Mobile Integrated Healthcare Intervention and Impact Analysis with a Medicare Advantage Population.

Mobile Integrated Healthcare (MIH) is a patient-centered, innovative delivery model offering on-demand, needs-based care and preventive services, delivered in the patient's home or mobile environment. An interprofessional MIH clinical team delivered a care coordination program for a Medicare Advantage Preferred Provider Organization that was risk assigned prior to intervention to target the highest risk members. Using claims and eligibility data, 6 months of pre-program experience and 6 months of program-influenced experience from the intervention cohort was compared to a propensity score-matched comparison cohort to measure impact. The intervention led to a reduction in inpatient and emergency department utilization, resulting in net savings amount totals of $2.4 million over the 6 months of the program. After accounting for the costs of implementing the program, the intervention produced a return on investment of 2.97. Additionally, high patient activation and experience lend strength to this MIH intervention as a promising model to reduce utilization and costs while keeping patient satisfaction high.

National trends in the use of postcardiac arrest therapeutic hypothermia and hospital factors influencing its use.

BACKGROUND: Therapeutic hypothermia (TH) in cardiac arrest continues to be underused in the United States. A better understanding of its utilization could inform future efforts and policies to improve utilization. This study investigates trends in TH use for in and out-of-hospital cardiac arrest, and hospital factors associated with its use. METHODS: We performed a cross-sectional analysis using the Nationwide Inpatient Sample (NIS), 2007-2010, of US adult hospitalizations with cardiac arrest. Annual rates of TH use and proportions of hospitals using TH were calculated using NIS weighting. Potential hospital factors associated with increased likelihood of TH utilization were assessed using logistic regression. RESULTS: Across 2007-2010, 1.35% of cardiac arrest patients received TH; increasing from 0.34% (2007) to 2.49% (2010). The proportion of hospitals using TH was 13.63%, increasing from 4.63% (2007) to 22.16% (2010). Significant hospital factors associated with TH utilization were: large hospitals, urban location, Northeast or West regions, teaching hospitals, non-safety net hospitals, increasing year, and hospitals with higher annual cardiac arrest volume. CONCLUSION: Utilization of TH in cardiac arrest remains low, but increased sevenfold from 2007 to 2010. The significant variability in implementation of TH, argues for nationwide best practices or regionalization of postcardiac arrest care hospitals.

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

BACKGROUND: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. METHODS: We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. RESULTS: Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. DISCUSSION: Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

Simulation-based education with mastery learning improves paracentesis skills.

BACKGROUND: Paracentesis is a commonly performed bedside procedure that has the potential for serious complications. Therefore, simulation-based education for paracentesis is valuable for clinicians. OBJECTIVE: To assess internal medicine residents' procedural skills before and after simulation-based mastery learning on a paracentesis simulator. METHODS: A team with expertise in simulation and procedural skills developed and created a high fidelity, ultrasound-compatible paracentesis simulator. Fifty-eight first-year internal medicine residents completed a mastery learning-based intervention using the paracentesis simulator. Residents underwent baseline skill assessment (pretest) using a 25-item checklist. Residents completed a posttest after a 3-hour education session featuring a demonstration of the procedure, deliberate practice, ultrasound training, and feedback. All residents were expected to meet or exceed a minimum passing score (MPS) at posttest, the key feature of mastery learning. We compared pretest and posttest checklist scores to evaluate the effect of the educational intervention. Residents rated the training sessions. RESULTS: Residents' paracentesis skills improved from an average pretest score of 33.0% (SD  =  15.2%) to 92.7% (SD  =  5.4%) at posttest (P < .001). After the training intervention, all residents met or exceeded the MPS. The training sessions and realism of the simulation were rated highly by learners. CONCLUSION: This study demonstrates the ability of a paracentesis simulator to significantly improve procedural competence.

Is it the athlete or the equipment? An analysis of the top swim performances from 1990 to 2010.

O'Connor, LM and Vozenilek, JA. Is it the athlete or the equipment? An analysis of the top swim performances from 1990 to 2010. J Strength Cond Res 25(12): 3239-3241, 2011-Forty-three world record swims were recorded at the 2009 Fédération Internationale de Natation (FINA) World Championship meet in Rome. Of the 20 FINA recognized long-course (50-m pool) swimming events, men set new world records in 15 of those events, whereas women did the same in 17 events. Each of the men's world records and 14 of the 17 women's records still stand. These performances were unprecedented; never before had these many world records been broken in such a short period of time. There was much speculation that full-body, polyurethane, technical swimsuits were the reason for the conspicuous improvement in world records. Further analysis led the FINA to institute new rules on January 1, 2010, that limited the types of technical swimsuits that could be worn by athletes. No long-course world record has been broken since then. We sought to understand this phenomenon by analyzing publicly available race data and exploring other possible causes including improvements in other sports, improvements in training science, changes in rules and regulations, gender differences, anaerobic vs. aerobic events, unique talent, and membership data.