Association between insurance status and in-hospital outcomes in patients with out-of-hospital ventricular fibrillation arrest.

BACKGROUND: Lack of health insurance is associated with adverse clinical outcomes; however, the association between health insurance status and in-hospital outcomes after out-of-hospital ventricular fibrillation (OHVFA) arrest is unclear. HYPOTHESIS: Lack of health insurance is associated with worse in-hospital outcomes after out-of-hospital ventricular fibrillation arrest. METHODS: From January 2003 to December 2014, hospitalizations with a primary diagnosis of OHVFA in patients ≥18 years of age were extracted from the Nationwide Inpatient Sample. Patients were categorized into insured and uninsured groups based on their documented health insurance status. Study outcome measures were in-hospital mortality, utilization of implantable cardioverter defibrillator (ICD), and cost of hospitalization. Inverse probability weighting adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality and ICD utilization and linear regression was performed to identify independent predictors of cost of hospitalization. RESULTS: Of 188 946 patients included in the final analyses, 178 005 (94.2%) patients were insured and 10 941 (5.8%) patients were uninsured. Unadjusted in-hospital mortality was higher (61.7% vs. 54.7%, p < .001) and ICD utilization was lower (15.3% vs. 18.3%, p < .001) in the uninsured patients. Lack of health insurance was independently associated with higher in-hospital mortality (O.R = 1.53, 95% C.I. [1.46-1.61]; p < .001) and lower utilization of ICD (O.R = 0.84, 95% C.I [0.79-0.90], p < .001). Cost of hospitalization was significantly higher in uninsured patients (median [interquartile range], p-value) ($) (39 650 [18 034-93 399] vs. 35 965 [14 568.50-96 163], p < .001). CONCLUSION: Lack of health insurance is associated with higher in-hospital mortality, lower utilization of ICD and higher cost of hospitalization after OHVFA.

Closing the Referral Loop: Improving Ambulatory Referral Management, Electronic Health Record Connectivity, and Care Coordination Processes.

More than 105 million referrals of Medicare beneficiaries to specialists occur annually. Different settings and electronic health records have made care coordination complex. PCPI (formerly American Medical Association-convened Physicians Consortium for Performance Improvement) and The Wright Center for Graduate Medical Education sponsored the Closing the Referral Loop pilot project. Twelve dyads of primary care and specialist physicians sought to improve ambulatory referrals by mapping the referral process, and using care compacts, metrics, and electronic health records. Referrals closed on time increased from 40% to 70%. Clinical questions answered increased from 50% to 75%. Adoption of the change package and lessons from this project may significantly improve ambulatory referral management.

Practice Transformation: Professional Development Is Personal.

Current efforts to achieve practice transformation in our health care delivery system are, for good reason, primarily focused on technical change. Such efforts include meaningful use, population health metrics reporting, and the creation and sustaining of team-based patient-centered medical home delivery sites. If practice transformation is meant to ultimately and fundamentally transform the health care system and its culture to achieve the quadruple aim of better health, better care, affordability, and satisfaction of patients and providers, these technical changes are necessary but not sufficient. Systemic transformation is contingent on the transformation of the individuals who make up the systems. Therefore, if the goal is to authentically transform medical practice in the United States, transformation of those who practice it is also required.

Nurturing 21st century physician knowledge, skills and attitudes with medical home innovations: the Wright Center for Graduate Medical Education teaching health center curriculum experience.

Purpose. The effect of patient centered medical home (PCMH) curriculum interventions on residents' self-reported and demonstrated knowledge, skills and attitudes in PCMH competency arenas (KSA) is lacking in the literature. This study aimed to assess the impact of PCMH curricular innovations on the KSA of Internal Medicine residents. Methods. Twenty four (24) Internal Medicine residents-12 Traditional (TR) track residents and 12 Teaching Health Center (THC) track residents-began training in Academic Year (AY) 2011 at the Wright Center for Graduate Medical Education (WCGME). They were followed through AY2013, covering three years of training. PCMH curricular innovations were focally applied July 2011 until May 2012 to THC residents. These curricular innovations were spread program-wide in May 2012. Semi-annual, validated PCMH Clinician Assessments assessing KSA were started in AY2011 and were completed by all residents. Results. Mean KSA scores of TR residents were similar to those of THC residents at baseline for all PCMH competencies. In May 2012, mean scores of THC residents were significantly higher than TR residents for most KSA. After program-wide implementation of PCMH innovations, mean scores of TR residents for all KSA improved and most became equalized to those of THC residents. Globally improved KSA scores of THC and TR residents were maintained through May 2014, with the majority of improvements above baseline and reaching statistical significance. Conclusions. PCMH curricular innovations inspired by Health Resources and Services Administration (HRSA's) Teaching Health Center funded residency program expansion quickly and consistently improved the KSA of Internal Medicine residents.

Association of vitamin D and incident statin induced myalgia--a retrospective cohort study.

BACKGROUND AND OBJECTIVES: Evidence is conflicting with regards to the role of vitamin D in statin induced myalgia (SIM). Studies so far have assessed cross-sectional association and were limited by study sample selected predominantly from cardiology clinics. In this retrospective cohort study we assessed the association between vitamin D and SIM and attempted to establish a serum vitamin D cutoff to identify patients at risk for developing SIM. METHODS: Medical charts of 5526 consecutive patients from a primary care practice in Scranton, Pennsylvania from 2005-2012 were reviewed. Vitamin D level (25-hydroxy cholecalciferol) at statin initiation was considered "Exposure level". Vitamin D levels were categorized into quartiles (≤ 10, 11-20, 21-30, >30 ng/ml). SIM was identified by patient report. RESULTS: 1160 out of 5526 patients were treated with statins. The mean age was 55.9 years. 276 (24%) developed SIM. Unadjusted 7-yr cumulative incidences of SIM for quartiles 1-4 of vitamin D were 32.3, 21.5, 18.3 and 14.6% respectively. The lowest quartile of vitamin D was independently associated with 1.21 times the hazard of the fourth quartile for developing SIM (95% CI: 1.09, 1.33; P-trend  = 0.001). Vitamin D cut-off ≤15 ng/ml, showed a positive predictive value, negative predictive value, likelihood ratio (LR) + and LR- of 81, 90, 5.1 and 0.1, respectively for predicting SIM. CONCLUSIONS: Low vitamin D level at statin initiation is associated with SIM, levels ≤15 ng/ml have a high predictive accuracy for SIM. Randomized controlled trials are needed to validate our results.

Serum vitamin D levels may not reflect tissue-level vitamin D in sarcoidosis.

Hypercalcemia in sarcoidosis is due to three mechanistic reasons: (1) systemic conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by the enzyme 1-α hydroxylase produced by activated monocyte/macrophage system, (2) production of parathormone-related peptide (PTHrP) by the sarcoid granuloma, (3) tissue-level conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by 1-αhydroxylase produced by local monocyte/macrophage system in the sarcoid granuloma. We report two cases of one proposed mechanism of hypercalcaemia in sarcoidosis (mechanism 3). Both individuals presented with sarcoidosis and 25-hydroxyvitamin D deficiency and developed symptomatic hypercalcaemia with vitamin D replacement. Given their low serum parathormone and parathormone-related peptide levels, low serum 25-hydroxy vitamin D and normal serum 1,25-dihydroxyvitamin D, the systemic 25-hydroxy vitamin D deficiency may not have reflected an increased activity of vitamin D at the local granulomatous tissue level.