologist within 60 days. This finding has implications for both the emergency department and outpatient treatment of these patients

Use and Outcomes Associated With Perioperative Amiodarone in Cardiac Surgery

Background: In randomized controlled trials, perioperative administration of amiodarone has been shown to reduce the incidence of postoperative atrial arrhythmias and length of stay (LOS) among patients undergoing coronary bypass surgery. However, little is known about the use or effectiveness of perioperative amiodarone in routine clinical practice. Methods and Results: We studied patients \u3e /=18 years old without a previous history of atrial or ventricular arrhythmias who underwent elective coronary bypass surgery between 2013 and 2014 within a network of 235 US hospitals. Perioperative amiodarone was defined as receipt of amiodarone either on the day of or the day preceding surgery. We used covariate-adjusted modeling and instrumental variable methods to examine the association between receipt of amiodarone and the development of atrial arrhythmias, in-hospital mortality, readmission, LOS, and cost. Of 12 758 patients, 2195 (17.2%) received perioperative amiodarone, 3330 (26.1%) developed atrial arrhythmias postoperatively, and the average LOS was 6.4 days (+/-2.6 days). Instrumental variable analysis showed that receipt of perioperative amiodarone was associated with lower risk of atrial arrhythmias (risk difference -11 percentage points, 95% CI -19 to -4 percentage points; P=0.002) and a shorter LOS (-0.7 day, 95% CI -1.39 to -0.01 days; P=0.048). There was no association between receipt of perioperative amiodarone and in-hospital mortality, cost, or readmission. Conclusions: Among patients undergoing coronary bypass surgery without previous arrhythmias, perioperative amiodarone is associated with a lower risk of atrial arrhythmias and shorter LOS. These findings are consistent with previous randomized trials and lend support to current guideline recommendations

Correlates of High Perceived Stress Among Pregnant Hispanic Women in Western Massachusetts

Prenatal psychosocial stress has been associated with adverse pregnancy outcomes, even after controlling for known risk factors. This paper aims to evaluate correlates of high perceived stress among Hispanic women, a group with elevated rates of stress during pregnancy

Prepregnancy body mass index, gestational weight gain, and elevated depressive symptoms in a Hispanic cohort.

Our objective was to assess the associations among prepregnancy Body Mass Index (BMI), gestational weight gain (GWG), and elevated depressive symptoms across pregnancy

Derivation and Validation of an Inâ Hospital Mortality Prediction Model Suitable for Profiling Hospital Performance in Heart Failure

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142499/1/jah32925_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142499/2/jah32925.pd

IDEAS for a healthy baby - reducing disparities in use of publicly reported quality data: study protocol for a randomized controlled trial

BACKGROUND: Publicly reported performance on quality measures is intended to enable patients to make more informed choices. Despite the growing availability of these reports, patients\u27 use remains limited and disparities exist. Low health literacy and numeracy are two barriers that may contribute to these disparities. Patient navigators have helped patients overcome barriers such as these in other areas, such as cancer care and may prove useful for overcoming barriers to using publicly reported quality data. METHODS/DESIGN: The goals of this study are: to determine the efficacy of a patient navigator intervention to assist low-income pregnant women in the use of publicly available information about quality of care when choosing a pediatrician; to evaluate the relative importance of factors influencing women\u27s choice of pediatric practices; to evaluate the effect of the intervention on patient engagement in management of their own and their child\u27s health care; and to assess variation in efficacy of the intervention for sub-groups based on parity, age, and race/ethnicity. English speaking women ages 16 to 50 attending a prenatal clinic at a large urban medical center will be randomized to receive an in-person navigator intervention or an informational pamphlet control between 20 to 34 weeks of gestation. The intervention will include in-person guided use of the Massachusetts Health Quality Partners website, which reports pediatric practices\u27 performance on quality measures and patient experience. The primary study outcomes will be the mean scores on a) clinical quality and b) patient experience measures. DISCUSSION: Successful completion of the study aims will yield important new knowledge about the value of guided website navigation as a strategy to increase the impact of publicly reported quality data and to reduce disparities in use of these data. TRIAL REGISTRATION: ClinicalTrials.gov #NCT01784575

Update to the study protocol for an implementation-effectiveness trial comparing two education strategies for improving the uptake of noninvasive ventilation in patients with severe COPD exacerbation

BACKGROUND: There is strong evidence that noninvasive ventilation (NIV) improves the outcomes of patients hospitalized with severe COPD exacerbation, and NIV is recommended as the first-line therapy for these patients. Yet, several studies have demonstrated substantial variation in NIV use across hospitals, leading to preventable morbidity and mortality. In addition, prior studies suggested that efforts to increase NIV use in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, our initial project aimed to compare two educational strategies: online education (OLE) and interprofessional education (IPE), which targets complex team-based care in NIV delivery. Due to the impact of the COVID-19 pandemic on recruitment and planned intervention, we had made several changes in the study design, statistical analysis, and implementation strategies delivery as outlined in the methods. METHODS: We originally proposed a two-arm, pragmatic, cluster, randomized hybrid implementation-effectiveness trial comparing two education strategies to improve NIV uptake in patients with severe COPD exacerbation in 20 hospitals with a low baseline rate of NIV use. Due to logistical constrains and slow recruitment, we changed the study design to an opened cohort stepped-wedge design with three steps which will allow the institutions to enroll when they are ready to participate. Only the IPE strategy will be implemented, and the education will be provided in an online virtual format. Our primary outcome will be the hospital-level risk-standardized NIV proportion for the period post-IPE training, along with the change in rate from the period prior to training. Aim 1 will compare the change over time of NIV use among patients with COPD in the step-wedged design. Aim 2 will explore the mediators\u27 role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and effectiveness. Finally, in Aim 3, through interviews with providers, we will assess the acceptability and feasibility of the educational training. CONCLUSION: The changes in study design will result in several limitation. Most importantly, the hospitals in the three cohorts are not randomized as they enroll based on their readiness. Second, the delivery of the IPE is virtual, and it is not known if remote education is conducive to team building. However, this study will be among the first to test the impact of IPE in the inpatient setting carefully and may generalize to other interventions directed to seriously ill patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04206735 . Registered on December 20, 2019

Smoking during pregnancy and risk of abnormal glucose tolerance: a prospective cohort study

Background: Disturbances in glucose metabolism during pregnancy are associated with negative sequalae for both mother and infant. The association between smoking and abnormal glucose tolerance (AGT) remains controversial. Therefore, the aim of this study was to examine the relationship between smoking prior to and during pregnancy and risk of AGT. Methods: We utilized data from a prospective cohort of 1,006 Hispanic (predominantly Puerto Rican) prenatal care patients in Western Massachusetts. Women reported pre- and early pregnancy smoking at recruitment (mean = 15 weeks) and mid pregnancy smoking at a second interview (mean = 28 weeks). AGT was defined as \u3e 135 mg/dL on the routine 1-hour glucose tolerance test (1-hr OGTT). We used multivariable regression to assess the effect of pre, early, and mid-pregnancy smoking on risk of AGT and screening plasma glucose value from the 1-hr OGTT. Results: In age-adjusted models, women who smoked \u3e 0-9 cigarettes/day in pre-pregnancy had an increased risk of AGT (OR = 1.90; 95% CI 1.02-3.55) compared to non-smokers; this was attenuated in multivariable models. Smoking in early (OR = 0.48; 95% CI 0.21-1.10) and mid pregnancy (OR = 0.38; 95% CI 0.13-1.11) were not associated with AGT in multivariable models. Smoking during early and mid pregnancy were independently associated with lower glucose screening values, while smoking in pre-pregnancy was not. Conclusions: In this prospective cohort of Hispanic women, we did not observe an association between smoking prior to or during pregnancy and risk of AGT. Findings from this study, although based on small numbers of cases, extend prior research to the Hispanic population