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Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

Direct oral anticoagulant (DOAC) starter packs are designed for unique treatment dosing for acute venous thromboembolism (VTE). Inappropriate use of 30-day DOAC starter packs in patients with atrial fibrillation (AF) may increase the risk for bleeding events given higher dosing in the first 1-3 weeks of treatment. A retrospective analysis of medical and outpatient pharmacy claims data from 2015 to 2018 in Optum's De-identified Clinformatics® Data Mart was performed. Patients greater than 18 years of age with AF and a new prescription of apixaban or rivaroxaban were included. Patients with an acute VTE were excluded. The main outcome of interest was adverse events (emergency department [ED] visits, hospitalizations, and deaths within 90 days after prescription fill date) associated with inappropriate DOAC starter pack prescription. A total of 90,950 DOAC-treated patients with AF were identified. The mean age was 74.5 years (SD 10.0) and 42,717 (47.0%) were female. Inappropriate starter packs were used by 117 (0.1%) patients, who were younger than non-starter pack patients (71.3 years vs. 74.5 years). Patients who received an inappropriate DOAC prescription were more likely to identify as Black (12.0% vs. 8.8%). Rates of ED visits, hospitalizations, and deaths overall were numerically lower in patients with starter pack compared to non-starter pack DOAC prescriptions. In contrast, rates of ED visits and hospitalizations related to significant bleeding were numerically higher in patients with starter pack compared to non-starter pack DOAC prescriptions. Among patients with AF but no VTE, those who received an inappropriate DOAC starter pack had numerically higher rates of severe bleeding leading to ED visits and hospitalizations compared to those prescribed an appropriate non-starter pack DOAC anticoagulant.

Item does not contain fulltext BACKGROUND: Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. METHODS: Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. RESULTS: A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). CONCLUSIONS: AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI. 01 april 2023

Objectives The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm. Methods We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED. Results Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings. Conclusions We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.

Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair.Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points.Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events.In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.

BACKGROUND: The 30-day direct oral anticoagulant starter pack has simplified the treatment of acute venous thromboembolisms, but it is not appropriate for use in patients with other indications for anticoagulation. METHODS: A retrospective analysis of national outpatient pharmacy claims data between January 1, 2015 and December 31, 2018, was performed. Adult patients (ages >18 years) with continuous insurance enrollment at least 12 months prior to and 1 month following a direct oral anticoagulant starter pack prescription during the study period were included. The primary study outcome was the rate of inappropriate prescription of direct oral anticoagulant starter packs, defined as a prescription without a venous thromboembolism diagnosis within the prior 45 days or a prescription with a prior starter pack fill within the past 45 days. RESULTS: A total of 3711 direct oral anticoagulant starter pack prescription fills were identified, representing 3634 unique patients. The mean patient age was 62.8 years (standard deviation [SD] 15.1) and 1871 (50.4%) were females. There were 770 (20.7%) direct oral anticoagulant starter pack fills identified as potentially inappropriate. Patients prescribed inappropriate fills were likely to be older than patients with appropriate fills (64.7 years vs 62.4 years, P < 0.001). There was no significant difference in the race or geographic location between patients with inappropriate and appropriate prescriptions. CONCLUSIONS: A significant proportion of patients using direct oral anticoagulant starter packs did not have a diagnosis of acute venous thromboembolism, raising concerns about inappropriate prescribing and potential bleeding complications. Future studies are needed to identify factors associated with inappropriate direct oral anticoagulant starter pack prescription and evaluate efforts to reduce this practice.

Key Points Question What factors are associated with a potentially missed diagnosis of appendicitis in the emergency department among adults and children? Findings In this cohort study of 123 711 patients diagnosed with appendicitis, insurance claims data indicated that appendicitis was potentially missed in 6.0% of adults and 4.4% of children during the initial emergency department visit. Factors associated with potentially missed appendicitis included female sex, the coexistence of abdominal pain and constipation, and the presence of comorbidities. Meaning Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may alert clinicians and mitigate the risk of missed diagnosis., Importance Appendicitis may be missed during initial emergency department (ED) presentation. Objective To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. Design, Setting, and Participants In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged, This cohort study uses insurance claims data to compare patients with a potentially missed diagnosis of appendicitis with those diagnosed with appendicitis during the initial emergency department visit to identify factors associated with potentially missed appendicitis among adults and children.

Background It is estimated that 9.3% of the population in the United States have diabetes mellitus (DM), 28% of which are undiagnosed. The high prevalence of DM makes it a common comorbid condition in hospitalized patients. In recent years, government agencies and healthcare systems have increasingly focused on 30-day readmission rates to determine the complexity of their patient populations and to improve quality. Thirty-day readmission rates for hospitalized patients with DM are reported to be between 14.4 and 22.7%, much higher than the rate for all hospitalized patients (8.5–13.5%). The objectives of this study were to (1) determine the incidence and causes of 30-day readmission rates for patients with diabetes listed as either the primary reason for the index admission or with diabetes listed as a secondary diagnosis compared to those without DM and (2) evaluate the impact on readmission of two specialized inpatient DM services: the Hyperglycemic Intensive Insulin Program (HIIP) and Endocrine Consults (ENDO). Methods For this study, DM was defined as any ICD-9 discharge diagnosis (principal or secondary) of 250.xx. Readmissions were defined as any unscheduled inpatient admission, emergency department (ED) visit, or observation unit stay. We analyzed two separate sets of patient data. The first pilot study was a retrospective chart review of all patients with a principle or secondary admission diagnosis of diabetes admitted to any adult service within the University of Michigan Health System (UMHS) between October 1, 2013 and December 31, 2013. We then did further uncontrolled analysis of the patients with a principal admitting diagnosis of diabetes. The second larger retrospective study included all adults discharged from UMHS between October 1, 2013 and September 30, 2014 with principal or secondary discharge diagnosis of DM (ICD-9-CM: 250.xx). Results In the pilot study of 7763 admissions, the readmission rate was 26% for patients with DM and 22% for patients without DM. In patients with a primary diagnosis of DM on index admission, the most common cause for readmission was DM-related. In the larger study were 37,702 adult inpatient discharges between October 1, 2013 and September 30, 2014. Of these, 20.9% had DM listed as an encounter diagnosis. Rates for all encounters (inpatient, ED and Observation care) were 24.3% in patients with DM compared to 17.7% in those without DM (p

In this study we examined spousal concordance for two aggregate measures of health risk status and compliance with preventive service recommendations among 9620 pairs of cohabitating, opposite-sex married couples.Health risk appraisals were the primary data source to measure two outcome variables. Health risk status was compiled from 12 health risks and categorized into three levels (low-, medium-, and high-risk status). Overall preventive service compliance status was estimated by seven age-sex specific preventive service recommendations and dichotomized into lower and higher compliance status. For each of the husband and wife populations, we conducted proportional odds models and logistic regression models to assess spousal concordance for the two aggregate measures respectively. All models were adjusted for household income, one's characteristics (age, race, education, disease burden), and the same set of characteristics and the corresponding outcome variable from the spouse.A positive correlation within spousal pairs was statistically significant for both health risk status and compliance status (p.001) based on multivariate modeling. The odds ratios were similar in magnitude for the two spouse populations.The analyses showed spousal concordance for aggregate measures of health behaviors. This study also provides some evidence for dominance of husband's education.

Background The relationship of distance to care with total health care utilization and disease burden is not well understood among the managed care population. Purposes The aim of this study was to examine the relationship between the distance from a patient's home to his or her primary care physician (PCP) and the patient's health characteristics. Methodology This was a population-based study of commercial health maintenance organization (HMO) members enrolled in one medium-sized health plan in Michigan in 2001. This study measured health care utilization from all settings (per member per year [PMPY]). Disease burden measure was based on the Adjusted Clinical Group (ACG) system. Distance was defined as straight-line distance between a member's residency and his or her PCP. Both direct standardization and regression modeling were used to assess the effect of distance on utilization. Findings Both utilization and disease burden increased as distance increased, especially among members selecting PCPs in an academic health system (AHS). The difference in observed utilization between local (0-10 miles) and distant (>30 miles) members was 973 dollars (PMPY) for the AHS and 193 dollars (PMPY) for the community independent practice associations (IPA). Compared with age-sex adjustment, ACG adjustment reduced local-distant difference within the same practice group to a greater extent (281 dollars and 59 dollars remaining for the academic and community groups, respectively). Distance as a whole exerted a statistically significant positive effect on either disease burden score or utilization in regression modeling. Practice implications HMO members consume more health care and had higher disease burden as their distance from their PCPs increased. The distance traveled by the individuals to their PCPs could be incorporated when adjusting managed care financial risk models. Other remedies include negotiating higher capitation rates for distant patients, carving out distant patients from any financial risk model, or excluding such patients from provider performance assessment.

Many academic medical centers have significant capacity constraints and limited ability to expand services to meet demand. Health care management should employ strategic thinking to deal with service demands. This article uses three organizational models to develop a theoretical framework to guide the selection of clinical services for outsourcing.

The clinical impetus to develop cancer centers has been the recognition that many cancer patients require a comprehensive treatment plan coordinated across multiple specialties. Developing an effective organizational and financial structure among the multiple entities that comprise an academic cancer center has, however, been a challenge. The authors describe an effort to realize a sustainable clinical operation at the University of Michigan Comprehensive Cancer Center (UMCCC) by developing an appropriate management structure and financial model. The modified organizational structure established a clear line of administrative authority and held faculty members accountable for their effort in the UMCCC. A unified budget aligned financial incentive among all stakeholders to increase efficiency, revenue, and margin. The authors report preliminary financial evidence of the success of the new managerial structure.

Objective. An examination of the physician efficiency and resulting cost patterns by region. Data Sources. Virginia Medicaid sinusitis related claims for 1993 were aggregated to physician level (n e 178), and Area Resources File for 1993 was used to identify regions for evaluation. Study Design. The best practice performance in the usage of five resources (i.e., primary care physician visits, referral services, emergency room visits, prescriptions, laboratory tests) was identified using Data Envelopment Analysis (DEA). Five regions in Virginia were identified according to regional planning to evaluate the variation in efficiency across these regions. Principal findings. Inefficient physicians consumed significantly more resources and were 48% more costly than efficient physicians. Substantial regional variation was found and mainly attributed to the differences in use of prescriptions and laboratory procedures. Urban-rural discrepancy may explain part of the variation. Conclusions. As this study reveals the existence of substantial variation in physician efficiency, actions should be taken to minimize the variation that is more affected by personal and structural factors. For example, information on efficient use of resources and corresponding patient outcomes can be disseminated to the attending physicians. Educational workshops can be conducted to allow sharing of experience between efficient and inefficient physicians. Efforts should also be directed to help inefficient physicians to adhere to practice guidelines.

Acute care hospitals have increasingly been forming local strategic hospital alliances (SHAs), which consume considerable resources in forming and may affect the competitiveness of provider markets. This research shows that SHAs and market factors, which have been perceived to be threats to hospitals, are related to hospitals' financial performance. Among the findings are that SHA members have higher net revenues but that they are not more effective at cost control. Nor do the higher net revenues result in higher cash flow. However, increasing SHA penetration in a market is related to lower net revenues per case. In addition, the penetration of private health maintenance organizations in markets is associated with lower revenues and expenses.

Purpose. Assess the association of taking incidental sickness absence with health risks and health status. Design. Observational. Setting. One Midwest health care system. Subjects. Individuals who were employed for 2 years (2006–2007) and had completed at least one health risk appraisal (HRA) in 2007 (N = 3790). Measures. Outcomes were any incidental sickness absence and absence duration in 2007 measured by an absence tracking system. Health risks and health status were estimated by HRAs. Program participation was captured using 7-year HRA data and 5-year wellness data. Analysis. Multivariate, binary logistic regression for the probability of taking any absence day among the overall population as well as four demographic subgroups; proportional odds model for the probability of taking more absence days. Results. Different patterns were observed in association with taking incidental sickness absence among age and gender subgroups. Among the overall population, three health risks (smoking overweight, and use of medication for relaxation) were positively associated with taking absence (at least p Conclusion. Sickness absence is an important productivity concern of employers. Employers may implement early interventions to focus on preventable causes. Special interventions may target absence-causing risks such as smoking behavior and excess body weight. Study limitation includes a lack of measures for psychosocial work environment.

Objective: To examine the association of behavioral intention with subsequent behavioral change in a worksite setting for three health behaviors, increasing physical activity, quitting smoking, and losing weight. Methods: Two-year health risk appraisal data came from one multistate company. Behavioral intention was captured in the 2004 health risk appraisal, and behavioral change was measured by comparing health behaviors in 2004 and 2005. Multivariate logistic regression was used to study the intention-behavior relationship. Results: A positive association with intention for change was found in increasing physical activity level (P = 0.0002) and quitting smoking (P = 0.018). Nevertheless, a negative relationship was observed in reducing weight (P = 0. 003 ). Conclusions: A positive intention-behavior change relationship was found in two of the three behaviors. Individuals may benefit from differential wellness programming based on their intention for change and health risks.

When tertiary health centers face capacity constraint, one feasible strategy to meet service demand is outsourcing clinical services to qualified community providers. Clinical outsourcing enables tertiary health centers to meet the expectations of service timeliness and provides good opportunities to collaborate with other health care providers. However, outsourcing may result in dependence and loss of control for the tertiary health centers. Other parties involved in clinical outsourcing such as local partners, patients, and payers may also encounter potential risks as well as enjoy benefits in an outsourcing arrangement. Recommendations on selecting potential outsourcing partners are given to minimize the risks associated with an outsourcing contract. Copyright © 2006 John Wiley & Sons, Ltd.

A before-and-after study was conducted to examine the combined effect of public profiling and quality improvement activities on management of heart failure (HF) in the hospital setting.Thirty-one hospitals in southeastern Michigan participated in this profiling and quality improvement study. One hospital closed after the baseline measurement. Two quality indicators were developed to evaluate the key processes of HF care, and one profiling indicator was designed for public profiling. The baseline results of the profiling indicator were publicly released. The individual hospitals were identified in the profiling report by name as "having statistically higher (or lower) rates than average." Remeasurement results were compared to the baseline results by using t-tests for the individual hospitals and all 30 hospitals as an aggregate.Two-thirds of the hospitals improved ejection fraction documentation; the aggregate result improved 5.4 percentage points (p0.05). No change was observed in the aggregate measure of prescribing angiotensin-converting enzyme inhibitors (ACEIs) to eligible HF patients at discharge. Hospitals with low baseline rates made improvement in ACEI use at discharge, but those with good baseline performance tended to decline in performance. There was a 2.2 percentage point increase (p0.05) in the profiling indicator.There seemed to be differential impacts of interventions across indicators and hospitals. Public profiling may have the most positive impact on hospitals with low performance at baseline. Maintaining the baseline good practice was a struggle for hospitals with relatively high baseline rates.

This study validates the measurements of performance of preventive practices and identifies organizational and market factors that affect variations in the preventive care practices of health maintenance organizations (HMOs). Confirmatory factor analysis was used to assess HMO performance, reflecting the rates of five preventive practice services. A structural equation model of the preventive practice performance of HMOs was evaluated. It was discovered that HMOs that employ more board-certified primary care practitioners have a higher rate of preventive care practices and that market competition and market forces do not influence the variation in HMO preventive care practices.