Small Area Analysis of Veterans Affairs Mental Health Services Data.

OBJECTIVE: To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment. METHODS: MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period. RESULTS: A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles. CONCLUSIONS: MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.

A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Patients who undergo endovascular aneurysm repair (EVAR) often require reintervention after the index repair. The long-term rate of reintervention and how this has changed with newer device technology are poorly understood. Therefore, we performed a systematic review and meta-analysis of the available literature to determine long-term freedom from reintervention after EVAR and the change in reintervention rates over time. METHODS: We performed a systematic review of MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials and observational studies that documented the rate of reintervention after EVAR. We performed a meta-analysis of Kaplan-Meier freedom from reintervention at each year after EVAR. We used linear regression to evaluate change in reintervention rate over time with newer device technology. RESULTS: We included a total of 30 studies (randomized trials, n = 3; observational studies, n = 27) comprising 32,126 patients in this review and meta-analysis. Studies ranged in the implantation date of the EVAR device from 1996 to 2014. The probability of freedom from reintervention was 81% (95% confidence interval [CI], 77%-85%) at 5 years, 70% (95% CI, 65%-76%) at 10 years, and 64% (95% CI, 46%-79%) at 14 years. Linear regression demonstrated an improvement in freedom from reintervention when results were stratified by the year of device implantation. At 1 year, estimated freedom from reintervention improved from 90% in 1998 to 94% in 2008 (n = 26 studies; R2 = 0.11; P = .10). At three years, estimated freedom from reintervention improved from 77% in 1998 to 90% in 2008 (n = 26 studies; R2 = 0.27; P = .006). At 5 years, estimated freedom from reintervention improved from 68% in 1998 to 81% in 2008 (n = 22 studies; R2 =0.12; P = .12). At 7 years, estimated freedom from reintervention improved from 51% in 1998 to 86% in 2011 (n = 22 studies; R2 = 0.40; P = .015). CONCLUSIONS: EVAR patients remain at risk for reintervention indefinitely, and therefore lifelong surveillance is imperative. Encouragingly, reintervention rates have improved over time, with newer devices exhibiting lower rates. Reintervention rate remains an important metric for new devices and registries.

The Durability of Active Surveillance in Patients with Asymptomatic Kidney Stones: A Systematic Review.

Introduction: The natural progression of asymptomatic kidney stones remains unclear. Such knowledge may promote value-aligned care for patients and reduce potentially unnecessary procedures. We sought to evaluate the natural history of asymptomatic kidney stones in adults undergoing active surveillance. Materials and Methods: Using themes of "Kidney Stone" and "Active Surveillance," we performed a systematic review by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, Cumulative Index to Nursing and Allied Health Literature, BIOSIS, Scopus, and Web of Science from inception through October 2017-in addition to ClinicalTrials.gov, American Urological Association Annual Meeting abstracts (2014-2017), Google Scholar, and references of included studies and prior reviews. Two blinded reviewers independently extracted data and assessed methodological quality. We qualitatively summarized rates of surgical intervention (primary outcome), spontaneous stone passage, symptom development, and stone growth. We assessed the relationship between surveillance duration and rate of surgical intervention with Pearson's correlation coefficient. Results: Of 7034 unique records, 13 studies met final eligibility criteria. There was substantial variation in reported rates of surgical intervention from 6/85 (7.1%) to 80/301 (26.6%), spontaneous stone passage from 1/32 (3.1%) to 101/347 (29.1%), symptom development from 7/96 (7.3%) to 231/300 (77.0%), and stone growth from 5/96 (5.2%) to 33/50 (66.0%). Mean surveillance duration spanned from 11.3 to 80 months (range 2-180 months). Longer mean duration of surveillance did not correlate with an increase in surgical intervention rate across studies (n = 13, r = 0.01, p = 0.98), and this finding persisted when restricting analysis to observational studies (n = 9, r = 0.12, p = 0.76). Conclusions: Active surveillance appears to be a durable strategy for a majority of patients with asymptomatic kidney stones, as there was no increase in failure of watchful waiting despite increasing duration of surveillance. Higher quality studies are needed to ascertain which patients may benefit most from active surveillance.

The effect of preoperative penicillin allergy testing on perioperative non-beta-lactam antibiotic use: A systematic review and meta-analysis.

Background: The majority of patients for elective surgery and with a history of penicillin allergy are placed on alternative prophylactic antibiotic therapies, which have been associated with the emergence of multidrug-resistant pathogens and increased morbidity and mortality rates. However, self-reporting of penicillin allergy alone may overestimate the prevalence of penicillin allergy in the population. Objective: To assess the effects of preoperative antibiotic allergy testing protocols in reducing the use of non-beta-lactam antibiotics. Methods: We searched medical literature data bases through July of 2018. Two reviewers independently extracted data from published studies and assessed the risk of bias in cohort studies by using the Newcastle-Ottawa Scale. We collected information related to study design, methodology, demographics, interventions, and outcomes. We pooled odds ratios for the rate of prescribing non-beta-lactam antibiotics by using a fixed-effects model. Results: Of 905 citations screened for eligibility, nine studies met inclusion criteria for qualitative analysis. Studies reported that the rates of non-beta-lactam use after preoperative skin testing ranged from 6 to 30%. In addition, four of the nine studies had sufficient control data to be included in a meta-analysis. These four studies found that preoperative testing protocols significantly decreased the rates of prescribing non-beta-lactam antibiotics compared with usual care (odds ratio 3.64 [95% confidence interval, 2.67-4.98]; p < 0.0001). Seven studies reported on adverse drug reactions after preoperative skin testing and found that the rate of such reactions was rare. Conclusion: Preoperative antibiotic allergy testing protocols seemed to be a safe and effective tool in reducing the use of non-beta-lactam antibiotics during surgery.

Use of Iterative Cycles in Quality Improvement Projects in Imaging: A Systematic Review.

PURPOSE: Studies suggest that quality improvement (QI) projects in health care lack scientific rigor, but the actual frequency of use of proven scientific QI methodology is unknown. The purposes of this study are to (1) conduct a systematic review of QI projects in radiology journals on the frequency of use of iterative cycles, a marker of proven QI methodology, and (2) assess association of the use of iterative cycles with characteristics of these projects. MATERIALS AND METHODS: We searched English-language radiology journals on MEDLINE between 2008 and 2015 for published QI studies. Three reviewers appraised studies and extracted data. Use of iterative cycles was identified, and results were summarized qualitatively. χ2 Analysis evaluated associations of iterative cycles with other data elements. RESULTS: Of 3,134 potentially eligible citations, 44 studies met inclusion criteria. Only 46% of these used iterative cycles to refine intervention. Use of iterative cycles were associated with projects designed to improve process, QI expert support, reporting of unintended effect of intervention, and explicitly stated use of iterative cycles. General lack of scientific rigor was represented by failure to report baseline data (9%), describe unintended effects (66%), and discuss limitations (36%). CONCLUSIONS: Our systematic review found fewer than half of the QI projects in radiology journals used iterative cycles to refine intervention, a scientific strategy central to many proven improvement methodologies. Use of iterative approach was associated with projects designed to improve processes, QI expert support, report of unintended effect, and explicitly stated use of iterative cycles.

Electronic Medical Record Reporting Enhances Proactive Psychiatric Consultation.

BACKGROUND: Numerous studies have demonstrated that psychiatric and substance use issues in general hospital inpatients result in increased length of stay and associated costs. Additional studies have demonstrated that proactive consultation models in psychiatry can effectively address these problems. Selecting patients for proactive interventions is less well studied. OBJECTIVE: We sought to develop an automated, electronic medical record-based screening tool to select patients who might benefit from proactive psychiatric consultation. METHODS: An automated daily report was developed using information stored in electronic medical record and billing systems. Discrete data fields populating the report included diagnoses, orders, and nursing care plans. RESULTS: Over a 9-month period, the report identified 2177 patients (19% of the total nonpsychiatric adult admissions) as potentially benefitting from proactive psychiatric interventions. Of these, 367 were confirmed as likely to benefit from intervention; 139 (38%) were randomized to the proactive psychiatric consultation group. Of those patients randomized to "treatment as usual," a subset later required psychiatric consultation, which was requested an average of 4 days after the time they were flagged by the report. CONCLUSIONS: The use of an electronic medical record-based automated report is feasible to select patients for proactive psychiatric interventions on admission and throughout the hospital stay. Early identification of patients may decrease length of stay and improve patient outcomes.

A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery.

OBJECTIVE: The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery. SUMMARY OF BACKGROUND DATA: The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT. METHODS: A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding. RESULTS: Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)]. CONCLUSIONS: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.

Strategies to prevent death by suicide: meta-analysis of randomised controlled trials.

BackgroundFew randomised controlled trials (RCTs) have shown decreases in suicide.AimsTo identify interventions for preventing suicide.MethodWe searched EMBASE and Medline from inception until 31 December 2015. We included RCTs comparing prevention strategies with control. We pooled odds ratios (ORs) for suicide using the Peto method.ResultsAmong 8647 citations, 72 RCTs and 6 pooled analyses met inclusion criteria. Three RCTs (n = 2028) found that the World Health Organization (WHO) brief intervention and contact (BIC) was associated with significantly lower odds of suicide (OR = 0.20, 95% CI 0.09-0.42). Six RCTs (n = 1040) of cognitive-behavioural therapy (CBT) for suicide prevention and six RCTs of lithium (n = 619) yielded non-significant findings (OR = 0.34, 95% CI 0.12-1.03 and OR = 0.23, 95% CI 0.05-1.02, respectively).ConclusionsThe WHO BIC is a promising suicide prevention strategy. No other intervention showed a statistically significant effect in reducing suicide.

A clinical care pathway to improve the acute care of patients with glioma.

BACKGROUND: Patients with glioma are at increased risk for tumor-related and treatment-related complications. Few guidelines exist to manage complications through supportive care. Our prior work suggests that a clinical care pathway can improve the care of patients with glioma. METHODS: We designed a quality improvement (QI) project to address the acute care needs of patients with gliomas. We formed a multidisciplinary team and selected 20 best-practice measures from the literature. Using a plan-do-study-act framework, we brainstormed and implemented various improvement strategies starting in October 2013. Statistical process control charts were used to assess progress. RESULTS: Retrospective data were available for 12 best practice measures. The baseline population consisted of 98 patients with glioma. Record review suggested wide variation in performance, with compliance ranging from 30% to 100%. The team hypothesized that lack of process standardization may contribute to less-than-ideal performance. After implementing improvement strategies, we reviewed the records of 63 consecutive patients with glioma. The proportion of patients meeting criteria for 12 practice measures modestly improved (65% pre-QI; 76% post-QI, P > .1). Unexpectedly, a higher proportion of patients were readmitted within 30 days of hospital discharge (pre-QI: 10%; post-QI: 17%, P > .1). Barriers to pathway development included difficulties with transforming manual measures into electronic data sets. CONCLUSIONS: Creating evidence-based clinical care pathways for addressing the acute care needs of patients with glioma is feasible and important. There are many challenges, however, to developing sustainable systems for measuring and reporting performance outcomes overtime.

Association between serum thyroid-stimulating hormone levels and serum lipids in children and adolescents: a population-based study of german youth.

CONTEXT: No studies have examined the association between TSH and lipid profiles of healthy children and adolescents in the general population. OBJECTIVE: The objective was to investigate the association between TSH and lipid profiles. DESIGN: We used a population-based cross-sectional study design and analyzed our results using multivariable regression models. SETTING: The study was conducted in Germany. PARTICIPANTS: We analyzed data from 6622 children (ages 3-10 y) and 6134 adolescents (ages 11-17 y) drawn from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Blood samples were collected, and serum TSH levels were measured using the electrochemiluminescence method. High and low serum TSH levels were defined according to age-specific reference limits for the assay. Total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride levels were determined with enzymatic color analyses. RESULTS: We found a significant positive association between TSH and all non-HDL parameters (total cholesterol, LDL-C, and triglycerides) in children (ß = 0.90, 95% confidence interval [CI], 0.53-1.27; ß = 0.78, 95% CI, 0.44-1.13; and ß = 0.90, 95% CI, 0.52-1.27, respectively) and in adolescents (ß = 0.90, 95% CI, 0.47-1.32; ß = 0.67, 95% CI, 0.29-1.05; and ß = 0.92, 95% CI, 0.49-1.35, respectively) (P < .05). Using stratified models, we found that this relationship was particularly present in overweight/obese children. Furthermore, high TSH levels in children were significantly associated with non-HDL parameters. CONCLUSIONS: Higher TSH levels are associated with less favorable lipid levels in children. Longitudinal studies are needed to clarify whether the association between TSH and lipid parameters in children and adolescents is a temporary phenomenon or is sustained into adulthood.

Improving the quality of care for patients diagnosed with glioma during the perioperative period.

PURPOSE: Although there is agreement on the oncologic management of patients with glioma, few guidelines exist to standardize other aspects of care, including supportive care. METHODS: A quality improvement (QI) project was chartered to improve the care provided to patients with glioma. A multidisciplinary team was convened and identified 10 best-practice measures. Using a plan-do-study-act framework, the team brainstormed and implemented various improvement interventions between June 2011 and October 2012. Statistical process control charts were used to evaluate progress. A dashboard of quality measures was generated to allow for ongoing measurement and reporting. RESULTS: The retrospective assessment phase consisted of 43 patients with diagnosis of glioma. A manual medical record review for these patients showed that compliance with 10 best-practice measures ranged from 23% to 100%. Several factors contributed to less-than-ideal process performance, including poor communication among disciplines and lack of familiarity with the larger system of care. After implementing improvement interventions, performance was measured in 96 consecutive patients with glioma. The proportion of patients who met criteria for 10 practice measures significantly improved (pre-QI work, 63%; post-QI work, 85%; P = .003). The largest improvement was observed in the measure assessing for preoperative notification of the neuro-oncology program (pre-QI work, 39%; post-QI work, 97%; P < .001). CONCLUSION: QI principles were used by a multidisciplinary team to improve the quality of care for patients with glioma during the perioperative period. Leadership involvement, ongoing dialogue across departments, and reporting of system performance were important for sustaining process improvements.