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

Education and training methods for healthcare professionals to lead conversations concerning deceased organ donation: An integrative review

Objectives: To determine which training methods positively influenced healthcare professionals’ communication skills and families’ deceased organ donation decision-making. Methods: An integrative review using systematic methods and narrative synthesis for data analysis. Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (EBSCO), Embase (OVID) and ProQuest Dissertations & Theses Global, were searched between August 1997 and March 2020, retrieving 1019 papers. Included papers (n = 14) were appraised using the Medical Education Research Study Quality Instrument. Results: Training programmes offered theory, experiential learning, feedback and debriefing including self-reflection, the opportunity to role-play and interact with simulated participants within realistic case scenarios. Programmes reported observed and self-rated improvements in communication learning and confidence. The methodological quality score averaged 13, (72% of maximum); few studies used an experimental design, examined behavioural change or families’ perspectives. Weak evidence suggested training could increase organ donation authorisation/consent rates. Conclusions: Multiple training strategies are effective in improving interprofessional healthcare professionals’ confidence and learning of specialised communication. Methodological limitations restricted the ability to present definitive recommendations and further research is warranted, inclusive of family decision-making experiences. Practice implications: Learning of specialised communication skills is enhanced by using multiple training strategies, including role-play and debriefing

User acceptance of observation and response charts with a track and trigger system: A multisite staff survey

Aims and objectives: To examine user acceptance with a new format of charts for recording observations and as a prompt for responding to episodes of clinical deterioration in adult medical–surgical patients. Background: Improving recognition and response to clinical deterioration remains a challenge for acute healthcare institutions globally. Five chart templates were developed in Australia, combining human factors design principles with a track and trigger system for escalation of care. Two chart templates were previously tested in simulations, but none had been evaluated in clinical practice. Design: Prospective multisite survey of user acceptance of the charts in practice. Methods: New observation and response charts were trialled in parallel with existing charts for 24 hours across 36 adult acute medical–surgical wards, covering 108 shifts, in five Australian states. Surveys were completed by 477 staff respondents, with open-ended comments and narrative from short informal feedback groups providing elaboration and context of user experiences. Results: Respondents were broadly supportive of the chart format and content for monitoring patients, and as a prompt for escalating care. Some concerns were noted for chart size and style, use of ranges to graph vital signs and with specific human factors design features. Information and training issues were identified to improve usability and adherence to chart guidelines and to support improved detection and response for patients with clinical deterioration. Conclusions: This initial evaluation demonstrated that the charts were perceived as appropriate for documenting observations and as a prompt to detect clinical deterioration. Further evaluation after some minor modifications to the chart is recommended. Relevance to clinical practice: Explicit training on the principles and rationale of human factors chart design, use of embedded change management strategies and addressing practical issues will improve authentic engagement, staff acceptance and adoption by all clinical users when implementing a similar observation and response chart into practice

Management of arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disease characterised by fibrofatty replacement of the ventricular myocardium due to specific mutations, leading to ventricular arrhythmias and sudden cardiac death. Treating this condition can be challenging due to progressive fibrosis, phenotypic variations and small patient cohorts limiting the feasibility of conducting meaningful clinical trials. Although widely used, the evidence base for anti-arrhythmic drugs is limited. Beta-blockers are theoretically sound, yet their efficacy in reducing arrhythmic risk is not robust. Additionally, the impact of sotalol and amiodarone is inconsistent with studies reporting contradictory results. Emerging evidence suggests that combining flecainide and bisoprolol may be efficacious.Radiofrequency ablation has shown some potential in disrupting ventricular tachycardia circuits, with combined endo and epicardial ablation yielding better results which could be considered at the index procedure. In addition, stereotactic radiotherapy may be a future option that can decrease arrhythmias beyond simple scar formation by altering levels of Nav1.5 channels, Connexin 43 and Wnt signalling, potentially modifying myocardial fibrosis.Future therapies, such as adenoviruses and GSk3b modulation, are still in early-stage research. While implantable cardioverter-defibrillator implantation is a key intervention for reducing arrhythmic death, the risks of inappropriate shocks and device complications must be carefully considered

Restrictive cardiomyopathy and hypertrophic cardiomyopathy overlap: the importance of the phenotype

Restrictive cardiomyopathy (RCM) is defined on the basis of the haemodynamic finding of restrictive ventricular physiology. However, restrictive ventricular pathophysiology is also a feature of other subtypes of cardiomyopathy, including hypertrophic cardiomyopathy (HCM). Clinically and aetiologically, there is an overlap between RCM and HCM with restrictive physiology. However, the clinical distinction between these two entities can be an important pointer towards the underlying aetiology. This review highlights the importance of the recognition of the clinical phenotype as the first step in the classification of cardiomyopathies

A hardware spinal decoder

Spinal codes are a recently proposed capacity-achieving rateless code. While hardware encoding of spinal codes is straightforward, the design of an efficient, high-speed hardware decoder poses significant challenges. We present the first such decoder. By relaxing data dependencies inherent in the classic M-algorithm decoder, we obtain area and throughput competitive with 3GPP turbo codes as well as greatly reduced latency and complexity. The enabling architectural feature is a novel alpha-beta incremental approximate selection algorithm. We also present a method for obtaining hints which anticipate successful or failed decoding, permitting early termination and/or feedback-driven adaptation of the decoding parameters. We have validated our implementation in FPGA with on-air testing. Provisional hardware synthesis suggests that a near-capacity implementation of spinal codes can achieve a throughput of 12.5 Mbps in a 65 nm technology while using substantially less area than competitive 3GPP turbo code implementations.Irwin Mark Jacobs and Joan Klein Jacobs Presidential FellowshipIntel Corporation (Fellowship)Claude E. Shannon Research Assistantshi

Improved long-term survival with tafamidis treatment in patients with transthyretin amyloid cardiomyopathy and severe heart failure symptoms

AIM: The value of disease-modifying treatment (such as tafamidis) in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) and severe heart failure symptoms has been debated. This study assessed long-term all-cause survival in patients with New York Heart Association (NYHA) class III symptoms in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) long-term extension (LTE) study. METHODS AND RESULTS: At the baseline of ATTR-ACT, 55/176 (31.3%) patients receiving tafamidis 80 mg and 63/177 (35.6%) receiving placebo had NYHA class III symptoms. After 30 months of treatment, patients could join an ongoing LTE study to receive open-label tafamidis. In an interim analysis of the LTE study (August 2021), all-cause mortality was lower among patients with NYHA class III symptoms who received continuous tafamidis in ATTR-ACT and the LTE study (hazard ratio: 0.64; 95% CI: 0.41-0.99; median follow-up: 60 months), as compared with those who received placebo in ATTR-ACT and tafamidis in the LTE study (median follow-up: 56 months). Similar findings were observed in patients with NYHA class I/II symptoms at baseline (0.50; 0.35-0.73; tafamidis 80 mg n = 121; placebo n = 114; median follow-up of 61 and 60 months, respectively). CONCLUSION: We observed reduced all-cause mortality with continuous tafamidis treatment compared with delayed tafamidis treatment (placebo then tafamidis) in patients with NYHA class III symptoms at baseline over a median follow-up of ~5 years. These findings demonstrate the value of tafamidis treatment in patients with ATTR-CM and severe heart failure symptoms, and emphasize the importance of early treatment. NCT01994889; NCT02791230

Arrhythmogenic Cardiomyopathy: A Disease or Merely a Phenotype?

Arrhythmogenic cardiomyopathy (AC) is a clinical entity that has evolved conceptually over the past 30 years. Advances in cardiac imaging and the introduction of genetics into everyday practice have revealed that AC comprises multiple phenotypes that are dependent on genetic or acquired factors. In this study, the authors summarise the approach to the identification of the AC phenotype and its underlying causes. They believe that AC represents a paradigm for personalised medicine in cardiology and that better stratification of the disease will enhance the development of mechanism-based treatments

Differences between familial and sporadic dilated cardiomyopathy : ESC EORP Cardiomyopathy & Myocarditis registry

Aims Dilated cardiomyopathy (DCM) is a complex disease where genetics interplay with extrinsic factors. This study aims to compare the phenotype, management, and outcome of familial DCM (FDCM) and non-familial (sporadic) DCM (SDCM) across Europe. Methods and results Patients with DCM that were enrolled in the prospective ESC EORP Cardiomyopathy & Myocarditis Registry were included. Baseline characteristics, genetic testing, genetic yield, and outcome were analysed comparing FDCM and SDCM; 1260 adult patients were studied (238 FDCM, 707 SDCM, and 315 not disclosed). Patients with FDCM were younger (P <0.01), had less severe disease phenotype at presentation (P <0.02), more favourable baseline cardiovascular risk profiles (P Conclusions We observed that FDCM and SDCM have significant differences at baseline but similar short-term prognosis. Whether modification of associated cardiovascular risk factors provide opportunities for treatment remains to be investigated. Our results also show a prevalent role of genetics in FDCM and a non-marginal yield in SDCM although genetic testing is largely neglected in SDCM. Limited genetic testing and heterogeneity in panels provides a scaffold for improvement of guideline adherence.Peer reviewe