High-touch care leads to better outcomes and lower costs in a senior population.

OBJECTIVES: There are several models of primary care. A form of high-intensity care is a high-touch model that uses a high frequency of encounters to deliver preventive services. The aim of this study is to compare the healthcare utilization of patients receiving 2 models of primary care, ​1 with high-touch care and 1 without. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective cohort study of 2 models of care used among Medicare Advantage populations. Model 1 is a high-touch care model, and model 2 is a standard care model. Compared with model 2, model 1 has smaller panel sizes and a higher frequency of encounters. We compared patients' healthcare utilization and hospitalizations between both models using a propensity score-matched analysis, matching by Charlson Comorbidity Index (CCI) score, age, and gender. RESULTS: We included 17,711 unmatched Medicare Advantage primary care patients and matched 5695 patients from both models of care. CCI scores, age, and gender were similar between both matched groups (P >.05). The median total per member per month healthcare costs in model 1 were $87 (95% CI, $26-$278) compared with $121 (95% CI, $52-$284) in model 2 (P <.01). The mean number of hospital admissions was lower in model 1 (0.10 ± 0.40) compared with model 2 (0.20 ± 0.58). The number of primary care physician visits and preventive medication use were higher in model 1 (P <.05 for both). CONCLUSIONS: In a propensity-matched sample of Medicare Advantage patients, those receiving high-touch care had lower healthcare costs and fewer hospitalizations. Potential explanations are higher preventive medication use and more frequent visits.

A screening echocardiogram to identify diastolic dysfunction leads to better outcomes.

BACKGROUND: Diastolic dysfunction (DD) can lead to heart failure and higher mortality. Echocardiograms can detect DD but are not indicated for screening in older adults. Our aim was to evaluate the prevalence of DD and the impact of identifying it in seniors. METHODS: We performed screening echocardiograms in 5227 consecutive patients between January 2014 and March 2015 in 36 senior-focused value-based clinics across six states. We determined the presence of the grade of DD and defined stage B grade II/III (asymptomatic) and of stage C grade II/III (symptomatic) DD by the presence or absence of typical HF symptoms. We obtained prescribed medications from the electronic health record to determine absolute changes in HF therapy before and after the echocardiogram. RESULTS: We included a group with no DD (n=649), a group with grade 1 DD (n=2875), and those with grades 2 and 3 (n=1357) who had normal ejection fraction. The prevalence of grade 2 or 3 DD with preserved ejection fraction was 25%; 95% CI: 24-26. The absolute change of ace-inhibitor use before and after the echocardiogram increased by 14, 19, 23, 27 in patients without DD, those with grade 1, grade 2 or 3 asymptomatic and grade 2 or 3 symptomatic, respectively. The use of ß-blocker, statin, and diuretic had similar trends. CONCLUSIONS: Seniors without previously known stage B or stage C heart failure have moderate-to-severe DD, 27% of whom were stage C. Identifying seniors with DD leads to improvement in care.

Screening echocardiograms in a senior focused value based primary care improves systolic heart failure detection and clinical management.

BACKGROUND: Screening echocardiograms are not indicated. Our aim is to evaluate the impact of screening echocardiograms on improving clinical management among older adults. METHODS: We performed screening echocardiograms for all consecutive patients and defined incident systolic heart failure (HF) as an ejection fraction of less than 50% among patients without a previous HF diagnosis. We reviewed medical record data to determine if the new cases where Stage B or C. We obtained prescribed medications and vital signs from the electronic health record to determine absolute changes before and after the echocardiogram. RESULTS: We performed an echocardiogram in 6,417 patients with a mean age of 71.4±6. The echocardiogram identified 292 seniors with new cases of systolic HF (5.34%; 95% CI: 4.7-5.9) and 239 were stage B HF. The increase in the use of ace-inhibitor, beta blocker when comparing the pre and post echocardiogram periods was highest in those with Stage C and those with ejection fraction lower than 40%. Systolic blood pressure (SBP) decreased from 140±19 to 136±15 (P<0.01) and low density lipoprotein (LDL) from 105±36 to 97±33 (P<0.01). CONCLUSIONS: Performing echocardiograms in senior-focused value-based primary care improves evidence-based cardiovascular treatment and short-term clinical outcomes, including lowering SBP and LDL.

(124)I PET/CT in Patients with Differentiated Thyroid Cancer: Clinical and Quantitative Image Analysis.

BACKGROUND: Although radioactive iodine (RAI) imaging/therapy is one of the earliest applications of theranostics, there remain a number of unresolved clinical questions as to the optimization of diagnostic techniques/protocols and improvements in patient-specific treatment planning strategies. The objectives of this study were to determine the imaging characteristics and clinical feasibility of (124)I positron emission tomography/computed tomography (PET/CT) for the determination of extent of disease and evaluation of RAI kinetics in its physiologic and neoplastic distribution in patients with differentiated thyroid cancer (DTC). METHODS: The study was designed as a prospective phase II diagnostic trial of patients with confirmed DTC. Following adequate preparation, patients received 2 mCi (124)I in liquid form and sequential whole-body PET/CT imaging was performed at five time points (2-4 h, 24 ± 6 h, 48 ± 6 h, 72 ± 6 h, and 96 ± 6 h post-administration). All patients who had (124)I imaging subsequently underwent RAI treatment with (131)I, with administered activities ranging from 100 to 300 mCi. Post-treatment scans were obtained 5-7 days after RAI treatment. A by-patient and by-lesion analysis of the (124)I images was performed and compared with the post-treatment (131)I scans as well as F-18 FDG PET/CT images. Quantitative image analysis was also performed to determine the total functional volume (mL), activity per functional volume (µCi/mL), and cumulated activity (µCi/h) for remnants, salivary glands, and nodal metastases. RESULTS: Fifteen patients (6 women; Mage = 57 years; range 29-91 years) were enrolled into the study. Forty-six distinct lesions were identified in these 15 patients on (124)I PET/CT images, with a sensitivity of 92.5%. In addition, (124)I identified 22.5% more foci of RAI-avid lesions compared with the planar (131)I post-treatment scans. This study demonstrates different kinetic profiles for normal thyroid remnants (peaked at 24 h with mono-exponential clearance), salivary glands (peaked at 4 h with bi-exponential clearance), and metastatic lesions (protracted retention), as well as individual variations in functional volumes and thus cumulated activities. CONCLUSIONS: (124)I PET/CT is a valuable clinical imaging tool/agent, both in determining the extent of disease in the setting of metastatic DTC and in the functional volumetric and kinetic evaluation of target lesions.