Examining How the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model Improves Health Equity for Underserved Communities and Safety Net Hospitals in New York State.

Safety net hospitals (SNHs) are essential to our healthcare ecosystem, providing quality healthcare to underserved communities. These institutions offer specialized services and acute medical care to populations facing structural or systemic healthcare barriers. However, for decades, the NYS Medicaid program reimbursed hospitals less than the cost of care, resulting in several independent SNHs becoming financially distressed, with many facing closure. Recently, the Center for Medicaid and Medicare Service Innovation Center (CMSI) introduced the State All-Payer Health Equity Approaches and Development (AHEAD) Model, which aims to support the financial needs of providers while also addressing the complex medical and social circumstances of underserved communities. This article will explore how the AHEAD model can be utilized as an alternative payment method for SNHs in New York State (NYS) to improve healthcare for underserved communities.

Safety-net Hospitals in Brooklyn, New York: A Review.

Safety-net hospitals (SNHs) provide health care services to individuals regardless of their ability to pay. These hospitals serve Medicaid recipients, the uninsured, and people with limited access to health care due to their socioeconomic status, race, or ethnicity. In addition to providing health care to the most vulnerable, SNHs are crucial in training the next generation of clinicians. Hospitals serving Medicaid patients and the uninsured have low operating margins because of a dated State Medicaid financial model, and as a result, many now face closure. This review provides historical context for the financial challenges facing SNHs in Brooklyn, New York. In addition, it examines how New York State's Medicaid reimbursement methodology threatens the viability of hospitals that serve low-income communities. Finally, the article suggests a solution to the health care crisis in Brooklyn, capitalizing on structural payment reform successes in other states.

Association of opioid exposure during intensive care unit stays with post-discharge opioid use: A retrospective study and literature review.

OBJECTIVE: To evaluate whether pain management strategies within intensive care unit (ICU) settings contribute to chronic opioid use upon hospital discharge in opioid-naive patients requiring invasive mechanical ventilation. DESIGN: A retrospective, observational study. SETTING: An 18-bed mixed ICU at a community teaching hospital located in Brooklyn, New York. PARTICIPANTS: This study included mechanically ventilated patients requiring continuous opioid infusion from April 25, 2017 to May 16, 2019. Patients were excluded if they received chronic opioid therapy at home or expired during this hospital admission. Eligible patients were identified using an electronic health record data query. MAIN OUTCOME MEASURE(S): The proportion of ICU patients who continued to require opioids upon ICU and hospital discharge. RESULTS: A total of 196 ICU patients were included in this study. Of these, 22 patients were transferred to a regular floor while receiving a fentanyl transdermal patch. However, the fentanyl patch treatment was continued only for three patients (2 percent) at hospital discharge. CONCLUSIONS: This retrospective study suggested that high-dose use of opioids in mechanically ventilated, opioid-naive ICU patients was not associated with continued opioid use upon hospital discharge.

Treatment With Tocilizumab for Patients With COVID-19 Infections: A Case-Series Study.

Tocilizumab (TCZ), a humanized monoclonal antibody targeting the interleukin-6 receptor, holds the potential for treating coronavirus disease 2019 (COVID-19) patients, particularly those at high risk of cytokine storm syndrome. However, data regarding the clinical impact of treatment with TCZ in patients with COVID-19 are limited. This study was conducted to evaluate the safety and effectiveness of TCZ as an adjunct therapy for the treatment of severe COVID-19 infection. This was a retrospective observational chart review of confirmed COVID-19 patients who received TCZ, along with other COVID-19 therapies. The outcomes of interest included changes in vital signs such as temperature and laboratory biomarkers, duration of mechanical ventilation, adverse events possibly associated with TCZ, and intensive care unit and hospital lengths of stay. This study included 38 patients with an average age of 63 years (IQR, 48-70 years). The average dose of TCZ given was 519 ± 61 mg. Median C-reactive protein significantly decreased following TCZ administration (189.9 vs 54.8 mg/L, P = .003). Nineteen of all febrile patients before the initiation of TCZ (73%) became fever free on the fourth day of TCZ treatment. Following TCZ treatment, 11 patients developed infections because of multidrug-resistant bacteria, and elevated liver transaminases were observed in 6 patients. The preliminary findings of this study suggested TCZ appeared to ameliorate COVID-19-related cytokine storm syndrome. However, large randomized, controlled trials are needed to investigate whether treatment with TCZ is associated with better outcomes in COVID-19.

AHA telemetry guidelines improve telemetry utilization in the inpatient setting.

OBJECTIVES: Overuse of telemetry among hospitalized patients results in poor patient care and wasted health care dollars. Guidelines addressing telemetry use have been developed by the American Heart Association (AHA) and are effective when applied to specific clinical practices and high-value care. The purpose of our intervention was to facilitate more effective utilization of telemetry in our hospital. We aimed to reduce patient days on telemetry through use of AHA guideline criteria for telemetry. STUDY DESIGN: We used Plan-Do-Study-Act cycles with chart review for pre- and postintervention measurement collection. METHODS: We included patients hospitalized at The Brooklyn Hospital Center on inpatient general medical wards from January 1, 2017, through July 31, 2018. The intervention consisted of a standard process of reviewing patients on telemetry based on AHA guidelines, educating teams on the guidelines, and changes to telemetry order sets. The primary outcome measured was the total number of days that patients remained on telemetry. Secondary measures included the daily number of telemetry downgrades and total number of patients on telemetry. Diagnosis-related group and case mix index were also noted. RESULTS: Patient average days on telemetry changed from 7.20 days preintervention to 3.51 days post intervention (P < .0001). The number of patients on telemetry with a diagnosis meeting AHA guidelines for telemetry increased. CONCLUSIONS: The stated intervention resulted in more effective use of telemetry, evidenced by fewer patient days on telemetry and increased numbers of patients on telemetry meeting AHA guidelines for telemetry.

Clinical and economic impact of the use of dexmedetomidine for sedation in the intensive care unit compared to propofol.

Background Despite the advantages of dexmedetomidine (DEX) over propofol (PRO) including minimal respiratory depression and the potential for preventing and/or treating intensive care unit (ICU) delirium, PRO has been the preferred agent due to its lower cost. However, the acquisition cost of DEX has considerably decreased as a generic version of DEX has recently become available. Objective To evaluate clinical and economic outcomes of DEX-based sedation compared to PRO in the ICU. Setting A retrospective cohort study of 86 ICU patients who received either DEX or PRO for a period ≥ 12 h. Method Patients were matched by age, sex, and Sequential Organ Failure Assessment scores in a 1:1 ratio. Main outcome measure Clinical outcomes included the duration of mechanical ventilation (MV), ICU and hospital length of stay (LOS), and requirements of concomitant sedatives and opioids. Economic outcomes included the ICU and hospital costs as well as the cost of sedatives or combined sedatives and opioids per patient. Results There were no significant differences in ICU and hospital LOS and time on MV in both groups (median ICU LOS 7 [DEX] vs. 9 [PRO] days, p = 0.07; median hospital LOS 12 [DEX] vs. 14 [PRO] days, p = 0.261; median time of MV 144 [DEX] vs. 158 [PRO] hours, p = 0.176). DEX-based sedation compared to PRO was associated with similar ICU and hospital costs (US$ 67,561 vs. 78,429, p = 0.39; US$ 71,923 vs. 71,084, p = 0.1). Conclusion The clinical outcomes and economic impact associated with DEX- and PRO-based sedation were similar.

Characterization of Critically Ill COVID-19 Patients at a Brooklyn Safety-Net Hospital.

Background The novel coronavirus disease 2019 (COVID-19) pandemic continues to spread across the country with over 3 million cases and 150,000 deaths in the United States as of July 2020. Outcomes have been poor, with reported admission rates to the intensive care team of 5% in China and mortality among critically ill patients of 50% in Seattle. Here we explore the disease characteristics in a Brooklyn safety-net hospital affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods A retrospective chart review of COVID-19 positive patients at The Brooklyn Hospital Center who were treated by the intensive care team prior to April 20, 2020. Data was extracted from the electronic health record, analyzed and correlated for outcome. Results Impact of various clinical treatments was assessed, showing no change in median overall survival (OS) of both hydroxychloroquine with azithromycin or vitamin C with zinc. Supplemental therapies were used in selected patients, and some were shown to increase median OS and patients requiring vasopressor support or invasive mechanical ventilation showed decreased OS. There was no statistically significant difference in overall survival based on ethnicity, healthcare status, or individual medical comorbidities, although a negative trend exists for diabetes. Despite this, there is a trend towards increasingly poor prognosis based on the number of comorbidities and Class 3 obesity.  Conclusions Despite the fact that we show no significant differences in mortality based on ethnicity, insurance status, or individual medical comorbidities, we show a high overall mortality. There is also a trend towards increased overall mortality in Class 3 obesity, which should be further investigated. We suggest that these findings may be attributed to both socioeconomic factors and an increased incidence of total medical comorbidities in our patient population.

Clostridioides difficile infection in US hospitals: a national inpatient sample study.

BACKGROUND: Hypervirulent strains of Clostridioides difficile have altered the landscape of hospital and community outbreaks. We aim to examine and compare spatiotemporal trends, incidence, hospital teaching status, mortality, and cost associated with hospital-acquired Clostridioides difficile infection (HCDI) and community-acquired Clostridioides difficile infection (CCDI). METHODS: Retrospective cohorts were studied using data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) from 2006 to 2015. RESULTS: A total of 76,124 cases of HCDI and 190,641 cases of CCDI were identified within the study period. The incidence of HCDI decreased from 8555 in 2006 to 7191 in 2015. Mortality also decreased during the same period (5.9% in 2006 to 1.4% 2015, p < 0.0001). Conversely, CCDI cases increased from 13,823 in 2006 to 20,637 in 2015. CCDI mortality decreased during the same period (4.3% in 2006 to 1.9% 2015, p < 0.0001). Rural hospital centers experienced the sharpest decline in HCDI mortality compared to urban and urban teaching centers (3.8%, p < 0.0001 vs 2.8%, p < 0.0001 vs 2.1%, p < 0.0001). Multivariate logistic regression indicated that increasing age (p = 0.0001), increasing hospital length of stay (p = 0.0001), and Medicare insurance (p = 0.002) were significant predictors of mortality for CDI mortality. Geospatial mapping of CCDI and HCDI revealed that the Eastern and Southern US experienced the largest incidence of CDI over 10 years. CONCLUSION: The incidence of HCDI has decreased in the past decade while the incidence of CCDI hospitalization is sharply on the rise. While hospital length of stay and mortality has decreased over time, the cost of treating CDI remains high.

Practice measures for controlling and preventing hospital associated Clostridium difficile infections.

Clostridium difficile (CD) is the most common cause of nosocomial diarrhea. We aim to highlight practice measures for controlling and preventing Clostridium difficile infections (CDI) in the hospital setting. Electronic databases including PubMed, MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Databases were searched for human studies that assessed strategic measures for the prevention of CDI. Bundled interventions can effectively reduce the rates of CDI. Current evidence support the implementation antibiotic stewardship programs, hygiene enhancement, dietary management with probiotics, use of copper surfaces, and the cautious use of PPIs. However, current guidelines do not advocate the use of copper, probiotics, or the discontinuation of PPIs as a means for reducing CDI. We review these practical and evidence-based approaches.

Evaluation of the Clinical Utility of Routine Daily Chest Radiography in Intensive Care Unit Patients With Tracheostomy Tubes: A Retrospective Review.

BACKGROUND: The utilization of imaging procedures is under scrutiny due to high costs and radiation exposure to patients and staff associated with some radiologic procedures. Within our institution's intensive care unit (ICU), it is common for patients to undergo chest radiography (CR) not only immediately following tracheostomy tube placement but also on a daily basis, irrespective of the patient's clinical status. We hypothesize that the clinical utility of performing routine daily CR on patients with tracheostomy tubes is low and leads to unnecessary financial cost. METHODS: A retrospective medical chart review was done on 761 CRs performed on 79 ICU patients with tracheostomy from April 2010 to July 2011. We searched the radiology reports of the 761 CRs for the presence of new radiographically detected complications and reviewed medical records to determine which complications were clinically suspected and which radiology reports led to changes in patient management. RESULTS: Of the 761 CRs, only 18 (2.3%) radiographs revealed new complications. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%). CONCLUSIONS: Routine daily imaging of patients with tracheostomy in an ICU provides little clinical utility, and CR in this population should be performed selectively based on the patient's clinical status.

Integrating Palliative Care into Critical Care: A Quality Improvement Study.

BACKGROUND: Many terminally ill patients experience an increasing intensity of medical care, an escalation frequently not consistent with their preferences. In 2009, formal palliative care consultation (PCC) was integrated into our medical intensive care unit (ICU). We hypothesized that significant differences in clinical and economic outcomes exist between ICU patients who received PCC and those who did not. METHODS: We reviewed ICU admissions between July and October 2010, identified 41 patients who received PCC, and randomly selected 80 patients who did not. We measured clinical outcomes and economic variables associated with patients' ICU courses. RESULTS: Patients in the PCC group were older (average 64 years, standard deviation [SD] 19.2 vs 55.6 years, SD 14.5; P = .021) and sicker (median Acute Physiology and Chronic Health Evaluation IV score 85.5, interquartile range [IQR] 60.5-107.5 vs 60, IQR 39.2-74.75; P < .001) than the non-PCC controls. PCC patients received significantly more total days of ICU care on average (8 days, IQR 4-15 vs 4 days, IQR 2-7; P < .001), had more ICU admissions, and were more likely to die during their ICU stay (64.3% vs 12.5%, P < .001). Median total hospital charges per patient attributable to ICU care were higher in the PCC group than in the controls (US$315,493, IQR US$156,470-US$486,740 vs US$116,934, IQR US$54,750-US$288,660; P < .001). After we adjusted for ICU length of stay, we found that median ICU charges per day per patient did not differ significantly between the groups (US$37,463, IQR US$27,429-US$56,230 vs US$41,332, IQR US$30,149-US$63,288; P = .884). Median time to PCC during the ICU stay was 7 days (IQR 2-14.5 days). CONCLUSIONS: Patients who received PCC had higher disease acuity, longer ICU lengths of stay, and higher ICU mortality than controls. "Trigger" programs in the ICU may improve utilization of PCC services, improve patient comfort, and reduce invasive, often futile end-of-life care.

Hypertriglyceridemic Pancreatitis Caused by the Oral Contraceptive Agent Estrostep.

Norethindrone acetate/ethinyl estradiol (Estrostep; Warner Chilcott, Rockaway, New Jersey) is an "estrophasic" type of oral contraceptive, which combines a continuous low progestin dose with a gradually increasing estrogen dose. In clinical trials, this medication failed to produce clinically significant changes in serum lipid levels. We report a case of severe hypertriglyceridemia-induced acute pancreatitis in a 24-year-old woman caused by Estrostep, occurring nearly 10 years after she began using the drug. The patient was admitted to the medical intensive care unit (ICU) for aggressive volume resuscitation and management of severe electrolyte abnormalities. Laboratory studies obtained on admission indicated severe hypertriglyceridemia (2,200 mg/dL), hyponatremia (120 mEq/L), and hypocalcemia (0.78 mmol/L). Amylase and lipase levels were also elevated (193 and 200 U/L, respectively). Ranson score calculated after 48 hours of admission was 4, and her Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 35. Treatment included an insulin infusion, ω-3 fatty acid esters, and gemfibrozil. The insulin infusion reduced serum triglyceride levels by 50% after 1 day of treatment and to 355 mg/dL by day 7 of her ICU course. We believe that this is the first reported case of severe, acute hypertriglyceridemia-induced pancreatitis caused by this medication.

Cocaine-induced agitated delirium: a case report and review.

Cocaine use continues to be a major public health problem in the United States. Although many of the initial signs and symptoms of cocaine intoxication result from increased stimulation of the sympathetic nervous system, this condition can present as a spectrum of acuity from hypertension and tachycardia to multiorgan system failure. Classic features of acute intoxication include tachycardia, arterial vasoconstriction, enhanced thrombus formation, mydriasis, psychomotor agitation, and altered level of consciousness. At the extreme end of this toxidrome is a rare condition known as cocaine-induced agitated delirium. This syndrome is characterized by severe cardiopulmonary dysfunction, hyperthermia, and acute neurologic changes frequently leading to death. We report a case of cocaine-induced agitated delirium in a man who presented to our institution in a paradoxical form of circulatory shock. Rapid evaluation, recognition, and proper management enabled our patient not only to survive but also to leave the hospital without neurologic sequelae.

Malignant nerve sheath tumor of the spinal accessory nerve: a unique presentation of a rare tumor.

BACKGROUND: Malignant peripheral nerve sheath tumors (MPNSTs), sarcomas originating from tissues of mesenchymal origin, are rare in patients without a history of neurofibromatosis. CASE REPORT: We report a case of an MPNST of the spinal accessory nerve, unassociated with neurofibromatosis, which metastasized to the brain. The tumor, originating in the intrasternomastoid segment of the spinal accessory nerve, was removed. Two years later, the patient presented with focal neurological deficits. Radiographic findings revealed a well-defined 2.2×2.2×2.2 cm, homogeneously enhancing mass in the left parieto-occipital region of the brain surrounded by significant vasogenic edema and mass effect, culminating in a 1-cm midline shift to the right. The mass was surgically removed. The patient had nearly complete recovery of vision, speech, and memory. CONCLUSIONS: To our knowledge, this is the first documented case of an MPNST arising from an extracranial segment of the spinal accessory nerve and metastasizing to the brain.

Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act.

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.

The Leapfrog initiative for intensive care unit physician staffing and its impact on intensive care unit performance: a narrative review.

The field of critical care has changed markedly in recent years to accommodate a growing population of chronically critically ill patients. New administrative structures have evolved to include divisions, departments, and sections devoted exclusively to the practice of critical care medicine. On an individual level, the ability to manage complex multisystem critical illnesses and to introduce invasive monitoring devices defines the intensivist. On a systems level, critical care services managed by an intensivist-led multidisciplinary team are now recognized by their ability to efficiently utilize hospital resources and improve patient outcomes. Due to the numerous cost and quality issues related to the delivery of critical care medicine, intensive care unit physician staffing (IPS) has become a charged subject in recent years. Although the federal government has played a large role in regulating best practices by physicians, other third parties have entered the arena. Perhaps the most influential of these has been The Leapfrog Group, a consortium representing 130 employers and 65 Fortune 500 companies that purchase health care for their employees. This group has proposed specific regulatory guidelines for IPS that are purported to result in substantial cost containment and improved quality of care. This narrative review examines the impact of The Leapfrog Group's recommendations on critical care delivery in the United States.

Gender is a risk factor for lung cancer.

Results of epidemiological studies suggest that, after one controls for the number of cigarettes smoked, women have a three times higher risk of getting lung cancer than men. Although the mechanism(s) explaining this gender-dependent difference in lung cancer risk is not known, it is thought that endocrine factors may play an important role. Normal human bronchial epithelial cells contain estrogen receptors and synthesize 17ß-estradiol (E(2)) and estrone (E(1)), which can undergo further metabolism into the catechol estrogens, 4-hydroxyestradiol (4-OHE(2)) and 4-hydroxyestrone (4-OHE(1)), respectively. Catechol estrogens are formed from E(2) by the actions of cytochrome p450 1B1 (CYP1B1). CYP1B1 is present in normal human bronchial epithelial) cells, and its activity is increased by cigarette smoking. Both 4-OHE(1) and 4-OHE(2) are mutagenic and carcinogenic and may exert their biological effects by inducing DNA adducts in cancer-related genes, including the tumor suppressor gene p53 and the proto-oncogene K-ras. Women with lung cancer have a different p53 mutational spectrum and a higher frequency of K-ras mutations than do men with lung cancer. Both clinical and basic research studies support the hypothesis that E(2) and cigarette smoking are cofactors in lung carcinogenesis in women. More specifically, cigarette smoke stimulates metabolism of E(2) into the genotoxic metabolites, 4-OHE(1) and 4-OHE(2,) which interact with DNA in cancer-related genes, including the tumor suppressor gene, p53, and the proto-oncogene K-ras, two genes frequently mutated in patients with lung cancer. E(2) may stimulate cellular proliferation and enhance tumor growth.

Investigation of critical care unit utilization and mortality in patients infected with Clostridium difficile.

BACKGROUND: A nationwide increase in the rate and severity of Clostridium difficile-associated disease may reflect infection with a virulent strain characterized by polymerase chain reaction as ribotype 027 (NAP1/B1). HYPOTHESIS: The high prevalence of ribotype 027 at our institution would allow investigation of the risk of mortality and admission to the intensive care unit (ICU) associated with C difficile infection. METHODS: In a retrospective cohort study, we identified 108 patients with positive enzyme-linked immunosorbant assay tests for C difficile toxins over a 6-month period and compared them to 108 patients who were suspected to have C difficile but with negative toxin assays. Proportions of all-cause mortality and ICU admission were compared using chi(2), and odds ratios (ORs) were estimated using logistic regression to adjust for potential confounders. Mean log lengths of stay were compared using t test. RESULTS: Comparing patients with C difficile to those without, mortality (20% vs 8%) and ICU admission (32% vs 17%) were significantly higher (P = .02 for both), whereas log length of stay was not (P = .29). Adjusting for potential confounders, the OR for mortality was 6.8 (95% confidence interval, 1.8-25.4; P = .01), whereas for ICU admission, the association was no longer observed (OR, 1.0; 95% confidence interval, 0.4-2.5; P = .97). CONCLUSION: C difficile infection was associated with increased all-cause mortality. An observed association with ICU admission and C difficile infection was identified through univariate analysis but was not significant in multivariate analysis. Although we did not strain-type isolates for patients infected with C difficile, the institutional prevalence of ribotype 027 C difficile infection was known to be high. These results document a strong association between ribotype 027 C difficile infection and mortality and underscore the need to identify effective C difficile preventive strategies.

Fulminant liver failure secondary to haemorrhagic dengue in an international traveller.

Dengue infections are caused by a single-stranded RNA virus, which has four serotypes (DEN 1-4); mosquitoes of the genus Aedes serve as vectors of transmission. Risk factors for dengue infection are related to both the host and virus. Age, gender, immune status, and genetic background of the host all contribute to the severity of dengue infection. Recently, international travel to endemic areas has also been identified as a major risk factor for both primary and secondary dengue infection. Dengue remains a diagnostic challenge, given its protean nature, ranging from mild febrile illness to profound shock. The most severe manifestation of dengue infection is dengue shock syndrome, which has an estimated mortality rate close to 50%. Dengue shock syndrome typically presents with increased anion gap metabolic acidosis, disseminated intravascular coagulation, severe hypotension, and jaundice. Liver involvement appears to occur more frequently when infections involve DEN-3 and DEN-4 serotypes. While hepatocellular damage has been reported previously in dengue infection, acute liver failure is an extremely rare occurrence in adults. We report a patient with dengue shock syndrome who presented with acute liver failure and hepatic encephalopathy after recent travel to an endemic area.