A Younger Demographic Defines Hepatitis C Patient Profiles in the Recent Direct-Acting Antiviral Era

A Younger Demographic Defines Hepatitis C Patient Profiles in the Recent Direct-Acting Antiviral Era Authors: Minawala, Ria1; Naylor, Paul H.2; Ehrinpreis, Murray N.2; Mutchnick, Milton G.2 Institutions: 1. Wayne State University School of Medicine, Detroit, MI, United States. 2. Wayne State University School of Medicine, Division of Gastroenterology, Detroit, MI, United States. Background: Highly effective and safe direct-acting antivirals (DAAs) against hepatitis C virus (HCV) combined with U.S. Preventive Services Task Force recommendation to screen for HCV in individuals born between 1945 and 1965 (age cohort; 54-79 years of age in 2019) was expected to reduce the number of actively infected patients via identification and treatment. Nevertheless, HCV infections remain a significant health concern. A study of HCV infected patients in our urban internal medicine practice, during the interferon era and prior to the introduction of DAAs, demonstrated a population within the age cohort. The objective of this study was to characterize the current patient population seen in the same practice with respect to age, race, and treatment status to determine the impact of DAA therapy on patient profiles and to test the hypothesis that there would be an increase in younger population among those infected. Methods: Using electronic medical records, we identified patients who presented to our urban GI practice in 2019. Data collected from patient charts included demographics, liver function tests, HCV genotype, viral load, imaging studies, and treatment history. Results: There were 601 patients with HCV seen in 2019 and the majority were African American (AA) (85%) and male (66%). Comparison of age alongside gender and race revealed that non-AA patients (51 years, SEM = 0.9) were significantly younger than AA patients (63 years, SEM = 0.4; p Conclusion: The primary shift in patient demographics as compared to the interferon era has been toward younger, non- AA females. In contrast, the predominant AA patients are still within the age cohort. The emergence of younger patients has important implications for screening, patient outreach, and treatment plans. A more intensive evaluation for risk factors and the role of COVID-19 in treatment is warranted. Many AA and non- AA patients were not started on any treatment in 2019, signifying a need for continued follow-up after initial visit to close the linkage to care gap

FAILURE TO TREAT HCV IN PATIENTS SEEN IN A PREDOMINATELY AFRICAN AMERICAN SOCIOECONOMICALLY CHALLENGED POPULATION

The research objective of this proposal is to investigate the impediment with respect to moving a patient from initial antibody/PCR positive to successful completion of treatment. Secondary objectives include determining the most effective way for patients to progress from initial antibody/PCR positive to treatment and identifying the roadblocks for HCV antibody/PCR positive patients to be treated effectively. Data was collected from 2019 HCV patient EMR charts, including demographics, laboratory studies, and treatment history. Concerning treatment, we evaluated linkage to the care; we defined success as treatment within six months of the initial visit. Thus, data on treatment initiation was collected through the first six months of 2020

CHARACTERISTICS OF PATIENTS WITH LOW HEPATITIS C TREATMENT RATES IN URBAN MEDICAL CENTER CLINICS

The objective of this study was to determine whether there were different characteristics between HCV patients who were treated and those not treated after their first visit to a Gastroenterology (GI) or Infectious Disease (ID) clinic. This information might identify potential targets for remedial actions that could be performed to increase the number of treated patients. Data was collected from 2019 HCV patient EMR charts including patient demographics, treatment history, and laboratory studies. We defined success as receiving treatment by July 2020 (6-18 months after the first visit). We found that of 587 patients with HCV who were seen at least once in the Wayne Health system, 441 patients (441/587=75%) were not treated and only 189 (189/441= 43%) were treated by July 2020. Treated and not treated patients were similar with respect to race, gender, age, and median income defined by zip code. They were also not different with respect to the clinic seen (ID vs GI), the type of insurance, or the degree of fibrosis. However, patients with an average of 4 visits were more likely to be treated than those having 2 visits. Having 1 visit was the most dramatic factor in the lack of treatment (42% vs 8% p\u3c0.0001). PCR available at first visit was an important factor with respect to treatment (treated 38% vs not treated 25% p\u3c0.02)

Creaky knees: Is there a reason for concern? A qualitative study of the perspectives of people with knee crepitus

Objective: Crepitus is a feature of osteoarthritis that may affect one's participation in exercise. An informed understanding is required of the perceptions that people have of their knee crepitus and how it affects their exercise behaviours. This study aims to investigate the role that crepitus may play in beliefs about exercise and knee health. Methods: Focus group and individual interviews were conducted online with participants who had knee crepitus. The transcripts were thematically analysed through an inductive approach. Results: Five main themes were identified from 24 participants: (1) individual variation of, (2) occurrence of, (3) meaning of knee crepitus, (4) attitudes and exercise behaviours regarding crepitus, and (5) knowledge deficits and needs concerning crepitus during exercise. The variety of crepitus sounds described occurred with a range of exercises or after inactivity. For those already with osteoarthritis or other symptoms, crepitus was of less concern than symptoms such as pain. Most participants had not ceased exercise but may have modified movement due to crepitus and associated symptoms; some had increased intentional strength training to try alleviating it. Participants agreed that more understanding about the processes causing crepitus and what exercise was safe for knee health would be beneficial. Conclusion: Crepitus does not appear to be a major cause of concern for people who experience it. However, it is a factor that influences exercise behaviours as is pain. If health professionals could guide people with concerns about their crepitus, they may be more confident in exercising to benefit their joint health

Impact of commonly prescribed exercise interventions on platelet activation in physically inactive and overweight men.

The exercise paradox infers that, despite the well-established cardioprotective effects of repeated episodic exercise (training), the risk of acute atherothrombotic events may be transiently increased during and soon after an exercise bout. However, the acute impact of different exercise modalities on platelet function has not previously been addressed. We hypothesized that distinct modalities of exercise would have differing effects on in vivo platelet activation and reactivity to agonists which induce monocyte-platelet aggregate (MPA) formation. Eight middle-aged (53.5 ± 1.6 years) male participants took part in four 30 min experimental interventions (aerobic AE, resistance RE, combined aerobic/resistance exercise CARE, or no-exercise NE), in random order. Blood samples were collected before, immediately after, and 1 h after each intervention, and incubated with one of three agonists of physiologically/clinically relevant pathways of platelet activation (thrombin receptor activating peptide-6 TRAP, arachidonic acid AA, and cross-linked collagen-related peptide xCRP). In the presence of AA, TRAP, and xCRP, both RE and CARE evoked increases in MPAs immediately post-exercise (P < 0.01), whereas only AA significantly increased MPAs immediately after AE (P < 0.01). These increases in platelet activation post-exercise were transient, as responses approached pre-exercise levels by 1 h. These are the first data to suggest that exercise involving a resistance component in humans may transiently increase platelet-mediated thrombotic risk more than aerobic modalities

Could the Pharmaceutical Industry Benefit from Full-Scale Adoption of Radio-Frequency Identification (RFID) Technology with New Regulations?

Healthcare regulators are directing attention to the pharmaceutical supply chain with the passage of the Drug Quality and Security Act (DQSA) and the Drug Supply Chain Security Act (DSCSA). Adoption of Radio-Frequency Identification (RFID) technology has the ability to improve compliance, reduce costs, and improve safety in the supply chain but its implementation has been limited; primarily because of hardware and tag costs. The purpose of this research study was to analyze the benefits to the pharmaceutical industry and healthcare system of the adoption of RFID technology as a result of newly implemented supply chain regulations. The methodology was a review following the steps of a systematic review with a total of 96 sources used. With the DSCSA, pharmaceutical companies must track and trace prescription drugs across the supply chain, and RFID can resolve many track-and-trace issues with manufacturer control of data. The practical implication of this study is that pharmaceutical companies must continue to have the potential to increase revenues, decrease associated costs, and increase compliance with new FDA regulations with RFID. Still, challenges related to regulatory statute wording, implementation of two-dimensional barcode technology, and the variety of interfaces within the pharmaceutical supply chain have delayed adoption and its full implementation

An intervention to improve care and reduce costs for high-risk patients with frequent hospital admissions: a pilot study

<p>Abstract</p> <p>Background</p> <p>A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.</p> <p>Methods</p> <p>Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.</p> <p>Results</p> <p>Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.</p> <p>Conclusions</p> <p>A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated.</p> <p>Trial registration</p> <p>Clinicaltrials.gov Identifier: <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1292096">NCT01292096</a></p

How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

Extent: 5p.Background: An increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases has led to new models of post-acute care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration. Overall, review of the literature suggests there is considerable uncertainty around the effectiveness and resource implications of the various model configurations and delivery approaches. In this paper, we review the current evidence on the efficacy of such programs, using the Australian Transition Care Program as a case study. Discussion: The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care. The program is intended to enable a significant proportion of care recipients to return home, rather than prematurely enter residential aged care, optimize their functional capacity, and reduce inappropriate extended lengths of hospital stay for older people. Broadly, the model is configured and targeted in accordance with programs reported in the international literature to be effective. Early evaluations suggest good acceptance of the program by hospitals, patients and staff. Ultimately, however, the program's place in the array of post-acute services should be determined by its demonstrated efficacy relative to other services which cater for similar patient groups. Summary: Currently there is a lack of robust evaluation to provide convincing evidence of efficacy, either from a patient outcome or cost reduction perspective. As the program expands and matures, there will be opportunity to scrutinise the systematic effects, with lessons for both Australian and international policy makers and clinical leaders.Leonard C Gray, Nancye M Peel, Maria Crotty, Susan E Kurrle, Lynne C Giles, and Ian D Camero

Hospital Readmission in General Medicine Patients: A Prediction Model

Background: Previous studies of hospital readmission have focused on specific conditions or populations and generated complex prediction models. Objective: To identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk. Design: Prospective observational cohort study. Patients: Participants encompassed 10,946 patients discharged home from general medicine services at six academic medical centers and were randomly divided into derivation (n = 7,287) and validation (n = 3,659) cohorts. Measurements: We identified readmissions from administrative data and 30-day post-discharge telephone follow-up. Patient-level factors were grouped into four categories: sociodemographic factors, social support, health condition, and healthcare utilization. We performed logistic regression analysis to identify significant predictors of unplanned readmission within 30 days of discharge and developed a scoring system for estimating readmission risk. Results: Approximately 17.5% of patients were readmitted in each cohort. Among patients in the derivation cohort, seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity index, SF12 physical component score, ≥1 admission(s) within the last year, and current length of stay >2 days. A cumulative risk score of ≥25 points identified 5% of patients with a readmission risk of approximately 30% in each cohort. Model discrimination was fair with a c-statistic of 0.65 and 0.61 for the derivation and validation cohorts, respectively. Conclusions: Select patient characteristics easily available shortly after admission can be used to identify a subset of patients at elevated risk of early readmission. This information may guide the efficient use of interventions to prevent readmission

Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study

<p>Abstract</p> <p>Background</p> <p>Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents.</p> <p>The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC) necessary were registered.</p> <p>Methods</p> <p>A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge.</p> <p>Results</p> <p>118 patients (65% female), with mean age 83.2 ± 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59%) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (25%) and service or help provided from the PHC (17%).</p> <p>Conclusions</p> <p>Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients.</p