Burden Of Medical Comorbidity Research Articles

Readmissions After Injury: Is Fragmentation of Care Associated With Mortality?

BackgroundUnplanned readmissions of surgical patients are associated with increased morbidity and mortality. “Fragmentation of care” (FOC) occurs when patients are readmitted to a different hospital than where they initially received care. FOC complicates accurate quantification of hospital readmission rates and is associated with worse outcomes in many surgical patient populations. However, few studies have evaluated the impact of FOC specifically on patients with traumatic injury. Materials and methodsWe performed a retrospective cohort study using the 2013 National Readmissions Database. Data on demographics, diagnosis, injury severity, readmissions, complications, and outcomes were collected. Patients readmitted to hospitals within 30 d after index admission were identified, and risk factors for readmission were discerned. Patients were stratified into groups readmitted to index versus nonindex hospital. Outcomes were compared between these groups. ResultsA total of 333,188 patients with index admission for injury were identified; 34,197 (10.3%) were readmitted within 30 d of discharge. Of these, only 24,747 (72.4%) were readmitted to their index hospital for an FOC rate of 27.6%. There was no significant difference in outcomes between patients readmitted to index versus nonindex hospitals. Among all readmitted patients, 30-d mortality was associated only with burden of medical comorbidities and age. ConclusionsSingle-institution readmission rates are not reflective of true readmission rates for trauma patients. FOC does not impact outcomes in trauma patients who are readmitted; however, age and number of comorbidities are associated with higher mortality in these patients. FOC rates are high in trauma patient populations and merit further investigation to determine potential etiologies and consequences.

Impact of Multi-Drug-Resistant Pneumonia on Outcomes of Critically Ill Trauma Patients.

Background: Rates of infections with multi-drug-resistant organisms (MDROs) are increasing among critically ill patients. Among non-surgical patients, MDROs increase directly the risk of adverse secondary events including death. However, similar effects do not appear to occur among surgical patients. Specifically, among critically injured trauma patients, it is unknown whether degree of injury versus the presence of an MDRO increases the risk of death. Methods: This is a retrospective chart review of admitted adult trauma patients. Data included demographics, medical comorbidities, injury severity score, infections, occurrence of pneumonia including microbiology sensitivity profile, hospital course, and outcomes. Results: Patients requiring adminission to the intensive care unit (ICU) were more severely injured with greater degree of thoracic and head trauma and had a greater burden of pre-trauma medical comorbidities. Among those admitted to the ICU, 93 patients developed pneumonia. Patients who developed pneumonia were younger and more severely injured, with higher rates of thoracic and head injuries and higher rates of smoking. Development of pneumonia was associated with worse outcomes. However, among patients with pneumonia, comparing MDRO to pan-sensitive (PanSens) infections, PanSens infection occurred earlier and were more likely associated with pre-trauma smoking status. There was no difference in injury patterns, medical comorbidities, or outcomes. Conclusion: The development of pneumonia among trauma patients reflects degree of injury and underlying medical status. However, development of MDRO versus PanSens pneumonia did not affect trauma-related outcomes further. This information will guide family discussions and critical care decisions better among vulnerable trauma patients.

A Retrospective Study of the Association between Pain Intensity and Opioid Use with Length of Stay during Musculoskeletal Inpatient Rehabilitation after Primary Knee and Hip Arthroplasty.

The relationship between pain intensity, opioid consumption, and length of stay (LOS) has received little attention in primary, lower extremity joint arthroplasty patients admitted to inpatient musculoskeletal rehabilitation. To assess how initial pain and other clinical factors are associated with rehabilitation LOS. Retrospective chart review. Rehabilitation hospital. One hundred ninety nine patients admitted for inpatient rehabilitation. Not Applicable. Pain intensities on the Numeric Rating Scale (NRS) were completed 3 times daily and total daily opioid consumption recorded in terms of morphine equivalents (MEQ). Confounding variables included patient demographics, medical comorbidity burden using the Charlson Comorbidity Index (CCI), and early functional status as measured by the motor subscale from the Functional Independence Measure (FIM). Mean day 3 NRS values of ≥5.2 and total day 3 opioid consumption of >50 MEQ were associated with a prolonged LOS by nearly 3 and 2 days, respectively. Within a multivariate linear regression, age, mean day 3 pain, comorbidity burden, and early motor functional status accounted for 36% of the variability seen in joint replacement rehabilitation LOS. With all other variables remaining constant, for every unit increase in mean day 3 pain and CCI, this amounted to an additional 5% and 4% increase to LOS, whereas each unit increase in admission motor FIM decreased estimated LOS by 3%. Mean pain intensity and total opioid consumption on day 3 of inpatient rehabilitation is associated with LOS. For the rehabilitation physician, this is useful information as the earlier identification of patients with poorly controlled pain can lead to directed intervention, better patient care, and significant cost savings.

ASSOCIATION BETWEEN GERIATRIC HOME VISIT AND EMERGENCY ROOM OR HOSPITAL UTILIZATION: A RETROSPECTIVE STUDY

Homebound older adults tend to have more medical comorbidities, higher risk of mortality, and higher healthcare utilization compared to non-homebound, community dwelling older adults in the U.S. Preventative primary care home visit have been shown to reduce hospitalizations and total healthcare costs in this population. Through a retrospective study, we aim to explore characteristics associated with ED and hospital utilization in patients who have received a home visit. A total 608 subjects, 70% female and median age of 86 years, were involved. A 184 (30%) of homebound subjects were hospitalized or visited the ED in 90 days. Comparing those with hospitalization or ED and those without, there was no significant difference in sex, age, race, marital status, or advance care planning. A 74% of those with 90 day ED/hospitalization had prior ED visit within 1 year of home visit compared to 59% of those without (p=0.0004). In addition, 58% of those with 90 day ED/hospitalization had prior hospitalization within 1 year of home visit compared to 44% of those without (p=0.0015). They also had significantly higher number of total medical comorbidities (median 4.5 vs 4, p=0.02). Our study suggests that prior healthcare utilization and medical comorbidity burden may be better predictors of 90 day hospitalization or ED use in geriatric patients who have received a home visit. Advance care planning and age did not significantly differ between the two groups in our study. Further studies should be performed to validate our findings in a prospective manner.

EDITORIAL COMMENT

Radical cystectomy (RC) is the standard of care for muscle-invasive and highest risk nonmuscle-invasive bladder cancer although is often burdened by a high rate of perioperative complications and a non-negligible mortality rate. 1 Mari A Campi R Tellini R et al. Patterns and predictors of recurrence after open radical cystectomy for bladder cancer: a comprehensive review of the literature. World J Urol. 2017; 36: 157-170https://doi.org/10.1007/s00345-017-2115-4 Crossref Scopus (69) Google Scholar , 2 Witjes JA Comperat E Cowan NC et al. EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol. 2014; 65: 778-792https://doi.org/10.1016/j.eururo.2013.11.046 Abstract Full Text Full Text PDF PubMed Scopus (779) Google Scholar In this study, the authors aimed to evaluate the impact of frailty, assessed through a claims-based frailty index extracting data from the US NRD, on perioperative outcomes of RC. More than 7% of patients were considered frail at time of surgery and frailty status was the strongest predictor of ICU-level complications as well as it was associated with a more than 2-fold increase of in-hospital mortality. Frailty was the main determinant of nonhome discharge and increased hospital costs, while, notably, medical comorbidity burden was not an independent predictor of frailty status. Therefore, frailty assessment is pivotal for an adequate risk stratification and preoperative counseling since comorbidity index, age and American Society of Anesthesiologists physical status classification alone seem not to be adequate. 3 Psutka SP Barocas DA Catto JWF et al. Staging the host: personalizing risk assessment for radical cystectomy patients. Eur Urol Oncol. 2018; 1: 292-304https://doi.org/10.1016/j.euo.2018.05.010 Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar

Characterizing DSM-5 and ICD-11 personality disorder features in psychiatric inpatients at scale using electronic health records.

Investigation of personality traits and pathology in large, generalizable clinical cohorts has been hindered by inconsistent assessment and failure to consider a range of personality disorders (PDs) simultaneously. We applied natural language processing (NLP) of electronic health record notes to characterize a psychiatric inpatient cohort. A set of terms reflecting personality trait domains were derived, expanded, and then refined based on expert consensus. Latent Dirichlet allocation was used to score notes to estimate the extent to which any given note reflected PD topics. Regression models were used to examine the relationship of these estimates with sociodemographic features and length of stay. Among 3623 patients with 4702 admissions, being male, non-white, having a low burden of medical comorbidity, being admitted through the emergency department, and having public insurance were independently associated with greater levels of disinhibition, detachment, and psychoticism. Being female, white, and having private insurance were independently associated with greater levels of negative affectivity. The presence of disinhibition, psychoticism, and negative affectivity were each significantly associated with a longer stay, while detachment was associated with a shorter stay. Personality features can be systematically and scalably measured using NLP in the inpatient setting, and some of these features associate with length of stay. Developing treatment strategies for patients scoring high in certain personality dimensions may facilitate more efficient, targeted interventions, and may help reduce the impact of personality features on mental health service utilization.

Medical and Psychiatric Comorbidities in Bipolar Disorder: Insights from National Inpatient Population-based Study.

ObjectivesThe objective of this study was to analyze the differences in the prevalence and association of medical and psychiatric comorbidities in bipolar disorder (BD) patients versus the general inpatient population.MethodsA cross-sectional analysis was conducted using the national inpatient sample (NIS). Using the international classification of diseases, ninth revision (ICD-9) diagnostic codes, we extracted the BD inpatients and then obtained information about comorbidities. The odds ratio (OR) of comorbidities in BD inpatients were evaluated using a logistic regression model.ResultsHypertension (31.1%), asthma (11.7%) and diabetes, obesity, and hypothyroidism (11% each) were the prevalent medical comorbidities found in BD inpatients. Hypothyroidism, asthma, and migraine were seen in BD inpatients (OR 1.59, OR 1.37 and OR 1.23; respectively) compared to general inpatients. Drug abuse (33.5%), anxiety disorders (31.8%), and alcohol abuse (18.3%) were the most prevalent psychiatric comorbidities in BD inpatients. They had a seven-fold higher likelihood of comorbid borderline personality disorders compared to general inpatients. Among other psychiatric comorbidities, the odds of the association were higher for drug abuse (OR 4.33), ADHD (OR 3.06), and PTSD (2.44).ConclusionA higher burden of medical and psychiatric comorbidities is seen in BD inpatients compare to the general inpatient population. A collaborative care model is required for early diagnosis and management of these comorbidities to improve the health-related quality of life.

Development and Validation of a Model Consisting of Comorbidity Burden to Calculate Risk of Death Within 6 Months for Patients With Suspected Drug-Induced Liver Injury

Patients with drug-induced liver injury (DILI) frequently have comorbid conditions, but the effects of non-liver comorbidities on outcomes are not well understood. We investigated the association between comorbidity burden and outcomes of patients with DILI, and developed and validated a model to calculate risk of death within 6 months. A multiple logistic regression model identified variables independently associated with death within 6 months of presenting with suspected DILI (6-month mortality) for 306 patients enrolled in the Drug-Induced Liver Injury Network prospective study at Indiana University (discovery cohort). The model was validated using data from 247 patients with suspected DILI enrolled in the same study at the University of North Carolina (validation cohort). Medical comorbidity burden was calculated using the Charlson Comorbidity Index-patients with scores higher than 2 were considered to have significant comorbidities. Six-month mortality was 8.5% in the discovery cohort and 4.5% in the validation cohort. In the discovery cohort, significant comorbidities (odds ratio, 5.4; 95% confidence interval [CI], 2.1-13.8), Model for End-Stage Liver Disease score (odds ratio, 1.11; 95% CI, 1.04-1.17), and serum level of albumin at presentation (odds ratio, 0.39; 95% CI, 0.2-0.76) were independently associated with 6-month mortality. A model based on these 3 variables identified patients who died within 6 months, with c-statistic values of 0.89 (95% CI, 0.86-0.94) in the discovery cohort and 0.91 (95% CI, 0.83-0.99) in the validation cohort. We developed a web-based calculator for use in the clinic to determine risk of death within 6 months for patients with suspected DILI. We developed and validated a model based on comorbidity burden, Model for End-Stage Liver Disease score, and serum level of albumin that predicts 6-month mortality in patients with suspected DILI.

Traumatic brain injury and coextensive psychopathology: New evidence from the 2016 Nationwide Emergency Department Sample (NEDS)

Traumatic brain injury (TBI) is a significant public health issue associated with increased medical comorbidity and economic burden. The majority of studies of TBI among clinical populations are geographically limited and rely on small samples. As such, the current study seeks to examine the prevalence and psychosocial correlates of TBI in a nationally representative emergency department (ED) sample. Using the 2016 Nationwide Emergency Department Sample, logistic regression was employed to examine the relationship between TBI history, sociodemographic factors and mental health disorders. An estimated 179,986 adults age 18 and older were admitted to United States EDs in 2016 with a personal history of TBI. The majority of patients were male (69.71%), ages 50 years or older (50.92%) with Medicare (44.30%) or Medicaid (28.65%) insurance. Diagnoses of posttraumatic stress disorder (AOR = 3.99), affective disorders (AOR = 2.97), anxiety disorders (AOR = 1.68), personality and behavior disorders (AOR = 2.77), and schizophrenia (AOR = 2.80) were significantly associated with history of TBI. These results provide insight into the developmental pathogenesis of TBI and its comorbid psychiatric consequences.

Burden of medical co-morbidities and benefit from surgical revascularization in patients with ischaemic cardiomyopathy.

The landmark STICH trial found that surgical revascularization compared to medical therapy alone improved survival in patients with heart failure (HF) of ischaemic aetiology and an ejection fraction (EF) ≤ 35%. However, the interaction between the burden of medical co-morbidities and the benefit from surgical revascularization has not been previously described in patients with ischaemic cardiomyopathy. The STICH trial (ClinicalTrials.gov Identifier: NCT00023595) enrolled patients ≥ 18 years of age with coronary artery disease amenable to coronary artery bypass grafting (CABG) and an EF ≤ 35%. Eligible participants were randomly assigned 1:1 to receive medical therapy (MED) (n = 602) or MED/CABG (n = 610). A modified Charlson co-morbidity index (CCI) based on the availability of data and study definitions was calculated by summing the weighted points for all co-morbid conditions. Patients were divided into mild/moderate (CCI 1-4) and severe (CCI ≥ 5) co-morbidity. Cox proportional hazards models were used to evaluate the association between CCI and outcomes and the interaction between severity of co-morbidity and treatment effect. The study population included 349 patients (29%) with a mild/moderate CCI score and 863 patients (71%) with a severe CCI score. Patients with a severe CCI score had greater functional limitations based on 6-min walk test and impairments in health-related quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire. A total of 161 patients (Kaplan-Meier rate = 50%) with a mild/moderate CCI score and 579 patients (Kaplan-Meier rate = 69%) with a severe CCI score died over a median follow-up of 9.8 years. After adjusting for baseline confounders, patients with a severe CCI score were at higher risk for all-cause mortality (hazard ratio 1.44, 95% confidence interval 1.19-1.74; P < 0.001). There was no interaction between CCI score and treatment effect on survival (P = 0.756). More than 70% of patients had a severe burden of medical co-morbidities at baseline, which was independently associated with increased risk of death. There was not a differential benefit of surgical revascularization with respect to survival based on severity of co-morbidity.

A Nationwide Analysis of Outcomes of Stroke in Hospitalized Patients with Essential Thrombocythemia: 2006 to 2014

Background:Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm which is associated with an increased risk of thrombohemorrhagic complications as well as progression to myelofibrosis and frank leukemia. Patients with ET are at an elevated risk for stroke. However, studies of prevalence and outcomes of stroke in hospitalized patients with ET have been limited to case series. The median survival of patients with ET is comparable to normal population but the quality of life may be significantly altered due to the occurrence of thrombotic events in the cerebrovascular and cardiovascular systems. By conducting a retrospective analysis of nationwide data from hospitalized ET patients between the years of 2006 and 2014, we sought to identify if there are any statistically significant associations between stroke and/or in-hospital mortality with respect to patients' gender, age group, race, and comorbidities like hypertension, diabetes atrial fibrillation and chronic kidney disease.Methods:Data from the National Inpatient Sample was utilized to identify outcomes in hospitalized patient with ET who were admitted for stroke. The National Inpatient sample is a database maintained by the Agency for Healthcare Quality and Research. Utilizing the current procedural terminology code (CPT) for ET, outcomes of patients with ET who were hospitalized with stroke were studied for the year 2006 to 2014. Patient demographics of age, gender and race were collected and hospital characteristics of location and size were correlated to outcomes. The extent of common medical comorbidities such as hypertension, diabetes, chronic kidney disease and atrial fibrillation was studied in ET patients who died with and without stroke. Chi square test was used to determine odds ratios and multiple logistic regression was used to determine independent predictors of mortality.Results:Between 2006 to 2014, 552422 hospitalizations involved patients with a diagnosis of ET of which 20650 hospitalizations were due to stroke. Of these patients with stroke there was a preponderance of prevalence in females (13400 vs. 7251). The percentage of stroke in these hospitalizations varied between 3.64 to 4.29 over 15 years and mortality in these patients did not significantly change during this time period. The prevalence of stroke was highest amongst Asians and Caucasians (4.7% and 3.86%) with a statistically significant difference (p=0.0000). The age group of 80+ years and the difference in prevalence between different age groups (18-34 vs. 35-49 vs, 50-64 vs. 75-79) was statistically significant (p=0.0000) with Medicare being the insurance for most of these patients (p=0.000)). Notably, mortality was highest in the same group but was not significantly different from other age groups. Large sized hospitals were noted to have a higher proportion of ET patients with stroke compared to smaller and medium sized hospitals (p=0.0002). No difference in such proportions was noted in hospitals varying by region (Northeast vs. Midwest vs. South vs. West). Burden of medical comorbidities as measured by Charlson's comorbidity index was noted to be in the 4-6 range. Similarly, hypertension, hyperlipidemia, diabetes, atrial fibrillation, smoking status were also found to be more frequent in ET patients with stroke. A majority of ET patients with stroke were discharged to skilled nursing facilities. Multiple regression showed that female gender, atrial fibrillation, stroke, higher Charlsons comorbidity score and 80+ age were independent predictors of mortality (OR: 0.75, 1.35, 1.8, 2 to 5.7, 13.9 respectively).Conclusions:Patients with ET who are hospitalized with stroke have significantly worse outcomes. This study demonstrated that a statistically significant difference exists among different age groups of patients with ET and stoke who died during hospitalization when stratification is made using age groups and Charlson Score. This study may serve as an initial point to include new risk factors for further risk stratification. Early identification of patients at higher risk may reduce the incidence and decrease the morbidity of stroke in patients with ET. DisclosuresKota:BMS: Honoraria; Novartis: Honoraria; Xcenda: Honoraria; Incyte: Honoraria; Pfizer: Honoraria.

Gender Differences and Comorbidities in U.S. Adults with Bipolar Disorder.

Background: Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. Methods: A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010–2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). Results: Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid inflammatory disorders like asthma (OR = 1.755), Crohn’s disease (OR = 1.197) and multiple sclerosis (OR = 2.440) compared to males. Females had a two-fold higher likelihood of comorbid post-traumatic stress disorder (PTSD) (OR = 2.253) followed by personality disorders (OR = 1.692) and anxiety disorders (OR = 1.663) compared to males. Conclusion: Women with bipolar disorder have a much higher medical comorbidity burden than men and may highly benefit from an integrated team of physicians to manage their condition and improve their health-related quality of life.

Natural History of Patients Postacute Coronary Syndrome Based on Heart Failure Status

The natural history of patients hospitalized for acute coronary syndrome (ACS) with pre-existing versus (vs) de novo heart failure (HF) has not been previously reported over an extended duration of follow-up. The IMPROVE-IT trial enrolled 18,144 patients hospitalized for ACS and randomized them to combination simvastatin (40 mg)/ezetimibe (10 mg) vs simvastatin (40 mg). Subjects were divided into 3 groups: pre-existing HF (i.e., defined by past medical history), de novo HF (i.e., defined by Killip class II or greater during index admission), and no HF. The final analytical cohort included 14,792 patients (82%) with HF status recorded at baseline. In total, 790 patients (5.3%) reported a pre-existing diagnosis of HF and 1374 patients (9.3%) experienced de novo HF. Patients with pre-existing or de novo HF were older, more likely to be woman, and had a greater prevalence of atrial fibrillation and diabetes mellitus. The incidences of death/HF-hospitalizations at 5 years were 32%/20% for pre-existing HF, 18%/7% for de novo HF, and 8%/3% for no HF. After adjusting for potential confounders, a history of pre-existing or de novo HF was independently associated with increased risk of death (pre-existing HF: hazard ratio [HR] 1.93, 95% confidence interval [CI] 1.68 to 2.22, p < 0.001; de novo HF: HR 1.51, 95% CI 1.33 to 1.72, p < 0.001) and hospitalizations for HF (pre-existing HF: HR 2.96, 95% CI 2.36 to 3.71, p < 0.001; de novo HF: HR 1.88, 95% CI 1.49 to 2.38, p < 0.001). There was no interaction among baseline HF status (i.e., pre-existing or de novo), lipid lowering therapy (i.e., simvastatin/ezetimibe vs simvastatin alone), and clinical outcomes. In conclusion, patients hospitalized for ACS with pre-existing or de novo HF were older and had a greater burden of medical co-morbidities. In conclusion, HF was independently associated with increased risk of long-term morbidity and mortality with the pre-existing HF cohort demonstrating the highest overall risk.

An investigation of the determinants of quality of life in adolescents and young adults with Down syndrome.

BackgroundYoung people with Down syndrome experience varying abilities in activities of daily living, cognitive functioning, behaviour and social skills. The aim of this research was to investigate, from a carer’s perspective, the factors that influenced the quality of life of these young people.MethodsFamilies of young people with Down syndrome (n = 197), aged 16–31 years, living in Western Australia, took part in a questionnaire study regarding young person daily functioning, family characteristics, medical background and quality of life measured by the Kidscreen 27-item scale. Kidscreen-10 total score was used as an outcome in the investigation of determinants with higher scores indicating better quality of life.ResultsAfter adjustment for confounders including carer’s mental health measured by the Depression and Anxiety Scale (DASS), global impact of illness as well as impact of mental health and bowel conditions were all negatively associated with the young person’s quality of life. Young people who had three or more friends had better quality of life than those with no friends. Scores were lower (reflecting poor quality of life) in individuals who had more behavioural problems but these relationships were attenuated after adjustment for confounders and DASS.ConclusionsOverall, our findings revealed that quality of life of young people with Down syndrome was most negatively associated with burden of medical conditions, but also with lack of friendships. We were somewhat surprised to find the effect of medical problems on quality of life persisting into adolescence and adulthood where in general the burden of medical comorbidities is much less than in childhood.

MP12-11 RATES AND RISK FACTORS OF LOST TO FOLLOW UP IN PROSTATE CANCER PATIENTS MANAGED WITH ACTIVE SURVEILLANCE

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance I1 Apr 2018MP12-11 RATES AND RISK FACTORS OF LOST TO FOLLOW UP IN PROSTATE CANCER PATIENTS MANAGED WITH ACTIVE SURVEILLANCE Kevin Ginsburg, Gregory Auffenberg, Ji Qi, Isaac Powell, James Montie, David Miller, Michael Cher, and For the Michigan Urological Surgery Improvement Collaborative Kevin GinsburgKevin Ginsburg More articles by this author , Gregory AuffenbergGregory Auffenberg More articles by this author , Ji QiJi Qi More articles by this author , Isaac PowellIsaac Powell More articles by this author , James MontieJames Montie More articles by this author , David MillerDavid Miller More articles by this author , Michael CherMichael Cher More articles by this author , and For the Michigan Urological Surgery Improvement CollaborativeFor the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.398AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Active surveillance (AS) has emerged as an appropriate management strategy for many men with prostate cancer (PC), however insufficient monitoring may increase the risk of undesired outcomes. We evaluated a large AS cohort across diverse practices in Michigan to determine rates of loss to follow-up (LTFU) and associated risk factors. METHODS MUSIC maintains a prospective registry of PC patients from 44 academic and community urology practices within the state of Michigan. We identified all patients in the registry managed with AS from 2011-2015. We defined LTFU as any 18-month period where no pertinent surveillance information was identified in the medical record by trained data abstractors (i.e., no PSA, prostate CT/MRI, or prostate biopsy). LTFU events were stratified as either (1) prolonged loss to follow up (PLTFU): a LTFU event with no further data entered; or (2) insufficient follow up (IFU): a LTFU event followed by subsequent data. We fit multivariable logistic regression models and compared adjusted rates of LTFU events across MUSIC practices. RESULTS Of 2211 men enrolled on AS from 2011-2015, 217 (9.8%) had a LTFU event. Of these, 184 (8.3%) patients had PLTFU and 33 (1.5%) had IFU. African American (AA) patients were more likely than Caucasian patients to be LTFU (17.0% vs 7.4%, p<0.05). In multivariable analyses, both AA race (OR 2.36, 95% CI 1.42-3.92) and Charlson comorbidity index (CCI) of ≥1 (OR 1.53, 95% CI 1.03-2.27) were independently associated with an increased likelihood of LTFU. There was wide variability in rates of LTFU across MUSIC practices, ranging from 2.6% to 41.4% of patients entering AS, p<0.05 (Figure 1). CONCLUSIONS Nearly ten percent of men placed on AS become LTFU, representing suboptimal implementation of this management strategy. Patient-specific factors associated with being LTFU include AA race and higher burden of medical co-morbidity. Practice-level variability in LTFU may reveal opportunities to identify systems of care used in higher-performing practices that can reduce LTFU across all sites thereby improving the long-term safety of AS for men with early-stage PC. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e139-e140 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Kevin Ginsburg More articles by this author Gregory Auffenberg More articles by this author Ji Qi More articles by this author Isaac Powell More articles by this author James Montie More articles by this author David Miller More articles by this author Michael Cher More articles by this author For the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pre-existing medical comorbidity is not associated with neurological outcomes in patients undergoing targeted temperature management following cardiac arrest.

The prognostic significance of chronic medical illness in comatose survivors of cardiac arrest who undergo targeted temperature management (TTM) remains largely unknown. We sought to assess the association between overall burden of pre-existing medical comorbidity and neurological outcomes in survivors of cardiac arrest undergoing TTM. We analyzed a prospectively collected cohort of 314 patients treated with TTM following cardiac arrest at a tertiary care hospital between 2007 and 2014. Overall burden of medical comorbidity was approximated with the use of the Charlson Comorbidity Index (CCI). Poor neurological outcome at hospital discharge, defined as a cerebral performance category (CPC) score >2, was the primary outcome. Secondary outcomes included death prior to hospital discharge and at 1year following cardiac arrest. Multivariable logistic regression was used to assess the association between CCI scores and outcomes. A poor neurological outcome at hospital discharge was observed in 193 (61%) patients. One hundred and seventy-nine (57%) patients died prior to hospital discharge and a total of 195 (62%) patients had died at 1-year post-arrest. In multivariable logistic regression, elevated CCI scores were not associated with increased odds of poor neurological outcomes (OR 1.04, 95% CI 0.90-1.19, p=0.608) or death (OR 0.99, 95% CI 0.86-1.13, p=0.816) at hospital discharge. No association was seen between CCI scores and death at 1-year post-arrest (OR 1.09, 95% CI 0.95-1.26, p=0.220). Increasing burden of medical comorbidity, as defined by CCI scores, is not associated with neurological outcomes or survival in patients treated with TTM.

Systems innovation model: an integrated interdisciplinary team approach pre- and post-bariatric surgery at a veterans affairs (VA) medical center

BackgroundProvision of bariatric surgery in the Veterans Health Administration must account for obese veterans’ co-morbidity burden and the geographically dispersed location of patients relative to Veterans Affairs (VA) bariatric centers. ObjectivesTo evaluate a collaborative, integrated, interdisciplinary bariatric team of surgeons, bariatricians, psychologists, dieticians, and physical therapists working in a hub-and-spokes care model, for pre- and post-bariatric surgery assessment and management. MethodsThis is a description of an interdisciplinary clinic and bariatric program at a VA healthcare system and a report on program evaluation findings. Retrospective data of a prospective database was abstracted. For program evaluation, we abstracted charts to characterize patient data and conducted a patient survey. ResultsSince 2009, 181 veterans have undergone bariatric surgery. Referrals came from 7 western U.S. states. Mean preoperative body mass index was 46 kg/m2 (maximum 71). Mean age was 53 years, with 33% aged>60 years; 79% were male. Medical co-morbidity included diabetes (70%), hypertension (85%), and lower back or extremity joint pain (84%). A psychiatric diagnosis was present in 58%. At 12 months, follow-up was 81% and percent excess body mass index loss was 50.5%. Among 54 sequential clinic patients completing anonymous surveys, overall satisfaction with the interdisciplinary team approach and improved quality of life were high (98% and 94%, respectively). ConclusionThe integrated, interdisciplinary team approach using a hub-and-spokes model is well suited to the VA bariatric surgery population, with its heavy burden of medical and mental health co-morbidity and its system of geographically dispersed patients receiving treatment at specialty centers. As the VA seeks to expand the use of bariatric surgery as an option for obese veterans, interdisciplinary models crafted to address case complexity, care coordination, and long-term outcomes should be part of policy planning efforts.

Abstract 12163: Pre-existing Medical Comorbidity is not Associated With Neurological Outcomes in Comatose Survivors of Cardiac Arrest Undergoing Targeted Temperature Management

Introduction: Evidence regarding the significance of pre-existing medical comorbidity in comatose survivors of cardiac arrest who undergo targeted temperature management (TTM) remains limited. Hypothesis: Increasing burden of medical comorbidity will predict poor neurological outcomes following TTM. Methods: We analyzed a prospectively collected cohort of 314 consecutive comatose survivors of cardiac arrest treated with TTM at a tertiary care hospital between 2007 and 2014. Overall burden of medical comorbidity was estimated with the use of the Charlson Comorbidity Index (CCI). Poor neurological outcome at hospital discharge, defined as a Cerebral Performance Category (CPC) score &gt;2, was the primary outcome. Secondary outcomes included death prior to hospital discharge and at 1 year following cardiac arrest. Results: Amongst all patients, the median CCI score was 1 (IQR 0-3, range 0-11). A poor neurological outcome at hospital discharge was observed in 193 (61%) patients. One hundred and seventy-nine (57%) patients died prior to hospital discharge and a total of 195 (62%) patients had died at 1 year post-arrest. In multivariable logistic regression, elevated CCI scores were not associated with increased odds of poor neurological outcomes (OR 1.04, 95% CI 0.90-1.19, p=0.608) or death (OR 0.99, 95% CI 0.86-1.13, p=0.816) at hospital discharge. No association was seen between CCI scores and death at 1 year post-arrest (OR 1.09, 95% CI 0.95-1.26, p=0.220), Table 1 . Conclusions: Increasing burden of medical comorbidity is not associated with neurological outcomes or survival in patients treated with TTM. Pre-existing comorbidity should not affect a patient’s candidacy for this treatment. Table 1. Adjusted odds ratios of poor neurological outcomes and death. CCI, Charlson Comorbidity Index; CI, confidence interval; CPR, cardiopulmonary resuscitation; OR, odds ratio; ROSC, return of spontaneous circulation; TTM, targeted temperature management.

Medical comorbidity and projected survival in patients admitted to a specialist addictions in-patient unit.

Aims and method To investigate the burden of medical comorbidity in a population receiving in-patient treatment for drug and alcohol problems. All patients admitted over a 6-month period were included in the data-set. We recorded diagnostic information on admission that allowed the calculation of predicted 10-year survival using a previously validated comorbidity index.Results Despite the majority of the sample having a predicted 10-year survival chance of greater than 75%, a sizeable minority (16.7%) are carrying a high burden of medical comorbidity, with a predicted 10-year survival chance of less than 50%. More than half (55.2%) of these patients were under the age of 55. Chronic respiratory disease was the most frequent diagnosis.Clinical implications In-patient substance misuse units serve a complicated group of patients, whose needs are met by active medical input, resident medical cover and effective liaison with general hospitals. This is important when planning and commissioning treatment services. The high burden of respiratory disease suggests the utility of robust smoking cessation interventions among this population.

Performance of depression rating scales in patients with chronic kidney disease: an item response theory-based analysis.

Because there is overlap between somatic symptoms of depression and symptoms of chronic kidney disease (CKD), it is unclear if self-reported depression rating scales can be used accurately in predialysis CKD patients, especially if CKD and other comorbidities are symptomatic. We assessed the performance of two depression scales - the Beck Depression Inventory (BDI) and the Quick Inventory of Depression Symptomatology (QIDS-SR16) - by CKD stage, diagnosis of diabetes and total medical comorbidity burden - using item response theory (IRT) in a sample of 272 predialysis CKD patients. We performed IRT by low versus high CKD stage, diabetes versus no diabetes and high (>3 diagnoses) versus low medical comorbidity burden. IRT models of each rating scale were affected in a limited way by CKD stage, diabetes and medical comorbidity burden. Sleep disturbances on the QIDS-SR16 were more discriminatory for depression in diabetics and those with high comorbidity burden. Pessimism and guilt from the BDI compared to QIDS-SR16 were more discriminatory of depression in the high CKD and high comorbidity groups, respectively. Overall item differences were modest, and chronic disease severity by CKD stage, diabetes mellitus or other medical comorbidities did not appreciably contribute to differences in scale performance.