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The objective of this analysis was to evaluate and report on the economic impact of implementing an integrated, quality, and operational improvement program on chronic obstructive pulmonary disease (COPD) care from acute through post-acute care settings. This initiative was established in a cohort of 12 hospitals in Alabama and sought to address COPD readmission through improved workflows pertaining to early diagnosis, efficient care transitions, and patient visibility across the entire care episode. Implementation of the initiative was influenced by lean principles, particularly cross-functional agreement of workflows to improve COPD care delivery and outcomes. A budget impact model was developed to calculate cost savings directly from objective data collected during this initiative. The model estimated payer annual savings over 5 years. Patients were classified for analysis based on whether or not they received noninvasive ventilation. Scenario analyses calculated savings for payers covering different COPD cohort sizes. The base case revealed annual per patient savings of $11,263 for patients treated through the quality improvement program versus traditional care. The model projected cumulative savings of $52 million over a 5-year period. Clinical incorporation of non-invasive ventilation (NIV) resulted in $20,535 annual savings per patient and projected $91 million over 5 years. We conclude that an integrated management program for COPD patients across the care continuum is associated with substantial cost savings and significantly reduced hospital readmissions.

[This corrects the article DOI: 10.1371/journal.pone.0235040.].

Background Although evidence suggests significant clinical benefits of home noninvasive ventilation (NIV) for management of severe chronic obstructive pulmonary disease (COPD), economic analyses supporting the use of this technology are lacking. Objectives To evaluate the economic impact of adopting home NIV, as part of a multifaceted intervention program, for severe COPD. Methods An economic model was developed to calculate savings associated with the use of Advanced NIV (averaged volume assured pressure support with autoexpiratory positive airway pressure; Trilogy100, Philips Respironics, Inc., Murrysville, PA) versus either no NIV or a respiratory assist device with bilevel pressure capacity in patients with severe COPD from two distinct perspectives: the hospital and the payer. The model examined hospital savings over 90 days and payer savings over 3 years. The number of patients with severe COPD eligible for home Advanced NIV was user-defined. Clinical and cost data were obtained from a quality improvement program and published reports. Scenario analyses calculated savings for hospitals and payers covering different COPD patient cohort sizes. Results The hospital base case (250 patients) revealed cumulative savings of $402,981 and $449,101 over 30 and 90 days, respectively, for Advanced NIV versus both comparators. For the payer base case (100,000 patients), 3-year cumulative savings with Advanced NIV were $326 million versus no NIV and $1.04 billion versus respiratory assist device. Conclusions This model concluded that adoption of home Advanced NIV with averaged volume assured pressure support with autoexpiratory positive airway pressure, as part of a multifaceted intervention program, presents an opportunity for hospitals to reduce COPD readmission-related costs and for payers to reduce costs associated with managing patients with severe COPD on the basis of reduced admissions.

Preview Victims of high heat and humidity may be young and healthy or old and debilitated. In either case, severe heatstroke may present a life-threatening situation if treatment is delayed. In this article, the authors examine the various therapeutic options, including physical cooling methods and supportive measures. They also describe therapy for the less serious summer ailments of heat edema, heat cramps, and heat syncope.

Background: To our knowledge, the new local coverage determination (LCD) adherence criteria for continued reimbursement of continuous positive airway pressure after 90 days has heretofore not been validated, including the effects of the policy on care for patients with obstructive sleep apnea. Methods: We examined a retrospective database of 150 patients who received neuropsychologic testing prior to treatment and 3 and 6 months post treatment. We categorized participants using the new LCD criteria. Comparisons of neuropsychologic variables were made between adherent and nonadherent groups. Results: Fifty-fi ve participants (37%) failed to meet the new criteria, although this number may not refl ect the actual rates of adherence in clinical settings because some efforts beyond standard care were made to ensure adherence to treatment among many of the participants. Of the 50 patients who did not receive any special adherence intervention, only 28 (56%) met the criteria. On most measures, patients with poor adherence demonstrated neuropsychologic improvements similar to their adherent counterparts. Nonadherent patients realized additional improvements in working memory between 3 and 6 months post treatment. Conclusions: This study highlights the potential effects of the new criteria for adherence on patients with obstructive sleep apnea and their clinical care. These data were taken from a study that was not designed to examine these criteria, so controlled trials are needed to better understand the effect of the guidelines on adherence and treatment outcomes. Trial Registration: clinicaltrials.gov; Identifi er: NCT00939601. CHEST 2010; 138(4):875–879 Abbreviations: ANOVA 5 analysis of variance; CPAP 5 continuous positive airway pressure; HVLT-R 5 Hopkins Verbal Learning Test-Revised; LCD 5 local coverage determination; OSA 5 obstructive sleep apnea; PAP 5 positive airway pressure; PASAT 5 Paced Auditory Serial Addition Test

Parasomnias are common clinical complaints. Formal sleep evaluation including PSG is indicated for parasomnias that are violent and potentially injurious; disruptive to the bed partner or other household members; accompanied by excessive daytime sleepiness; or associated with medical,psychiatric, or neurologic symptoms or findings [2]. Multiple sleep latency testing should be considered for patients who have complaints of excessive daytime sleepiness. An extensive history, including medical, neurologic,psychiatric, and sleep disorder, and a review of medication, alcohol, illicit drug use, and family history of parasomnias, may provide useful clues. Distinguishing between a parasomnia and a seizure may be difficult as both can present as recurrent, stereotypical behaviors. Evaluation may be aided by an expanded EEG montage during overnight PSG studies.

A variety of treatment options are available for the treatment of obstructive sleep apnea in addition to positive pressure therapy and surgery. These modes of treatment might be employed in patients who cannot tolerate positive pressure therapy despite aggressive measures to improve compliance. These options include weight reduction, sleep hygiene, positional therapy, and oxygen therapy. Some of the options are still experimental and include pharyngeal muscle and hypoglossal nerve stimulators. A variety of pharmacological agents have also been used. The mechanisms by which these drugs improve sleep-disordered breathing include increasing ventilatory drive and upper airway muscle tone, reducing the amount of rapid eye movement (REM) sleep, and enhancing daytime wakefulness.

Medications can appreciably affect the states of sleep and wakefulness by producing daytime somnolence or insomnia. In addition, their use can give rise to nightmares and abnormal behaviors during sleep. These effects canbe a primary therapeutic effect of the drug or be an adverse reaction. Knowledge of the common sleep effects of drugs is important in selecting therapy and averting adverse events. This article concentrates on three main effects of drugs: (1) hypersomnolence, (2) insomnia, and (3) abnormal behaviors in sleep or parasomnias.

The sleep-related breathing disorders have been categorized in various ways. The most basic schema divides them into obstructive or central apneic events. An American Academy of Sleep Medicine (AASM) Task Force Report published in 1999 defined four separate syndromes associated with abnormal respiratory events during sleep among adults, namely, obstructive sleep apnea-hypopnea syndrome (OSAHS), central sleep apnea-hypopnea syndrome, Cheyne-Stokes breathing syndrome, and sleep hypoventilation syndrome. In this classification, the upper airway resistance syndrome was not regarded as a distinct syndrome; instead, respiratory event-related arousals (RERAs) were considered part of the syndrome of OSAHS.

Pulmonary artery hypertension (PAH) is the primary cardiovascular complication encountered in chronic obstructive pulmonary disease (COPD). Cor pulmonale can range clinically from mild changes in right ventricular function to frank right heart failure. The prevalence of PAH increases as COPD worsens, and the development of PAH and cor pulmonale appears to affect survival of patients with COPD. Potential causes proposed to explain the development of PAH in COPD include gas exchange abnormalities, destruction of the pulmonary vascular bed, alterations in respiratory mechanics, changes in intrinsic pulmonary vessel tone, and increased blood viscosity. Standard clinical evaluation, including history, physical examination, spirometry, electrocardiography, and chest radiography, is generally inadequate in identifying right ventricular dysfunction. Noninvasive techniques, such as echocardiography, radionuclide ventriculography, and magnetic resonance imaging, have largely replaced invasive pulmonary artery catheterization in the initial assessment of cor pulmonale. The goals of therapy consist of attenuation of PAH, enhancement of right ventricular function, alleviation of clinical symptoms, and improvement in survival. The agents that have been most extensively evaluated for these purposes include oxygen, vasodilators, theophylline, and inotropic medications.

PREVIEWPulmonary injury due to smoke inhalation is a significant cause of death in fire victims. Singed nasal hair and carbonaceous sputum are easily recognized warning signs, but other subtle clues should prompt thorough evaluation and aggressive treatment. Dr Lee-Chiong describes the basic mechanisms of injury and discusses how to assess and manage complications caused by smoke inhalation.

Ankylosing spondylitis is a chronic inflammatory disease that affects chiefly the joints of the axial skeleton. It is a multisystem disease. Several extra-auricular manifestations of ankylosing spondylitis have been described including ocular, cardiovascular, renal, and neurologic complications. Pulmonary involvement consists principally of upper lobe fibrocystic changes and chest wall restriction. Relapsing polychondritis, on the other hand, is a rare disorder characterized by progressive inflammation and degeneration of the cartilaginous structures and other connective tissues throughout the body. Involvement of the respiratory tract is identified in more than one-half of patients with relapsing polychondritis.

Normally, the pleural spaces contain sterile lubricating fluid that enables smooth expansion and contraction of the lungs. But when microorganisms gain entry, directly or through contiguous spread of infection, the fluid becomes increasingly dense and viscous as purulence progresses. This article outlines clinical, radiographic, and pleural fluid features that can aid in distinguishing between pleural collections that usually respond to medical therapy and those that probably require surgical intervention.

The spectrum of heat-related illnesses ranges from simple syncope to life-threatening heatstroke. Persons of all ages can be affected. Heat edema, heat cramps, heat syncope, and heat exhaustion respond readily to simple management techniques. Treatment of heatstroke must include aggressive cooling, adequate fluid and electrolyte repletion, maintenance of adequate cardiovascular performance, and prompt correction of any related or resulting complications.

One half of all cases of lung cancer occur in patients aged 65 years and older. Although adenocarcinoma is the predominant histologic subtype in the general population, squamous cell carcinoma has remained the most common type in the elderly. Although lung cancer tends to present at a less advanced stage with increasing age, the percentage of elderly patients undergoing treatment tends to decline despite the fact that they can tolerate the aggressive therapy that may enhance survival.

Monitoring of respiration during sleep allows the assessment of physiologic variables that are required to characterize SRBD events. The patency of the upper airway, the pattern of breathing, oxygenation, and ventilation usually can be inferred from simultaneous measurements of airflow, respiratory effort, thoracic volume, and blood gases. As new techniques of respiratory monitoring emerge, the respiratory therapist and sleep technologist must be familiar with the advantages and shortcomings of each modality.

The lung is a common target of drug toxicity. A variety of medications, including cancer chemotherapeutic drugs, anti-inflammatory medications, antimicrobial agents, cardiac drugs and anticonvulsants have been recognized as causative agents in the genesis of lung injury. As newer pharmacological agents are continuously being introduced into the therapeutic armamentarium, this list is expected to grow.

Diffuse pulmonary hemorrhage (DPH) is a syndrome defined by the clinical triad of hemoptysis, iron-deficiency anemia and transient diffuse acinar infiltrates on chest radiography [1–3]. Widespread damage of the alveolar-capillary lining leads to extensive hemorrhage from the pulmonary vasculature. DPH is caused by a heterogeneous group of disorders including Goodpasture’s syndrome, idiopathic pulmonary hemosiderosis, rapidly progressive glomerulonephritis, chemical-and drug-induced lung injury, coagulopathies, mitral stenosis and necrotizing pulmonary infections. This syndrome must be distinguished from localized alveolar hemorrhage with secondary spread of blood as seen with thromboembolism, chronic bronchitis, bronchiectasis, pneumonia and tumor [2].