Transition Networks in a Cohort of Patients with Congestive Heart Failure: A Novel Application of Informatics Methods to Inform Care Coordination.

BACKGROUND: Unnecessary hospital readmissions are one source of escalating costs that may be reduced through improved care coordination, but how best to design and evaluate coordination programs is poorly understood. Measuring patient flow between service visits could support decisions for coordinating care, particularly for conditions such as congestive heart failure (CHF) which have high morbidity, costs, and hospital readmission rates. OBJECTIVES: To determine the feasibility of using network analysis to explore patterns of service delivery for patients with CHF in the context of readmissions. METHODS: A retrospective cohort study used de-identified records for patients ≥18 years with an ICD-9 diagnosis code 428.0-428.9, and service visits between July 2011 and June 2012. Patients were stratified by admission outcome. Traditional and novel network analysis techniques were applied to characterize care patterns. RESULTS: Patients transitioned between services in different order and frequency depending on admission status. Patient-to-service CoUsage networks were diffuse suggesting unstructured flow of patients with no obvious coordination hubs. In service-to-service Transition networks a specialty heart failure service was on the care path to the most other services for never admitted patients, evidence of how specialist care may prevent hospital admissions for some patients. For patients admitted once, transitions expanded for a clinic-based internal medicine service which clinical experts identified as a Patient Centered Medical Home implemented in the first month for which we obtained data. CONCLUSIONS: We detected valid patterns consistent with a targeted care initiative, which experts could understand and explain, suggesting the method has utility for understanding coordination. The analysis revealed strong but complex patterns that could not be demonstrated using traditional linear methods alone. Network analysis supports measurement of real world health care service delivery, shows how transitions vary between services based on outcome, and with further development has potential to inform coordination strategies.

Haemosiderin deposition in Donkey (Equus asinus) livers: Comparison of quantitative histochemistry for iron and liver iron content.

Post mortem liver samples from 12 donkeys (Equus asinus) aged 21-57 years (4 females, 1 stallion, 7 geldings), were assessed chemically for copper and iron content on a wet weight basis and histologically for stainable iron. Chemical liver copper content ranged from 2.7 to 4.8µg/g (mean 3.5±0.05µg/g). Chemical liver iron content ranged from 524 to 5010µg/g (mean 1723±1258µg/g). Histochemical iron was measured morphometrically using a computer-based image analysis system; percentage section area staining for iron ranged from 0.84% to 26.69% (mean 10.82±8.36%). There was no clear correlation, within the wide range of iron values, between histochemically demonstrable iron and chemically measured iron content. No clear age-related increase was apparent for either parameter in these aged donkeys. The accumulation of iron in the liver of donkeys may represent a physiological haemosiderosis rather than pathological haemochromatosis.

Guidelines for constructing a statewide hospital syndromic surveillance network.

INTRODUCTION: The process to initiate a comprehensive and inexpensive statewide hospital emergency department-based syndromic surveillance system (HEDSS) in Connecticut can serve as a template for others. OBJECTIVES: With limited financial resources, the Connecticut Department of Public Health (CDPH) determined the requirements necessary to establish and routinely conduct hospital emergency department (HED)-based syndromic surveillance. METHODS: A statewide survey assessed ability and willingness of Connecticut hospitals to participate in HED syndromic surveillance. The New York City HED-based system protocol and analysis programs, available without financial charge, were modified for use in Connecticut. This system is based on hospitals sending daily standardized files of chief complaint data through encrypted e-mail or an FTP protocol to CDPH with subsequent categorization into syndromes using a SAS program. Anticipating regional surveillance needs during the Republican National Convention in New York City (RNC), CDPH initiated HEDSS in August 2004. RESULTS: Most Connecticut HEDs were willing and able to participate on a voluntary basis. Beginning in July 2004, hospital recruitment began. By the time of the RNC, 11 of 32 Connecticut hospitals participated in HEDSS. Since then, an additional six HEDs have joined. CONCLUSION: Establishing a voluntary statewide HEDSS was possible using an existing, readily available protocol with minimum financial resources and consensus from a statewide workgroup over a several-month time period.

Hospital admissions syndromic surveillance--Connecticut, September 200-November 2003.

On September 11, 2001, the Connecticut Department of Public Health (CDPH) initiated daily, statewide syndromic surveillance based on unscheduled hospital admissions (HASS). The system's objectives were to monitor for outbreaks caused by Category A biologic agents and evaluate limits in space and time of identified outbreaks. Thirty-two acute-care hospitals were required to report their previous day's unscheduled admissions for 11 syndromes (pneumonia, hemoptysis, respiratory distress, acute neurologic illness, nontraumatic paralysis, sepsis and nontraumatic shock, fever with rash, fever of unknown cause, acute gastrointestinal illness, and possible cutaneous anthrax, and suspected illness clusters). Admissions for pneumonia, gastrointestinal illness, and sepsis were reported most frequently; admissions for fever with rash, possible cutaneous anthrax, and hemoptysis were rare. A method for determining the difference between random and systemic variation was used to identify differences of >/=3 standard deviations for each syndrome from a 6-month moving average. HASS was adapted to meet changing surveillance needs (e.g., surveillance for anthrax, smallpox, and severe acute respiratory syndrome). HASS was sensitive enough to reflect annual increases in hospital-admission rates for pneumonia during the influenza season and to confirm an outbreak of gastrointestinal illness. Follow-up of HASS neurologic-admissions reports has led to diagnosis of West Nile virus encephalitis cases. Report validation, syndrome-criteria standardization among hospitals, and expanded use of outbreak-detection algorithms will enhance the system's usefulness.

Testing pregnant women for HIV: a survey of obstetricians and review of patient prenatal/obstetric medical records--Connecticut 1996-1997.

High rates of prenatal testing are needed to identify all HIV-infected pregnant women and prevent transmission to their offspring. To evaluate HIV testing of pregnant women in Connecticut, a survey was conducted in 1998 of licensed obstetricians and a review was performed of 992 randomly sampled prenatal and obstetric medical records for births occurring in 1996. Results of the survey indicated that 78.8% of respondents routinely offered HIV counseling and 76.4% routinely offered HIV testing to pregnant patients in 1997. However, only 44% reported that greater than half of their patients were being tested. Providers who had an HIV testing policy that included HIV-testing unless the patient refused had the highest rate (80.8%; P < 0.05). The review of medical records revealed that only 28.8% of women who delivered in 1996 had an HIV test performed during prenatal care. Maternal characteristics associated (P < 0.05) with testing included Hispanic ethnicity (51.8% tested), younger age (53.6%, < 20 years old), having Medicaid (48.0%), hospital clinic services (44.6%), and history of intravenous drug use (IDU) (76.9%). Testing rate varied by hospital from 0% to 82.8%. These results indicate that considerable modification of provider and hospital practices and policies is needed to raise HIV screening rates.

Training adaptations of baboons to light and moderate treadmill exercise.

We evaluated training adaptations by 18 baboons (Papio cynocephalus anubis) to low and moderate quadrupedal walking exercise on a motorized treadmill. Moderate training produced 47% increases in lactate threshold, 63% increases in muscle citrate synthetase activity, increases in percentage of Type IIc muscle fibers, and reduced plasma insulin concentrations. Low training produced only reduced plasma insulin concentrations. Only results indicate that the baboon response to exercise training was similar to that of Homo sapiens, and dependent on exercise intensity.

Diet and oral premalignancy in female south Indian tobacco and betel chewers: a case-control study.

The diets of 158 tobacco/betel quid-chewing women diagnosed with oral premalignant lesions and 155 quid-chewing but lesion-free controls, frequency matched for age, tobacco/betel habits, and socioeconomic status, were assessed using a food frequency survey. Index scores generated from the food frequency survey indicated that the mean levels of consumption for foods of animal origin (p < 0.001), total vegetables and fruit (p = 0.001), vegetables alone (p = 0.006), fruits alone (p = 0.006), and green leafy vegetables (p = 0.015) were significantly lower in cases than in controls. The mean index score for cobalamin (vitamin B12) was lower in cases with a borderline significance (p = 0.05), whereas the indexes for folate and carotene were not significantly different. The analysis of index scores estimating the number of 100-g servings per week of foods of animal origin [meat, eggs, milk, curd (yogurt), fish] consumed revealed that women who ate fewer servings were more likely to have premalignant lesions than those who ate more animal foods [odds ratio (OR) 3.38, 95% confidence interval (CI) 2.07-5.54, p = 0.001]. The risk for low consumption of vegetables was not as significant as that for foods of animal origin. However, those eating low levels of vegetables and low levels of foods of animal origin were at the greatest risk for lesions (OR 5.38, 95% CI 1.72-22.17, p < 0.05). In South Indian female tobacco/betel chewers, a diet deficient in foods of animal origin appears to be a more significant risk factor for oral premalignancy than is a diet deficient in fruits and vegetables.

A longitudinal study of dental caries in the primary teeth of children who suffered from infant malnutrition.

A prospective, four-year longitudinal study of 209 Peruvian children was conducted to evaluate the effect of a single malnutrition episode occurring at infancy (i.e., < 1 year of age) on dental caries in the primary teeth. Children were recruited into the study at age 6-11 months after they had suffered from a malnutrition episode and were thus classified by anthropometry as either: (1) Normal; (2) Wasted (low weight for height); (3) Stunted (low height for age); or (4) Stunted and Wasted (S and W). Eruption of the primary teeth was significantly delayed in all malnourished children; however, the effect of stunting--that is, retarded linear growth--was more pronounced and lasted longer than that of wasting or acute malnutrition (i.e., 2.5 vs. 1.5 years, respectively). By age 4 years, children from group 4 (S and W) showed a significantly higher caries experience in the primary teeth than did those in any of the other three groups. In summary, this longitudinal study has confirmed previous studies in animals and indirect epidemiological evidence which had suggested a cause-effect relationship between early malnutrition and increased dental caries.

PIP: The study was conducted from 1986 through 1990 among 209 children residing in Canto Grande, a poor community located north of Lima, Peru. The children were recruited as infants, aged 6-11 months, from the outpatient population of the Canto Grande Health Center, or from two other hospitals. All children were of full-term gestation and normal birth weight ( 2500 g). Each child was assigned to 1 of 4 study groups ascertained by weight and height measurements, with the National Center for Health Statistics standards used as the reference: 1) normal; 2) wasted, indicating current acute malnutrition; 3) stunted, indicating past or chronic malnutrition; and 4) stunted and wasted, indicating malnutrition soon after birth. The data, composed of 2700 examinations, were analyzed by the Statistical Analysis System (SAS) General Linear Models (GLM) program for computation of ANOVA tables. The mean numbers of teeth at ages 1 and 1.5 years for normal children were significantly higher than those of the children who were either wasted, stunted, or stunted and wasted as infants. At age 2, normal children had significantly more teeth in the mouth than did stunted children and stunted and wasted children. At age 2.5, the number of teeth in the normal children was still significantly higher than in stunted children. At age 4, all 4 groups had their full 20 teeth. At age 4, children who were stunted and wasted during infancy showed a significantly higher number of decayed, extracted, and filled teeth (def) compared with that of the other 3 groups. When grouped into 4 def categories of low, moderate, high, and very high caries experience, the distribution of the 4th group was distinctly different from that of the other 3 groups. 17.2% of stunted and wasted children had a very high caries experience (i.e., def 13) at age 4, significantly higher than that in any of the other 3 groups (i.e., normal 9.8%, wasted 4.4%, and stunted 3.6%, respectively; p 0.001).