Hospital Corporation Of America Research Articles

Incidence of Heparin-Induced Thrombocytopenia in Non-Surgical Patients

Introduction: Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin exposure. HIT occurs when Platelet Factor 4 (PF4) forms a complex with heparin, resulting in the formation of autoantibodies. HIT occurs more frequently in surgical patients compared with non-surgical patients due to the inflammatory release of PF4 and perioperative heparin exposure. Previously, unfractionated heparin (UFH) has been compared to low molecular weight heparin (LMWH) solely among surgical patients which has been correlated with a higher incidence of HIT relative to LMWH. However, there is little data regarding UFH versus LMWH in non-surgical patients. The purpose of this study was to determine whether there was a significant difference in the incidence of HIT between these two forms of anticoagulation in non-surgical patients. We also sought to delineate differences in incidence of HIT with respect to BMI, gender, and age. Methods: This is a retrospective study that included all patients admitted to 14 hospitals within Hospital Corporation of America's (HCA) North Florida Division between January 2016 and September 2022. Data was retrieved and analyzed by HCA statisticians. Patient selection was based not only on whether they had been diagnosed with HIT, but various other factors including age, weight, gender and type of anticoagulation (LMWH vs UFH). Patients who had undergone surgery or even been hospitalized within the six months had been excluded. Other excluded conditions include disseminated intravascular coagulation (DIC), hemolytic-uremic syndrome (HUS), immune thrombocytopenic purpura (ITP), drug induced systemic lupus erythematosus (DILE), and systemic lupus erythematosus (SLE). Results: A total of 2,061 patients were included. Unfractionated heparin group was significantly associated with the likelihood of the patient being diagnosed with HIT (χ 2 = 184.06, p < 0.0001). The odds ratio is 0.237, indicating that patients who received unfractionated heparin were 4.219 (1/0.237) times as likely to develop HIT as patients who received LMWH. When controlling for age, sex, and BMI, age was significantly associated with the likelihood of the patient being diagnosed with HIT (χ 2 = 8.423, p < 0.01). The odds ratio was 1.010, indicating that with each additional year of age, patients were 1.010 times as likely to develop HIT. BMI was also significantly associated with likelihood of HIT (χ2 = 4.892, P < 0.03), indicating that obesity was identified as a potential factor associated with the development of HIT. Female were less likely to develop HIT when compared to men overall (χ2 = 7.238, P < 0.05). Conclusions: HIT is a rare but important cause of morbidity and mortality in patients exposed to heparin containing products. This study explored the profile of HIT incidence in non-surgical patients receiving UFH versus LMWH and in young versus older age groups. Here we provide evidence that a long-standing understanding regarding the incidence of HIT in surgical patients holds true in strictly non-surgical patients. Additionally, we have acquired evidence that age may very well play a role in HIT.

Differences in Regional Anesthesia Utilization by Hospital Region in the United States.

Regional anesthesia has been associated with improved postoperative outcomes. Disparities in regional anesthesia utilization exist; however, no studies have examined utilization rates as a function of hospital region. A national hospital database (Hospital Corporation of America {HCA}) was queried for patients aged 18 years or older that received selected surgical procedure codes between January 2016 and June 2021. Surgical procedures included were total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, total abdominal hysterectomy (TAH), open reduction and internal fixation (ORIF) of the ankle, and arteriovenous (AV) fistula creation. Regional anesthesia was defined as any form of neuraxial and/or peripheral nerve blocks. Basic summary statistics were utilized to calculate the rates of regional anesthesia (RA), and chi-squared analyseswere calculated to determine significant differences in the rate of RA utilization. There were 52,068 patients included in this study, of which 2,114 (4.1%) received RA. The greatest RA rates were for TSA (5.8%), TKA (4.5),and anterior cruciate ligament reconstruction (ACLR) (3.6%), whereas the lowest RA rate was for TAH (1.1%). For the TKA cohort, the Midwest had a significantly greater utilization rate than the South or West (10.9% vs. 4.8% or 3.1%, p<0.001). The Midwest also had the highest utilization rate in the ACLR cohort (8.1%, p<0.001), TAH cohort (16.7%, p<0.001), and AV fistula cohort (6.4%, p<0.001). For the carpal tunnel cohort, the West had the highest utilization rate (11.8% vs. 8.1%, 1.1%, 0%, p<0.001). The West region also had the highest utilization rate for the ankle ORIF (7.8%, p<0.001). No significant differences were found by region for TSA (p=0.31). Significant variations in RA utilization rates were found by region, with the West having the highest utilization for ankle ORIF and carpal tunnel, and the Midwest having the highest rate for TKA, ACLR, TAH, and AV fistula.

Validation of a Clinical Prediction Rule for Distinguishing Bacterial and Aseptic Meningitis in Pediatric Patients.

Introduction The treatments and prognosis of bacterial meningitis differ greatly from those of aseptic meningitis, making early identification and differentiation essential. Several different clinical prediction rules have been developed to distinguish bacterial meningitis from aseptic meningitis. We sought to validate one clinical prediction rule for pediatric patients utilizing a centralized data warehouse that collects daily data from 184 hospitals across the United States. Methods We retrospectively collected data on all patients aged 29 days to 14 years who presented to Hospital Corporation of America (HCA) Healthcare hospitals from January 1, 2016, to May 31, 2021, with a diagnosis of meningitis. Our study replicated the original study of the meningitis score for emergencies (MSE) for the pediatric clinical prediction rule and assigned 3 points for procalcitonin (PCT) >1.2 ng/dL, 2 points for CSFprotein >80 mg/dL, and 1 point for each of the other variables of C-reactive protein (CRP) >40 mg/L and CSF absolute neutrophil count >1000 cells per mm3. Patients were categorized either as having bacterial or aseptic meningitis. Using the clinical prediction rule, a calculation of the sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic (ROC) curve was performed. Results The optimum test characteristic was found to have a score of ≥ 3, showing a sensitivity of 92.86% (95% CI, 83.3-100), a specificity of 65.22% (95% CI, 51.5-79), a positive predictive value of 61.90% (95% CI, 47.2-76.6), and a negative predictive value of 93.75% (95% CI, 85.4-100). The ROC curve from this study showed an area under the curve (AUC) of 0.7892 (95% CI, 0.681-0.897). Conclusion Our study validated a high sensitivity for distinguishing bacterial meningitis from aseptic meningitis, suggesting the clinical prediction rule has clinical utility as a predictive screening tool. Although the original MSE advised a cutoff score of ≥1, our study suggests that a score ≥3 would give the best test performance.

Prevalence of Failed Back Surgery Syndrome Across Hospital Corporation of America Healthcare in the United States, Their Correlation With Mood Disorders and Other Lifestyle-Related Comorbidities.

About 16million adults present with chronic back pain, the sixth most costly condition in the United States (US). Estimates suggest that about 60% of initial back surgeries have a successful outcome; however, many don't, leaving over 80,000 failed back surgeries per year. Failed Back Surgery Syndrome (FBSS) is defined by the International Association for the Study of Pain as back pain, with or without radiating pain, located in the lower limbs, of unknown origin, which persists or begins after surgical procedures are performed to treat lumbar disc herniations. Psychiatric comorbidities and psychosocial factors have been associated with patients presenting with this syndrome. A retrospective cross-sectional study was performed to identify the prevalence of FBSS in a population of patients during the period of January 2019-December 2020 across Hospital Corporation of America (HCA) Healthcare in the US. With a sample of 28,426 patients who underwent back surgery only 8% had FBSS. Those with FBSS (N = 2434) were mainly females (54.27%) with a mood disorder (61.18%), P-value <.0001. Among those with FBSS, there was a statistically significant relationship between mood disorder and smoking (57.37%) and obesity (54.61%) compared to non-smokers and non-obese. Lifestyle interventions may ameliorate disabling symptoms and improve the well-being of this population.

Takotsubo Syndrome: An Epidemiologic Evaluation.

Takotsubo syndrome is characterized by regional wall motion abnormalities that reflect impairment of myocardial contractility in the absence of culprit epicardial coronary artery disease. The pathophysiologic mechanisms responsible for Takotsubo syndrome remain unknown and predominately occur in postmenopausal females suffering either a psychological or physical stressor. This study used the Hospital Corporation of America (HCA) Healthcare database evaluating demographic distribution of patients with Takotsubo syndrome to identify what comorbid conditions were most prevalent in patients found to have Takotsubo syndrome in the United States population and compare them to the traditional patient population with the condition. The patient population in the HCA Healthcare United States database was similar to prior known demographic factors including postmenopausal females and Caucasian ethnicity. Interestingly, in both the previously diagnosed group and diagnosed at the time of presentation with the Takotsubo syndrome group, there was a mismatch between the number of patients diagnosed with an underlying mood disorder and on psychiatric medication. This may provide further evidence of Takotsubo syndrome being a dramatic presentation of a mood disorder.

Implementing a health-system–wide antibiotic stewardship program in ambulatory surgery centers

Background: In 2016, the CDC released the Core Elements of Outpatient Antibiotic Stewardship, which extended the requirements previously released for hospital facilities and nursing homes to the outpatient setting. Several regulatory agencies focused on outpatient antimicrobial use. However, The Joint Commission and the Ambulatory Surgery Center (ASC) Leapfrog Group excluded ambulatory surgery centers from their medication management standards and questions. Due to the public health and patient safety benefits of implementing an antimicrobial stewardship program (ASP) and increasing regulatory interest in the matter, the Hospital Corporation of America (HCA) Ambulatory Surgery Division formally launched a nationwide ASP for its ambulatory surgery centers in March 2021. Methods: HCA is a large healthcare system with 146 ASCs in 16 states in 2021. The structure of the ASCs are local surgery centers with a medical director, a nurse responsible for infection prevention, and a pharmacist at a regional level. The types of surgeries vary based on location and ASC site. In 2019, a multidisciplinary team formed the corporate planning committee. The program was modeled after the CDC Core Elements and The Joint Commission’s requirements for an ASP. Each ASC was asked to build a local ASP team, led by a local physician and a regionally based pharmacist. In addition, a stewardship goal was established to update all preoperative antibiotic surgical-site infection prophylaxis order sets. The corporate committee provided educational resources, including evidence-based guidelines for appropriate antibiotic selection for surgical-site infections. They collected antibiotic cost per case as a baseline metric to track and analyze. Pediatric, ophthalmic, and gastrointestinal endoscopic procedures were excluded from the program. Results: From January 1, 2020, through December 31, 2021, including only centers that were operational during this period and excluding single specialty endoscopy centers, antibiotic cost per case decreased annually from $2.38 to $1.84 (t = 4.157; P &lt; .005), and the postoperative infection rate also declined from 0.370 to 0.304 (t = 2.079; P = .040). Conclusions: Our findings suggest that implementing a health-system–wide outpatient antibiotic stewardship program in the ambulatory surgery center setting is feasible and may contribute to decreased antibiotic cost per case and improved postoperative surgical site infection rates.Disclosures: None

Using FOCUS-PDSA Quality Improvement Methodology Model in Healthcare: Process and Outcomes.

Using FOCUS-PDSA Quality Improvement Methodology Model in Healthcare: Process and Outcomes.

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19.

Identifying COVID-19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID-19 patients but have not been evaluated in a large cohort. To determine whether well-known risk scores can predict poor outcomes among hospitalized COVID-19 patients. A retrospective cohort study of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021. Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at presentation. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated. We identified 90,376 patients with community-acquired COVID-19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality (0.593, confidence interval [CI]: 0.588-0.597), ICU admission (0.602, CI: 0.599-0.606), mechanical ventilation (0.614, CI: 0.610-0.619), and vasopressor receipt (0.600, CI: 0.595-0.604). Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID-19 patients to develop more effective risk-based triage.

299 The Diagnostic Value of D-dimer Levels for the Exclusion of Aortic Dissection

Acute aortic dissection is a highly fatal disorder if not diagnosed promptly. The current gold standard for diagnosis of aortic dissection is with CT angiogram, MRI, or transesophageal echocardiogram. These advanced imaging techniques are expensive, time-consuming, and carry risks, so they are not ideal, especially for low risk patients. A universal, rapid-screening biomarker could reduce the need for advanced imaging tests to exclude the diagnosis of acute aortic dissection. Some prior studies have suggested that serum d-dimer levels are elevated in patients with aortic dissection, but the diagnostic value of d-dimer levels for ruling out aortic dissection remains uncertain. Thus, we sought to further assess the diagnostic usefulness of d-dimer levels as a means to rule out aortic dissection in emergency department patients. This was a retrospective analysis of emergency department patients from the Hospital Corporation of America (HCA) database. We queried the database to find patients who had a diagnosis of acute aortic dissection and who had a d-dimer test result within 24 hours of arrival to the emergency department. We also identified patients who had a diagnosis of (nonspecific) chest pain and who had a d-dimer test result within 24 hours of arrival to the emergency department. The median d-dimer value was compared in the aortic dissection group and the chest pain group using the Wilcoxon Rank Sum Test. We determined the sensitivity and specificity of d-dimer for aortic dissection using the standard cutoff value of 500 ng/mL, and we formulated a receiver operating characteristic (ROC) curve. Finally, we sought to determine if there is a different d-dimer cutoff value with better test characteristics than the standard 500 ng/mL. D-dimer values are reported in fibrinogen equivalent units (FEUs). A total of 48,902 patients’ records were analyzed for this study. This sample included 572 aortic dissection patients and 48,330 chest pain patients. The median d-dimer value for the aortic dissection group was 2455 ng/mL, and for the chest pain group, it was 385 ng/mL. The difference between the median values of each group of 2070 ng/mL was statistically significant (p-value <0.0001). Using a standard cutoff of 500 ng/mL, we found the sensitivity of the d-dimer to be 91.1% and the specificity to be 71.4%. To achieve a sensitivity greater than 95% for aortic dissection, the d-dimer cutoff had to be reduced to 375 ng/mL, at which point the sensitivity was 95.1% and the specificity was 48.5%. The Youden index maximized at 835 ng/mL, at which point the sensitivity was 82.9% and the specificity was 86.3%. The area under the ROC curve was 0.91 (95% CI 0.89 to 0.92). In general, serum d-dimer values are higher in patients with an aortic dissection than in those with nonspecific chest pain. At the standard cutoff of 500 ng/mL, the serum d-dimer seems to have a high sensitivity for aortic dissection, but it is likely not high enough such that d-dimer levels alone can be used to exclude aortic dissection.

Incidence of Acute Ischemic Stroke in Hospitalized Patients With Atrial Fibrillation Who Had Anticoagulation Interruption: A Retrospective Study.

BackgroundAtrial fibrillation (AF) is one of the leading causes of acute ischemic stroke requiring anticoagulation. Many patients experience treatment interruption in the hospital setting. The aim of this study was to evaluate the effect of anticoagulation interruption on short-term risk of ischemic stroke in hospitalized patients with AF.MethodsWe performed a retrospective medical record review using the Hospital Corporation of America (HCA) database. We included patients admitted to our institution between December 2015 and December 2018 who had a prior history of AF. Patients were excluded if they had ischemic stroke, hemorrhagic stroke, history venous thromboembolism or mechanical valve on admission. We compared the incidence of ischemic stroke in patients in whom anticoagulation was interrupted for more than 48 h to those who continued anticoagulation.ResultsA total of 2,277 patients with history of AF were included in the study. In this cohort, 79 patients (3.47%) had anticoagulation interruption of more than 48 h during their hospital stay. There was no difference in incidence of stroke between the interruption and no interruption groups (1.27% (n = 1) vs. 0.23% (n = 5), P = 0.19). Interruption of anticoagulation did not associate with a significant increase in the risk of in-hospital ischemic stroke. CHA2DS2VASc score was a strong predictor of in-hospital stroke risk regardless of anticoagulation interruption (odds ratio: 7.199, 95% confidence interval: 2.920 - 17.751).ConclusionIn this study, the in-hospital incidence of ischemic stroke in patients with AF did not significantly increase by short-term anticoagulation interruption.

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition

Rigorous evidence describing the relationship between private equity acquisition and changes in hospital spending and quality is currently lacking. To examine changes in hospital income, use, and quality measures that may be associated with private equity acquisition. This cohort study identified 204 hospitals acquired by private equity firms from 2005 to 2017 and 532 matched hospitals not acquired by private equity. Using a difference-in-differences design, this study evaluated changes in net income, charges, charge to cost ratios, case mix index (a measure of reported illness burden), share of discharges for patients with Medicare or Medicaid coverage, discharges per year, and aggregate hospital quality measures associated with private equity acquisition through 3 years after acquisition, adjusted for case mix, hospital beds, calendar year, and adjustment for multiple hypothesis testing. In subgroup analyses, changes in outcomes for private equity-owned Hospital Corporation of America (HCA) hospitals and non-HCA hospitals relative to matched controls were assessed. Eight hospital income and use measures and 3 aggregate hospital quality measures were examined. Relative to 532 control hospitals, the 204 private equity-acquired hospitals showed a mean increase of $2 302 391 (95% CI, $956 660-$3 648 123; P = .009) in annual net income, an increase of $407 (95% CI, $296-$518; P < .001) in total charge per inpatient day, an increase of 0.61 (95% CI, 0.48-0.73; P < .001) in emergency department charge to cost ratio, an increase of 0.31 (95% CI, 0.26-0.37; P < .001) in total charge to cost ratio, an increase of 0.02 (95% CI, 0.01-0.02; P = .007) in case mix index, and a decrease of 0.96% (95% CI, 0.46%-1.45%; P = .002) in share of Medicare discharges. Medicaid's share of discharges (-0.16%; 95% CI, -0.86% to 0.53%; P > .99) and total hospital discharges (98; 95% CI, -54 to 250; P > .99) did not change differentially in a statistically significant manner. The aggregate quality score for acute myocardial infarction increased by 3.3% (95% CI, 1.6%-5.0%; P = .002), and the aggregate score for pneumonia increased by 2.9% (95% CI, 1.8%-3.9%; P < .001) in private equity-acquired hospitals relative to controls. The aggregate score for heart failure (1.3%; 95% CI, -0.2% to 2.7%; P = .92) did not differentially change in a statistically significant manner. In subgroup analyses, HCA hospitals showed similar findings to the entire sample. Among non-HCA hospitals, the only statistically significant relative changes were the increase in the emergency department charge to cost ratio (0.30; 95% CI, 0.12-0.48; P = .02) and the decrease in Medicare's share (-1.15%; 95% CI, -1.88% to -0.43%; P = .02). Non-HCA hospitals showed a decrease in the aggregate heart failure score (-3.3%; 95% CI, -5.3% to -1.3%; P = .01) and no statistically significant changes in the aggregate score for acute myocardial infarction (2.4%; 95% CI, -0.7% to 5.4%; P > .99) or pneumonia (0.2%; 95% CI, -1.4% to 1.7%; P > .99). Hospitals acquired by private equity were associated with larger increases in net income, charges, charge to cost ratios, and case mix index as well as with improvement in some quality measures after acquisition relative to nonacquired controls. Heterogeneity in some findings was observed between HCA and non-HCA hospitals.

Demographics and Length of Stay for Osteomyelitis in Opioid Drug Users: A Unique Population with High Healthcare Costs.

Osteomyelitis is an infection of the bone. Risk factors include, but are not limited to, diabetes and intravenous drug use. The hypotheses for the primary objectives of this study were that the opioid epidemic would cause a younger population of patients to be seen with osteomyelitis and the treatment for this population has special considerations including longer hospitalization for proper intravenous antibiotics. This retrospective chart review compared 2,150 cases of osteomyelitis in the Hospital Corporation of America (HCA Healthcare) West Florida Division. A sample group of osteomyelitis with diabetes was compared to a group with reported opioid use. The results showed a significantly younger age at which the osteomyelitis was occurring in opioid drug users and a significantly longer hospitalization for the treatment. With the rising costs of healthcare and the continuing growth of drug abuse, the 11.501-year younger age difference (95% confidence interval [9.204, 13.799], p-value <0.001) and 4.992-day longer hospitalization (95% confidence interval [3.053, 6.931], p-value <.001) can raise awareness on an additional impact of drug abuse on healthcare costs.

QIM119-120: Utilizing Technology to Identify Oncology Patients to Impact Patient Care

Background: Sarah Cannon has established a standardized nurse navigation program for breast, lung, and Gi cancer patients. Navigators play a significant role in addressing barriers that may adversely impact patient outcomes. Historically, nurse navigators were spending up to 65% of their time data mining to identify new patients for navigation. This lost time compromises a navigator’s ability to effectively support patients. Sarah Cannon implemented a technology solution to address this manual process. Methods: A patient identification software application (patient ID), utilizing natural language processing technology, was developed to identify positive pathology reports across the enterprise in real time. Patient ID instantly routes those reports to a tumor site-specific oncology nurse navigator. The impact of this technology was assessed in 3 Hospital Corporation of America (HCA) markets from December 2016–March 2017. Total patient recall, total volume of reports reviewed, navigated patient volumes, navigator time allocation, and time from diagnosis to first treatment were studied. Results: Patient ID reviewed 47,544 pathology reports during the 4-month pilot, identifying 7,224 potential cancer reports. 2,782 of those represented breast, lung, or Gi cancer patients and were routed to a nurse navigator. Patient ID performed with an overall total patient recall of 98%, respectively. Decreased time spent data mining was observed, and navigator caseload increased by 71%. Time from diagnosis to first treatment decreased by an average of 6 days. Time allocated to direct patient contact and physician interaction increased by 35%. Conclusions: Implementation of a technology solution to rapidly identify new cancer patients for navigation in a community health system is feasible and associated with multiple benefits. Increased navigator patient volumes and navigator productivity were observed. Navigator time spent with patients and physicians increased with a concurrent reduction in data mining time. Timeliness of care metrics improved, suggesting a favorable impact on quality. This technology is now being deployed across the HCA enterprise.

Nissen Fundoplication–Preserving Laparoscopic Sleeve Gastrectomy

Gastroesophageal reflux disease (GERD) is significantly more prevalent in obese patients. Nissen fundoplication alleviates symptoms in those refractory to dietary changes and optimal medical management. The need for concomitant treatment of GERD and obesity is becoming more prevalent. The objective of this study was to determine whether Nissen-preserving laparoscopic sleeve gastrectomy (SG) is a safe and effective weight loss option for patients with pre-existing Nissen fundoplication. The study was conducted at the Hospital Corporation of America, Memorial Health, Savannah, Georgia, academic institution. We retrospectively reviewed five patients who underwent laparoscopic Nissen-preserving SG between 2011 and 2017. We compared pre- and postoperative subjective GERD symptoms, occurrence of any immediate postoperative complications, change in BMI, and excess weight loss. Of the five patients, four were female and one was male. The mean age was 50.6 years. The mean preoperative BMI was 44.8 ± 5.4, one-month postoperative BMI was 41.2 ± 6.1 (P < 0.001), and six-month postoperative BMI was 37.5 ± 8.1 (P < 0.009), with mean excess weight loss at six months of 33.9 ± 23 per cent. There were no immediate postoperative complications. Subjective GERD symptoms were unchanged in two patients and improved in the other three. We demonstrate the early feasibility of Nissen-preserving SG for surgical weight loss in patients with existing Nissen fundoplication. Although our results are early, we feel encouraged by mean excess weight loss to date and control of GERD symptoms.

Market Power: Price Variation Among Commercial Insurers For Hospital Services.

Much research has focused on differences in hospital prices paid by private (commercial) versus public (Medicare and Medicaid) health insurers. Far less is known about price differences across commercial payers-health maintenance organizations (HMOs) or preferred provider organizations (PPOs) versus other payers, such as casualty (automobile), workers' compensation, and travel insurers. We found that other insurers had far less negotiating power with hospitals than commercial HMO/PPO insurers did. In the period 2010-16, the median price paid by HMO/PPO insurers for hospital services in Florida increased from 1.9 times to 2.5 times the Medicare price, respectively, while the median price paid by other insurers increased from 2.8 times to 3.8 times the Medicare price. Commercial HMO/PPO insurers' prices were similar across major hospital systems, regardless of ownership, while other insurers' prices differed substantially across systems. In 2016 the twenty hospitals with the highest prices (7.8-14.1 times the Medicare rate) for other insurers in Florida were all affiliated with the Hospital Corporation of America. These hospitals generated 24percent of their commercial net revenue (median) from other payers, despite treating a relatively small proportion of patients covered by these payers. Protecting patients with other insurance from high hospital prices requires efforts by policy makers, hospitals, and insurers.

Assessment of clinical and educational interventions that Advanced Pharmacy Practice Experience (APPE) students contributed to a family medicine residency program

Background and purposeThe literature firmly establishes that clinical interventions made by pharmacy students on Advanced Pharmacy Practice Experience (APPE) rotations contribute significantly to cost-savings realized by the hosting practice sites. The Accreditation Council for Pharmacy Education (ACPE) specifies the experiential curricula include opportunities for students to learn about, from, and with other members of the healthcare team through interprofessional education activities. Educational activityThis study assesses clinical and educational interventions contributed by APPE students at a family medicine residency program to determine the extent students were engaged in the interprofessional team and physicians’ receptiveness to the recommendations. FindingsStudent interventions made from January 2009 to September 2012 were recorded in a Microsoft Excel Spreadsheet. Data was evaluated to determine 1) the most common types of clinical and educational interventions, 2) potential associated cost-savings/avoidance, and 3) provider receptiveness to recommendations based upon acceptance rates. A standardized scheme was utilized to assign a cost savings value according to Midwest America Division of Hospital Corporation of America (HCA) clinical savings standards. Pharmacy students contributed 2868 interventions in 3.5 years. A total of 59.2% of interventions were clinical and accounted for an estimated cost savings of $55,892. The remaining 40.8% of interventions were pharmacy care activities, none were associated with a cost savings and three-fourths were considered educational. Intervention acceptance rate was over 80%, showing providers were very receptive to pharmacy students. SummaryThis study lends support that APPE students provide substantial clinical and educational contributions to healthcare providers and patients affiliated with family medicine residency programs. Additionally, healthcare providers and patients are very receptive to pharmacy students as members of the interprofessional team.

The Sepsis Early Recognition and Response Initiative (SERRI)

Duration of Initiative 48 months and currently ongoing. Setting The Houston Methodist Hospital System and affiliated hospitals (3 facilities with 2 hospital-run skilled nursing facilities in and around Houston), St. Joseph's Regional Health Center (1 acute care hospital and 2 skilled nursing facilities in Bryan, Texas), Hospital Corporation of America (2 acute care facilities in Houston, 1 acute care facility in McAllen, Texas [Rio Grande Valley]), Kindred Healthcare (2 long term acute care facilities in Houston), Select Medical Specialty Hospitals (2 long term acute care facilities in Houston). Whom This Should Concern Hospital administrators, quality and safety officers, performance improvement and patient safety professionals, clinic managers, infection control and prevention staff, and other physicians, nurses, and clinical staff.

Nursing and Implementation of Modern Technology

Introduction. Implementation of technol-ogy in health care has become a global trend. The society modernization has led to the increasing development of technol-ogy and information systems. Nurses in everyday work encounter with the applica-tion of communications and information technologies. The implementation of mod-ern technology in nursing increases nurses efficiency, but it is also changing the way of care for patients. Implementation of mod-ern technology in nursing is the result of interactions between technical skills, cul-ture and social acceptance in the working environment.Aim. The aim of this article was to inves-tigate the application of modern technol-ogy in nursing and how it affects the nurs-ing profession, what competencies are required for the introduction of technol-ogy and the role of nurses in the process.Materials and methods. PubMed database, OJIN base (Online Journal of Issues in Nursing), HCA (Hospital Corporation of America) were searched with the aim of finding appropriate studies and articles. Keywords which were used: nursing, mod-ern technology, nursing challenges, educa-tion.Conclusion. Modern technology in the nursing profession is in its infancy, a lot of factors are contributing to slower de-velopment such as high cost, a shortage of nurses and training of medical staff to work with the new technology.Results. During a search of the databases, we found seven articles of which accord-ing to the inclusion criteria for this study we used three. Data from the literature that was used showed that the application of modern technology in nursing is still in the initial process of adaptation.

COVENANT DESIGN IN FINANCIAL CONTRACTS: A CASE STUDY OF THE PRIVATE EQUITY ACQUISITION OF HCA

A buyout deal involves several parties, including private equity firms, the target company, and lending banks. All these parties are legally connected by contractual arrangements, and covenants among all interest parties are important. However, a comprehensive study on designing covenants among parties in a buyout deal to achieve commitment and avoid risk in closing a deal is seldom seen in current literature. By investigating one of the world's largest buyout deals – the acquisition of Hospital Corporation of America (HCA), this paper not only probes into the design of contracts and covenant, but also provides several managerial implications. This paper concludes that well-designed covenants in buy-out deals can appropriately align all participants’ diversified interests.

A Model for Building a New Adult Blood and Marrow Program

St. David’s South Austin Medical Center: The hospital, along with its sponsor organizations, Hospital Corporation of America (HCA) and the St. David’s Foundation, provided the neccessary infrastructure, including staff, equipment, supplies and a new unit and clinic specifically designed for the care of HSCT patients. Texas Transplant Institute/Methodist Hospital: Texas Transplant Institute, a well-established provider of HSCT services, provided the clinical expertise through physician coverage, guidance, nurse/technician education, and quality management. Cell Therapy Processing services are provided by Methodist Hospital.