Risk stratification in deep brain stimulation surgery: Development of an algorithm to predict patient discharge disposition with 91.9% accuracy.

Clinical decision making is susceptible to biases and can be improved with the application of predictive models and decision support systems (DSS). The purpose of this study was to develop a predictive risk stratification model and DSS that could accurately predict whether a patient was likely to be of high- or low-acuity discharge disposition (DD) status subsequent to DBS surgery. Data were collected for 135 DBS patients by reviewing medical records. Multivariate logistic regression was applied to develop the predictive algorithm. The two significant predictive models showed good fit and were calibrated by using AUROC curve analysis. The model predicting DD in all patients (n = 135) yielded a predictive accuracy of 91.9% (AUROC = 0.825, p < .001). The model predicting DD in Parkinson's Disease patients (n = 91) yielded a predictive accuracy of 89.0% (AUROC = 0.853, p < .001). Age was a significant predictor of DD across all patients (OR = 1.11, p < .05) and BMI was a significant predictor of DD amongst Parkinson's Disease patients (OR = 1.16, p < .05). It is possible to accurately predict the DD of DBS patients using routinely collected preoperative variables. The predictive algorithms were applied in the form of a model-driven DSS to assist in improving clinical decision making and patient safety.

Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway.

STUDY DESIGN: Quality improvement with before and after evaluation of the intervention. OBJECTIVE: To improve lumbar spine postoperative care and quality outcomes through a series of Lean quality improvement events designed to address root causes of error and variation. SUMMARY OF BACKGROUND DATA: Lumbar spine fusion procedures are common, but highly variable in process of care, outcomes, and cost. METHODS: We implemented a standardized lumbar spine fusion clinical care pathway through a series of Lean quality improvement events. The pathway included an evidence-based electronic order set; a patient visual tool; and multidisciplinary communication, and was designed to delineate expectations for patients, staff, and providers. To evaluate the effectiveness of the intervention, we performed a quality improvement study with before and after evaluation of consecutive patients from January 2012 to September 2014. Outcomes were hospital length of stay and quality measures before and after the April 1, 2013 intervention. Data were analyzed with chi-square and t tests for before and after comparisons, and were explored graphically for temporal trends with statistical process control charts. RESULTS: Our study population was 458 patients (mean 65 years, 65% women). Length of stay decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI 0.3, 0.8, P < 0.001). Discharge disposition also improved with 75% (183/244) being discharged to home postintervention versus 64% (136/214) preintervention (P = 0.002). Urinary catheter removal also improved (P = 0.003). Patient satisfaction scores were not significantly changed. CONCLUSION: Applying Lean methods to produce standardized clinical pathways is an effective way of improving quality and reducing waste for lumbar spine fusion patients. We believe that quality improvements of this type are valuable for all spine patients, to provide best care outcomes at lowest cost. LEVEL OF EVIDENCE: 4.

Initial Experience with the Use of Thrombopoetin Receptor Agonists in Patients with Refractory HIV-Associated Immune Thrombocytopenic Purpura: A Case Series.

HIV-associated immune thrombocytopenic purpura (ITP) has decreased in incidence 10-fold since the advent of highly active antiretroviral therapy (HAART). For patients with detectable HIV viral loads, first-line treatment approaches involve optimizing HAART followed by standard ITP options used to treat those without HIV infection. In the general population, the thrombopoetin receptor agonists (TRAs), eltrombopag and romiplostim, are effective when used as salvage ITP therapy. In addition, eltrombopag has been used effectively in patients with thrombocytopenia secondary to hepatitis C--a virus seen commonly in HIV-infected patients, especially in those who also have a history of intravenous drug use. There are, however, few reports or studies of TRAs use in those with HIV infection. Herein, we describe 5 cases of refractory HIV-associated ITP managed with TRAs. Although platelet counts improved for all patients, 2 patients succumbed to thromboembolic complications. Our initial experience, as well as our findings from a Medline review, supports the potential utility of TRA as salvage therapy in the treatment of HIV-related ITP; however, we recommend caution in the use of these agents in those who are at highest risk of thrombosis. Additional studies are needed to determine the efficacy and, more importantly, the safety of TRAs in treatment of HIV-associated ITP.