An Academic Medical Center-Based Incubator to Promote Clinical Innovation and Financial Value.

INTRODUCTION: Within a health care landscape characterized by increasing financial pressures, fluctuating payment models, and an increasing prevalence of clinician burnout, structures to strategically support innovation are imperative to financial and clinical success. METHODS: We developed the Brigham Care Redesign Incubator and Startup Program (BCRISP), a flexible model to test, evaluate, and scale innovative care redesign proposals. We evaluated its impact via analysis of programmatic and financial data, as well as through exploration of individual project outcomes. RESULTS: In 5 years, BCRISP has evaluated 283 innovations, piloted 25 projects, and generated $1.8 million in total medical expense reduction and $7.1 million in increased net revenue for our institution. Initially, it was conceived as a mechanism to engage staff in population health initiatives. As shifts toward risk-based reimbursement have slowed, we have observed a similar transition among proposed and supported innovation in the program. CONCLUSIONS: BCRISP enabled front-line clinical employees to design and pilot solutions to common and important clinical care problems, delivering financial return and improvements in care delivery. The underlying structure has been able to adapt to the changing political and economic climate, demonstrating a flexible and powerful approach to strategic investment that could be applied broadly by many health care provider organizations.

A Decision-Making Algorithm for Initiation and Discontinuation of RRT in Severe AKI.

BACKGROUND AND OBJECTIVES: AKI is an increasingly common and devastating complication in hospitalized patients. Severe AKI requiring RRT is associated with in-hospital mortality rates exceeding 40%. Clinical decision making related to RRT initiation for patients with AKI in the medical intensive care unit is not standardized. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a 13-month (November of 2013 to December of 2014) prospective cohort study in an academic medical intensive care unit involving the implementation of an AKI Standardized Clinical Assessment and Management Plan, a decision-making algorithm to assist front-line clinicians caring for patients with AKI. The Standardized Clinical Assessment and Management Plan algorithms provided recommendations about optimal indications for initiating and discontinuing RRT on the basis of various clinical parameters; 176 patients managed by nine nephrologists were included in the study. We captured reasons for deviation from the recommended algorithm as well as mortality data. RESULTS: Patients whose clinicians adhered to the Standardized Clinical Assessment and Management Plan recommendation to start RRT had lower in-hospital mortality (42% versus 63%; P<0.01) and 60-day mortality (46% and 68%; P<0.01), findings that were confirmed after multivariable adjustment for age, albumin, and disease severity. There was a differential effect of Standardized Clinical Assessment and Management Plan adherence in low (<50% mortality risk) versus high (≥50% mortality risk) disease severity on in-hospital mortality (interaction term P=0.02). In patients with low disease severity, Standardized Clinical Assessment and Management Plan adherence was associated with lower in-hospital mortality (odds ratio, 0.21; 95% confidence interval, 0.08 to 0.54; P=0.001), but no significant association was evident in patients with high disease severity. CONCLUSIONS: Physician adherence to an algorithm providing recommendations on RRT initiation was associated with lower in-hospital mortality.

Uncoupling proteins in heart failure.

The development of heart failure is associated with alterations in the expression of a wide variety of structural, signaling, and metabolic proteins. One such effect is the downregulation of uncoupling proteins in the setting of heart failure. This group of proteins regulates the mitochondrial membrane potential and therefore plays a role in mitochondrial energy metabolism as well as reactive oxygen species generation by the mitochondria. This review discusses the role of uncoupling proteins in regulating oxidant stress and implications with respect to the pathogenesis of heart failure and potential treatments.