Health Care Utilization and Pain Outcomes Following Early Imaging for Low Back Pain in Older Adults.

BACKGROUND: Professional societies have provided inconsistent guidance regarding whether older patients should receive early imaging for low back pain, in the absence of clinical indications. The study assesses the implications of early imaging by evaluating its association with downstream utilization in an elderly population. METHODS: Patients were included if they had a Medicare Advantage plan, had claims-based evidence of low back pain in 2014, and lacked conditions justifying early imaging. The outcomes examined were short-term, nonchronic, and chronic opioid use, steroid injections, and spinal surgery in the following 730 days, and persistent low back pain at 180 to 365 days. Morphine dose equivalents of opioid use was used as a measure of intensity. Logistic and γ regressions were used to assess the association between imaging in the first 6 weeks and the outcomes. RESULTS: Among the 57,293 patients meeting inclusion criteria, the mean age was 71.2, and 26,606 (46.4%) received early imaging. Early imaging was associated with increased adjusted odds of short-term (odds ratio [OR], 1.21; 95% CI, 1.15 to 1.28), nonchronic (OR, 1.78; 95% CI, 1.69 to 1.88), and chronic (OR, 1.13; 95% CI, 1.07 to 1.18) opioid use, as well as steroid injections (OR, 2.55; 95% CI, 2.28 to 2.85) and spinal surgery (OR, 3.40; 95% CI, 2.97 to 3.90). Patients that received early imaging were more likely to experience persistent pain (OR, 1.09; 95% CI, 1.05 to 1.14) and used significantly more morphine dose equivalents if they had nonchronic opioid use. CONCLUSIONS: Early imaging for low back pain in older individuals was common, and was associated with greater utilization of downstream services and persistent pain.

A Bold Goal: More Healthy Days Through Improved Community Health.

Humana, a large health care company, has set a goal of 20% improvement in health in the communities it serves by 2020. The metric chosen for the Bold Goal initiative was the HRQOL-4 version of the Centers for Disease Control and Prevention (CDC) Healthy Days survey. This paper presents the methods for measuring progress, reports results for the first year of tracking, and describes Humana's community-based interventions. Across 7 specially designated "Bold Goal" communities, mean unhealthy days declined from 10.98 in 2015 to 10.64 in 2016, which represented a 3.1% relative, or 0.34 absolute, decline. This compares with a 0.17 absolute unhealthy days decline in Humana's national population overall. The paper also describes how additional work identifying associations between social determinants of health (SDOH) and Healthy Days is influencing Humana's strategy. Lastly, a strategy of community engagement is illustrated through 2 case examples: San Antonio and Knoxville. In the San Antonio area, the community in which Humana has been involved the longest, unhealthy days dropped by 9.0% (-0.95 absolute) from a mean 10.52 to 9.57 unhealthy days. In Knoxville, one of the newer areas of engagement, mean unhealthy days declined by 4.8% (-0.61 absolute), representing declines in both physically and mentally unhealthy days. Overall, results are encouraging, and Humana expects declines to accelerate over time as initiatives are launched and scaled in Bold Goal communities.

Proficiency in identifying, managing and communicating medical errors: feasibility and validity study assessing two core competencies.

BACKGROUND: Communication skills and professionalism are two competencies in graduate medical education that are challenging to evaluate. We aimed to develop, test and validate a de novo instrument to evaluate these two competencies. METHODS: Using an Objective Standardized Clinical Examination (OSCE) based on a medication error scenario, we developed an assessment instrument that focuses on distinctive domains [context of discussion, communication and detection of error, management of error, empathy, use of electronic medical record (EMR) and electronic medical information resources (EMIR), and global rating]. The aim was to test feasibility, acceptability, and reliability of the method. RESULTS: Faculty and standardized patients (SPs) evaluated 56 trainees using the instrument. The inter-rater reliability of agreement between faculty was substantial (Fleiss k = 0.71) and intraclass correlation efficient was excellent (ICC = 0.80). The measured agreement between faculty and SPs evaluation of resident was lower (Fleiss k = 0.36). The instrument showed good conformity (ICC = 0.74). The majority of the trainees (75 %) had satisfactory or higher performance in all six assessed domains and 86 % found the OSCE to be realistic. Sixty percent reported not receiving feedback on EMR use and asked for subsequent training. CONCLUSION: An OSCE-based instrument using a medical error scenario can be used to assess competency in professionalism, communication, using EMRs and managing medical errors.

Discovering untapped relationship potential with patients in telehealth: a qualitative interview study.

OBJECTIVES: To explore factors that influence relationship building between telehealth professionals and patients with chronic illness over a distance, from a telehealth professional's perspective. DESIGN: 4 focus group interviews were conducted in June 2014. Digital recordings were transcribed verbatim and qualitative content analysis was performed using an iterative process of 3 coding rounds. PARTICIPANTS: 20 telehealth professionals. SETTING: A telehealth service centre in the south of Germany that provided care for 12,000 patients with chronic heart failure across Germany. RESULTS: Non-video telehealth technology creates an atmosphere that fosters sharing of personal information and a non-judgemental attitude. This facilitates the delivery of fair and equal healthcare. A combination of a protocol-driven service structure along with shared team and organisational values provide a basis for establishing long-term healthcare relationships. However, each contact between a telehealth professional and a patient has an uncertain outcome and requires skillful negotiation of the relationship. Although care provision was personalised, there was scope to include the patients as 'experts on their own illness' to a greater extent as advocated by person-centred care. Currently, provision of person-centred care is not sufficiently addressed in telehealth professional training. CONCLUSIONS: Telehealth offers a viable environment for the delivery of person-centred care for patients with long-standing disease. Current telehealth training programmes may be enhanced by teaching person-centred care skills.

Bypass surgery versus endovascular interventions in severe or critical limb ischemia.

OBJECTIVE: Critical limb ischemia is associated with a significant morbidity and mortality. We systematically reviewed the evidence to compare bypass surgery with endovascular revascularization in patients with critical limb ischemia. METHODS: We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus through October 2014 for comparative studies (randomized and nonrandomized). Predefined outcomes of interest were mortality, major amputation, patency, and wound healing. We pooled odds ratios (ORs) of the outcomes of interest using the random-effects model. RESULTS: Nine studies that enrolled 3071 subjects were included. There was no significant difference in mortality (OR, 0.72; 95% confidence interval [CI], 0.44-1.16) or amputation (OR, 1.2; 95% CI, 0.87-1.65). Bypass surgery was associated with higher primary patency (OR, 2.50; 95% CI, 1.25-4.99) and assisted primary patency (OR, 3.39; 95% CI, 1.53-7.51). The quality of evidence was low for mortality and amputation outcomes and moderate for patency outcomes. CONCLUSIONS: Low quality of evidence due to imprecision and heterogeneity suggests that bypass surgery and endovascular approaches may have similar effect on mortality and major amputations. However, better primary and primary assisted patency can be expected with surgery.

Nonrevascularization-based treatments in patients with severe or critical limb ischemia.

OBJECTIVE: The aim of this systematic review was to synthesize the existing evidence about various nonrevascularization-based therapies used to treat patients with severe or critical limb ischemia (CLI) who are not candidates for surgical revascularization. METHODS: We systematically searched multiple databases through November 2014 for controlled randomized and nonrandomized studies comparing the effect of medical therapies (prostaglandin E1 and angiogenic growth factors) and devices (pumps and spinal cord stimulators). We report odds ratios (ORs) and 95% confidence intervals (CIs) of the outcomes of interest pooling data across studies using the random effects model. RESULTS: We included 19 studies that enrolled 2779 patients. None of the nonrevascularization-based treatments were associated with a significant effect on mortality. Intermittent pneumatic compression (OR, 0.14; 95% CI, 0.04-0.55) and spinal cord stimulators (OR, 0.53; 95% CI, 0.36-0.79) were associated with reduced risk of amputation. A priori established subgroup analyses (combined vs single therapy; randomized vs nonrandomized) were not statistically significant. CONCLUSIONS: Very low-quality evidence, mainly due to imprecision and increased risk of bias, suggests that intermittent pneumatic compression and spinal cord stimulators may reduce the risk of amputations. Evidence supporting other medical therapies is insufficient.

The natural history of untreated severe or critical limb ischemia.

OBJECTIVE: Critical limb ischemia (CLI) is associated with high morbidity and mortality. Because most patients with CLI will eventually undergo some type of revascularization, the natural history of CLI is not well defined, although it is important to know when patients decide to pursue treatment. METHODS: We systematically searched multiple databases for controlled and uncontrolled studies of patients with CLI who did not receive revascularization with a minimum follow-up of ≥1 year. Predefined outcomes of interest were mortality, major amputation, and wound healing. Random-effects meta-analysis was used to pool cumulative incidence across studies. RESULTS: We identified 13 studies enrolling 1527 patients. During a median follow-up of 12 months, all-cause mortality rate was 22% (confidence interval [CI], 12%-33%) and major amputation rate was 22% (CI, 2%-42%). Worsened wound or ulcer was found at 35% (CI, 10%-62%). There was a trend toward improvement in mortality and amputation rate in studies done after 1997. The quality of evidence was low because of increased risk of bias and inconsistency. CONCLUSIONS: Mortality and major amputations are common in patients who have untreated CLI during a median follow-up of 1 year, although these outcomes have improved in recent times.

Teaching quality improvement in occupational medicine: improving the efficiency of medical evaluation for commercial drivers.

OBJECTIVE: To describe a successful, resident-led quality improvement (QI) project that improved the efficiency of the Department of Transportation (DOT) medical examination process. METHODS: After learning QI principles through didactics, workshops, and online modules, residents led a QI project to streamline the process of the DOT examination. An interdisciplinary group of key stakeholders collaborated to analyze the process and to design and implement interventions. RESULTS: Following the Model for Improvement and Lean concepts, residents ran seven Plan-Do-Study-Act cycles over a 4-month period with multiple iteration and testing changes. Compared with the baseline, the team successfully reduced the total visit time (from check-in to check-out) by 28 minutes (102 minutes vs. 130 minutes; P < 0.001). The accuracy of certificate issuance, as proxy for quality of the examinations, improved after the interventions. CONCLUSIONS: Residents successfully improved the efficiency of the DOT examination process.

Improving sleep: outcomes from a worksite healthy sleep program.

OBJECTIVE: Unhealthy and inadequate sleep is a common and significant problem impacting absenteeism, presenteeism, health, and productivity. This study aimed at analyzing the effect of a worksite-based healthy sleep program. METHODS: Retrospective analysis of 53 adult members of a worksite wellness center who participated in an 8-week healthy sleep program and completed pre- and postintervention health behavior questionnaires. RESULTS: Following the intervention participants felt significantly more rested, more confident in their ability to deal with sleep problems, and more knowledgeable about sleep. In addition, they reported a reduction in their stress level, improved quality of life, and increase energy level. CONCLUSIONS: These results support the effectiveness of worksite programs designed to promote healthy sleep. Future randomized studies are needed to further investigate the effectiveness and optimal delivery of healthy sleep promotion.

The association of 9p21-3 locus with coronary atherosclerosis: a systematic review and meta-analysis.

BACKGROUND: Studies suggest that the 9p21-3 locus may influence susceptibility to myocardial infarction. We performed a systematic review and meta-analysis to assess whether this locus is associated with severity of coronary atherosclerosis and adverse clinical outcomes in those with known coronary disease. METHODS: Multiple electronic databases were searched from inception through August 2012. Studies examining 9p21-3 genotype in patients with known coronary artery disease were included. We extracted the association of the 9p21-3 locus with measures of severity of coronary atherosclerosis [number of diseased vessels, Gensini Score, Duke CAD Prognostic Index (DPI)], angiographic outcomes [change in minimum lumen diameter (∆MLD) and number of new lesions at follow-up], and key clinical outcomes (all-cause mortality, recurrent myocardial infarction and the need for coronary revascularization). Relative risks (RR) and weighted mean difference (WMD) were pooled using the random effects models. RESULTS: 23 cohorts enrolling 16,860 participants were analyzed. There was no significant difference between HR and LR genotypes in terms of all-cause mortality, recurrent myocardial infarction or the frequency of coronary revascularization. HR genotype was associated with increased risk of triple vessel disease (RR = 1.34; 95% CI 1.08-1.65; P = 0.01) and increased baseline Gensini Score (WMD = 5.30; 95% CI 0.66-9.93; P = 0.03). However there was no association with DPI (WMD = 4.00; 95% CI 2.94-10.94; P = 0.26). HR genotype did not predict ∆MLD or number of new lesions at follow-up. CONCLUSIONS: Patients of coronary atherosclerosis who carry the high risk genotype of the 9p21-3 allele may be more likely to have multi-vessel CAD. However the effect of this allele on CAD progression and disease specific clinical outcomes are not observed possibly due to diminishing genetic risk following dietary modification and therapy.

Effect of exercise on anthropometric measures and serum lipids in older individuals: a systematic review and meta-analysis.

OBJECTIVES: Overweight and obesity are increasing in individuals over age 60 years. This systematic review quantifies the effect of exercise on body mass index (BMI), waist circumference (WC) and lipids in overweight and obese individuals over the age of 60 years. SETTINGS: Nine randomised controlled trials conducted in Brazil, Great Britain, Iceland, Japan and the USA compared aerobic and/or resistance exercise with a control group. PARTICIPANTS: Final analysis reviewed 1166 participants over the age of 60 years for 3-9 months. PRIMARY OUTCOME MEASURES: This study reviewed the effects of exercise on BMI, WC and low-density lipoprotein (LDL). RESULTS: Exercise produced a significant reduction in BMI (-1.01 kg/m(2), 95% CI -2.00 to -0.01) and WC (-3.09 cm, 95% CI -4.14 to -2.04) but not LDL cholesterol (-0.31 mg/dL, 95% CI -0.81 to 0.19). Analyses revealed substantial heterogeneity likely due to the type and intensity of exercise. Data on adverse effects were minimal. The overall level of evidence is moderate due to imprecision and heterogeneity. CONCLUSIONS: Exercise in overweight and obese older individuals improves anthropometric measures such as BMI and WC. The effect of exercise on serum lipids is unclear.

Self-report of tobacco use status: comparison of paper-based questionnaire, online questionnaire, and direct face-to-face interview--implications for meaningful use.

Identifying tobacco use status is essential to address use and provide resources to help patients quit. Being able to collect this information in an electronic format will become increasingly important, as the Centers for Medicare and Medicaid Services has included the assessment of tobacco use as part of its Stage 1 Meaningful Use criteria. The objective was to compare the accuracy of online vs. paper assessment methods to ascertain cigarette smoking status using a face-to-face structured interview as the gold standard. This was a retrospective analysis of a stratified opportunity sample of consecutive patients, reporting in 2010 for a periodic health evaluation, who completed either a scannable paper-based form or an online questionnaire and underwent a standardized rooming interview. Compared with face-to-face structured interview, the overall observed agreement and kappa coefficient for both methods combined (paper and online) were 97.7% and 0.69 (95% confidence interval (CI) 0.51-0.86) . For the online form they were 97.4% and 0.61 (95% CI 0.33-0.90), and for the paper form they were 97.9% and 0.75 (95% CI 0.54-0.96). There was no statistically significant difference in agreement between the online and paper-based methods (P=0.76) compared with a face-to-face structured interview. Online assessment of tobacco use status is as accurate as a paper questionnaire, and both methods have greater than 97% observed agreement with a face-to-face structured interview. The use of online assessment of tobacco use status has several advantages and more widespread use should be explored.

Improving patient-centered care: agenda-setting in occupational medicine.

OBJECTIVE: To improve patient satisfaction with care at an occupational medicine clinic by promoting agenda-setting before the visit. METHODS: We distributed agenda-setting form to 77 randomly selected patients attending an occupational health clinic and used another randomly selected sample of 36 patients as control group. Patients completed a survey regarding the acceptability of this procedure and whether they felt clinicians addressed their important concerns. RESULTS: Most patients found the form helpful (73%) and wanted it offered in future visits (74%). There was no statistically significant difference in terms of the proportion of patients expressing greatest satisfaction by answering, "strongly agree" (intervention [86%], control [97%]; odds ratio, 0.17; 95% confidence interval, 0.02 to 1.38; P = 0.06). CONCLUSION: Agenda-setting can improve patient experience before occupational visits but does not improve postvisit satisfaction.

The effect of coffee consumption on blood pressure and the development of hypertension: a systematic review and meta-analysis.

CONTEXT: Coffee is one of the most widely consumed beverages worldwide and is known to acutely raise blood pressure (BP), but the effects of chronic consumption on BP is unclear. OBJECTIVES: To conduct a systematic review and meta-analysis of available randomized controlled trials (RCTs) and cohort studies to assess the effect of chronic coffee consumption on BP and the development of hypertension. DATA SOURCES: Ovid, MEDLINE (from 1948), EMBASE (from 1988), and all of Web of Science and Scopus. STUDY SELECTION: RCTs and cohort studies of at least 1-week duration that assessed BP and/or the incidence of hypertension in coffee consumers compared with a control group that consumed less or no coffee. DATA EXTRACTION: Two authors independently reviewed abstracts and full-text articles for inclusion. Data were abstracted using standardized forms. Risk of bias in the RCTs was examined using the method described in the Cochrane Handbook for Systematic Reviews of Interventions. Quality of the cohort studies were assessed using the Newcastle-Ottawa quality assessment scale for cohort studies. DATA SYNTHESIS: Six hundred and ten articles were retrieved and a total of 15 (10 RCTs and five cohort studies) met inclusion criteria. Meta-analysis of RCTs demonstrated a pooled weighted difference in mean change in SBP of -0.55 mmHg [95% confidence interval (CI) -2.46 to 1.36) and DBP -0.45 mmHg (95% CI -1.52 to 0.61). Meta-analysis of the cohort studies demonstrated a pooled risk ratio for developing hypertension of 1.03 (95% CI 0.98-1.08). CONCLUSION: Low-quality evidence did not show any statistically significant effect of coffee consumption on BP or the risk of hypertension. Given the quality of the currently available evidence, no recommendation can be made for or against coffee consumption as it relates to BP and hypertension.

Occlusion of PFO with a dedicated adjustable device: influence on one year outcome.

AIMS: Though the association of patent foramen ovale with cryptogenic stroke in young patients has been known for 20 years, most interventional closure systems are not specifically designed for PFO closure, but instead are adapted from ASD closure systems. We describe the safety, feasibility and efficacy of transcatheter closure of PFO using a dedicated adjustable device specifically designed to overcome some of the pitfalls of PFO occlusion like erosion, left atrial thrombus formation, embolisation, maladaptation to cardiac structures and excessive foreign material deposition. METHODS AND RESULTS: Seventy-two consecutive patients, aged between 20 and 72 years, underwent PFO occlusion using the Premere® PFO occluder, for the greater part for presumed paradoxical embolism causing cryptogenic stroke or transient ischaemic attack. Forty patients received the 20 mm, while 32 received the 25 mm device. Implantation was successful in all patients. Residual shunt rate, excluding absolutely trivial shunts, was 2.8% at six months on contrast TEE study. Peri- and postprocedural adverse events with some possibility of a causal link to the procedure occurred in six patients. The postprocedural annual recurrence rate (0.99%) was lower than reported in most other series. CONCLUSIONS: PFO occlusion using the dedicated Premere® PFO occluder is effective and safe. The residual shunt rate and post-interventional recurrence rate compares favourably to the literature.

Improving the efficiency of patient throughput via centralized inpatient scheduling.

Advocate Illinois Masonic Medical Center implemented a centralized scheduling system in order to increase efficiency and throughput, improve customer satisfaction, improve communication between departments,and create a single schedule (IP/ED/OP) per modality. Most resistance for the change came from technologists, so a formal design team was established for each modality, which included a core information systems (IS) team member,the lead technologist of the modality, and the technologist most able to influence the other technologists who might be resistant to change. Overall,throughput increased by 3.14% post-implementation of the inpatient scheduling software.