Advanced care at home at scale in an integrated health care system.

OBJECTIVES: To assess the feasibility of scaling advanced care at home (ACAH) (otherwise known as hospital at home) within an integrated health care delivery system. STUDY DESIGN: Retrospective cohort study of patients qualified for hospital-level care who were admitted to either ACAH or a traditional hospital. METHODS: From April 29, 2020, to November 14, 2021, patients requiring hospital-level care received Kaiser Permanente at Home or traditional hospital care. In a subgroup of patients, we compared outcomes for Kaiser Permanente at Home vs traditional hospital care using regression models. RESULTS: A total of 1005 patients were admitted to Kaiser Permanente at Home. Average daily census (ADC) was intentionally increased over time in stages, from 7.2 to 8.8, then to 12.7. The maximum daily census was 22, with a peak ADC of 16, representing 9% of the total hospital inpatient medicine service census. During this time, there were numeric decreases in Kaiser Permanente at Home escalation rates (17.5% to 10.8%), median length of stay (7.43 days to 5.46 days), and readmission rates (9.79% to 9.24%). A subgroup of Kaiser Permanente at Home patients contributed to the comparative analyses, which showed that patients admitted to Kaiser Permanente at Home were 64% less likely to experience delirium than patients admitted for traditional hospital care (OR, 0.36; 95% CI, 0.15-0.88; P = .026). Comparisons of quality metrics across stages of implementation (readmissions, escalations, length of stay) were inconclusive. CONCLUSION: In an integrated delivery system, ACAH care can be scaled and can create hospital capacity. However, our data were inconclusive regarding quality throughout scaling due to the small effective sample size, necessitating replication in a larger prospective study with adequate power/precision.

A Dialectical and Dialogical Approach to Health Policies and Programs: The Case of Open Defecation in India.

A multi-pronged approach to health policy and programs related to open defecation (OD) is proposed via a qualitative study conducted in rural India. A dialogic and dialectic perspective is employed to interpret the key findings from nine focus groups, highlighting the dialectical views toward OD and latrines. Findings indicate that current policy may be too narrow as it does not fully deal with the multiple reasons, including social communication as well as gender, cultural, health and work identity issues, for OD. The results suggest that OD is more complicated than it appears and a multi-pronged, poly-vocal approach to health communication campaigns and policy should be considered.

Value of Targeted Epidural Blood Patch and Management of Subdural Hematoma in Spontaneous Intracranial Hypotension: Case Report and Review of the Literature.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a more common than previously noted condition (1-2.5 per 50,000 persons) typically caused by cerebrospinal fluid (CSF) leakage. Initial treatment involves conservative therapies, but the mainstay of treatment for patients who fail conservative management is the epidural blood patch (EBP). Subdural hematoma (SDH) is a common complication occurring with SIH, but its management remains controversial. METHODS: In this report, we discuss a 62-year-old woman who presented with a 5-week history of orthostatic headaches associated with nausea, emesis, and neck pain. Despite initial imaging being negative, the patient later developed classic imaging evidence characteristic of SIH. Magnetic resonance imaging was unrevealing for the source of the CSF leak. Radionuclide cisternography showed possible CSF leak at the right-sided C7-T1 nerve root exit site. After failing a blind lumbar EBP, subsequent targeted EBP at C7-T1 improved the patient's symptoms. Two days later she developed a new headache with imaging evidence of worsening SDH with midline shift requiring burr hole drainage. This yielded sustained symptomatic relief and resolution of previously abnormal imaging findings at 2-month follow-up. RESULTS: A literature review revealed 174 cases of SIH complicated by SDH. This revealed conflicting opinions concerning the management of this condition. CONCLUSIONS: Although blind lumbar EBP is often successful, targeted EBP has a lower rate of patients requiring a second EBP or other further treatment. On the other hand, targeted EBP has a larger risk profile. Depending on the clinic situation, treatment of the SDH via surgical evacuation may be necessary.

Tackling 30-Day, All-Cause Readmissions with a Patient-Centered Transitional Care Bundle.

In 2008, Kaiser Permanente Northwest identified the transition from hospital to home as a pivotal quality improvement opportunity and used multiple patient-centered data collection methods to identify unmet needs contributing to preventable readmissions. A transitional care bundle that crosses care settings and organizational functions was developed to meet needs expressed by patients. It comprises 5 elements: risk stratification, a specialized phone number for discharged patients, timely postdischarge follow-up, standardized patient discharge instructions and same-day discharge summaries, and pharmacist-supported medication reconciliation. The transitional care bundle has been in place for 6 years. Readmission rates decreased from 12.1% to 10.6%, Hospital Consumer Assessment of Healthcare Providers and Systems scores for the discharge instruction composite moved from below the 50(th) to above the 90(th) national percentile, average time to the first postdischarge appointment decreased from 9.7 days to 5.3 days, and error rates on the discharge medication list decreased from 57% to 21% (P<.0001 for all). The program, which continues to evolve to address sustainability challenges and organizational initiatives, suggests the potential of a multicomponent, patient-centered care bundle to address the complex, interrelated drivers of preventable readmissions.

Volume of contrast and selectivity for lumbar transforaminal epidural steroid injection.

BACKGROUND: It has been shown that L4/L5 selective nerve root blocks become nonselective after injecting 1 mL and 0.5 mL of contrast. Volumes of less than 0.5 mL have not been used to determine a volume of definite specificity. OBJECTIVE: This study attempts to identify the minimum volume of contrast at which selectivity is maintained without spread to the superior or inferior end plate. STUDY DESIGN: Prospective, nonrandomized, observational human study of 70 patients receiving lumbar transforaminal epidural steroid injection. METHODS: Using biplanar imaging, needle tip position was confirmed just caudad to the pedicle shadow at 6 o'clock position in the AP view and mid or ventral aspect of the foramen in the lateral view. Contrast was then injected in aliquots of 0.2 mL to a total volume of 2.0 mL. Fluoroscopic images were recorded at 0.2 mL increments. These images were evaluated to determine which 0.2 mL volume increment was no longer specific. Volume of contrast at which the spread extended to the superior and inferior end plates and crossed the midline to the contralateral side was also recorded. RESULTS: Three patients had extraforaminal flow and one had an initial intravascular injection. Data were analyzed for 66 patients. Average (s.d) volume of contrast at which selectivity was demonstrated was 0.41 mL (0.26). Superior and inferior spread was noted at 0.82 mL (0.49) and 0.83 mL (0.44), respectively. Seventy-eight point eight percent of SNRB were selective for the specified nerve root after injecting 0.2ml of dye. Selectivity decreased to 33.3% after injecting 0.6 mL; 1.2 mL of dye injected was selective only in 6% of patients. Superior spread of contrast was more common as compared to inferior (P = 0.016). Also, initial spread was superior in 50% of cases at L4 level and 64.7% at L5 level (P <0.05). LIMITATIONS: Relatively small number of patients with a nonrandomized design. CONCLUSIONS: Diagnostic selective nerve root blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes as low as 0.2 mL. Also, spread of the contrast to the superior nerve root was more likely than spread to the inferior nerve root.

Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome.

OBJECTIVE: This study evaluated the early effectiveness of isolated pectoralis minor tenotomy (PMT) in the surgical treatment of selected patients with neurogenic thoracic outlet syndrome (NTOS) compared with supraclavicular decompression (SCD; as scalenectomy, neurolysis, and first rib resection) plus PMT (SCD+PMT). METHODS: Data were obtained for 200 patients undergoing operative treatment for disabling NTOS between 2008 and 2011. Isolated PMT was offered to 57 patients with physical examination findings limited to the subcoracoid space, and SCD+PMT was offered to 143 with scalene triangle and subcoracoid findings. Functional outcomes were assessed before and 3 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) survey and related instruments. RESULTS: There were no significant differences (P > .05) between PMT and SCD+PMT patients with respect to age (overall, 37 ± 1 years), sex (73% women), side affected (52% right, 14% bilateral), or the frequency of various NTOS symptoms, but fewer PMT patients had a bony anomaly (0% vs 18%; P < .01) or a history of injury (35% vs 61%; P < .01). Mean preoperative DASH scores were similar between PMT and SCD+PMT groups (49.9 ± 3.6 vs 50.8 ± 1.6), but previous use of opiate pain medications was higher in PMT patients (47% vs 20%; P = .0004). PMT was conducted as an outpatient procedure, whereas the mean hospital stay after SCD+PMT was 4.8 ± 0.1 days, with two patients (1%) requiring early reoperations for persistent lymph leaks. Mean DASH scores 3 months after surgery were significantly improved after isolated PMT (29.6 ± 4.2; P < .01) and SCD+PMT (41.5 ± 2.2; P < .01), but the mean extent of improvement in DASH scores was not significantly different in PMT (32% ± 9%) vs SCD+PMT (19% ± 5%). There were also no significant differences in the proportion of PMT vs SCD+PMT patients demonstrating improvement in functional outcome measures (75% vs 72%) or in overall use of opiate medications (35% vs 27%). CONCLUSIONS: Isolated PMT is a low-risk outpatient procedure that is effective for the treatment of selected patients with disabling NTOS, with early outcomes similar to SCD+PMT. These findings emphasize the importance of recognizing subcoracoid brachial plexus compression as part of the spectrum of NTOS and support the role of PMT in surgical management.

Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control.

The elderly population is projected to make up 20% of the total United States population by the year 2030. In addition, epidemiological data suggests increasing prevalence of chronic pain and frailty with advancing age. Pain, being a subjective symptom, is challenging to manage effectively. This is more so in elderly populations with age-specific physiological changes that affect drug action and metabolism. Elderly patients are also more likely to have multiple chronic health pathologies, declining function, and frailty. The barriers present for patients, providers, and health systems also negatively impact efficient and effective pain control. These factors result in disproportionate utilization of health resources by the older population group. The scientific literature is lagging behind in age-specific studies for the elderly population. As a result, there is a lack of age-specific standardized management guidelines for various health problems, including chronic pain. Increasing efforts are now being directed to studies on pain control in the elderly. However, pain management remains inconsistent and suboptimal. This article is an attempt to suggest an informed, comprehensive guide to achieve effective pain control in the presence of these limitations.

Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations.

OBJECTIVE: This study was conducted to better define clinical results and understand factors determining responsiveness to surgical treatment for neurogenic thoracic outlet syndrome (NTOS) in adolescent and adult populations. METHODS: A retrospective review was conducted for 189 patients with disabling NTOS who underwent primary supraclavicular decompression (scalenectomy, brachial plexus neurolysis and first rib resection, with or without pectoralis minor tenotomy) from April 2008 to December 2010. Clinical characteristics were compared between 35 adolescent patients (aged<21 years) and 154 adults (aged>21 years). Functional outcome measures were assessed before surgery and at 3- and 6-month follow-up using a composite NTOS Index combining the Disabilities of the Arm, Shoulder and Hand (DASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a 10-point visual analog scale (VAS) for pain. RESULTS: Adolescent and adult patients were not significantly different with respect to sex (overall 72.5% female), side affected (58.7% right, 60.3% dominant limb), bony anomalies (23.3%), previous injury (55.6%), coexisting pain disorders (11.1%), and positive responses to scalene muscle anesthetic blocks (95.6%). Compared with adults, adolescent patients had a significantly (P<.05) lower incidence of depression (11.4% vs 41.6%), motor vehicle injury (5.7% vs 20.1%), previous operations (11.4% vs 29.9%), preoperative use of opiate medications (17.1% vs 44.8%), and symptom duration>2 years (24.2% vs 50.0%). Mean preoperative NTOS Index (scale 0-100) was significantly lower in adolescent vs adult patients (46.5±3.6 vs 58.5±1.7; P=.009), and hospital length of stay was 4.4±0.2 vs 4.9±0.1 days (P=.03), but the rate of postoperative complications was no different (overall, 4.2%). Although both groups exhibited significant improvement in functional outcome measures at 3 and 6 months, adolescent patients had significantly lower NTOS Index (10.4±3.1 vs 39.3±3.3; P<.001) and use of opiate medications (11.4% vs 47.4%; P<.001) compared with adults. CONCLUSIONS: Adolescents undergoing supraclavicular decompression for NTOS had more favorable preoperative characteristics and enhanced 3-month and 6-month functional outcomes than adults. Further study is needed to delineate the age-dependent and independent factors that promote optimal surgical outcomes for NTOS.

Vertebral augmentation for compression fractures caused by malignant disease.

Vertebral compression fractures are common in malignant disease and frequently cause severe back pain. However, management of that pain with conventional medical, radiotherapy, or surgical modalities is often inadequate. Vertebral augmentation techniques, such as vertebroplasty and kyphoplasty, are minimally invasive techniques in which methylmethacrylate bone cement is percutaneously injected into compressed vertebral bodies. Vertebral augmentation often improves mechanical stability of compressed vertebrae, provides pain relief, and may prevent progression of vertebral collapse. Kyphoplasty may provide increased chance for vertebral body height restoration, but the clinical importance of slight change in vertebral body height is unclear. Vertebral augmentation can be used in conjunction with other treatment modalities, and associated pain relief may improve patient tolerance of needed antitumor therapies, such as radiation therapy. Vertebral augmentation is generally very well tolerated, and complications associated with bone cement extravasation beyond the vertebral body have rarely been reported. Because it often provides good to excellent relief of otherwise intractable pain and is generally well tolerated, vertebral augmentation is becoming a first-line agent for management of painful vertebral compression fractures, especially in the setting of malignant disease.

Systematic review of the role of sedation in diagnostic spinal interventional techniques.

BACKGROUND: There is ongoing controversy regarding the validity of controlled diagnostic blocks due to variability in sensitivity, specificity, and accuracy. Consequently, identification of false-positive rates, false-negative rates, and placebo responses is crucial. The reasons described for false-positive responses to diagnostic anesthetic blocks are many; however, sedation and psychological factors have been implied as causes. Further, there is no consensus with regards to sedation prior to controlled diagnostic blocks and their influence on the accuracy and validity of a diagnosis. STUDY DESIGN: A systematic review of the literature evaluating the influence of sedation on diagnostic spinal interventional techniques. OBJECTIVES: To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of controlled diagnostic blocks in the diagnosis of chronic spinal pain. METHODS: A comprehensive evaluation of the literature relating to sedation in diagnostic interventional techniques was performed. The methodologic quality assessment of the studies was carried out by utilizing Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher included in the assessment of the level of evidence. Level of evidence was based on the U.S. Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. LIMITATIONS: All 3 of the studies were produced by one group of authors. Thus paucity of the literature on the subject of facet joint pain and the lack of literature on the subjects of discogenic pain and sacroiliac joint pain are major limitations. RESULTS: Three studies were identified which met inclusion and methodologic assessment quality criteria. Sedation can be a confounding factor in a small population of patients specifically if fentanyl is employed and non-stringent criteria are followed. Based on the 3 randomized double-blind trials with stringent criteria utilizing 80% pain relief and the ability to perform prior painful movements without any significant pain following the diagnostic injection in evaluation of facet joint pain, the indicated evidence is Level II-1. CONCLUSION: This systematic review provides no significant evidence of the influence of sedation either with midazolam or fentanyl in the evaluation of cervical and lumbar facet joint pain with controlled cervical and lumbar facet joint nerve blocks with an indicated evidence of Level II-1, with application of stringent criteria of at least 80% pain relief and the ability to perform previously painful movements after the diagnostic blocks.

Foxy methoxy: a new drug of abuse.

INTRODUCTION: In 1999, a new synthetic tryptamine, 5-MeO-DIPT, became known as a street drug, with the street name of "Foxy" or "Foxy Methoxy". By February 2003, the DEA reported law enforcement seizures and/or reports of abuse in 12 states. We report a case along with an analysis of poison center data on this new drug of abuse. CASE REPORT: A 19-year-old male was brought to the emergency department following ingestion of a larger than his usual dose of Foxy. Upon arrival, he had hallucinations, hypertension, tachycardia, mydriasis, and catalepsy. Symptoms resolved within two hours after administration of lorazepam and he recovered uneventfully. DISCUSSION: The AAPCC TESS database contained 41 exposures to "Foxy" between April, 2002 and June, 2003; 26 had moderate or major effects, indicating this drug has significant toxic potential. Given the expanding use of this and other club drugs, the spectrum of toxicity from this new agent will continue to be elucidated.