News Article | May 8, 2017
In an analysis of medical records gathered from more than 300 hospitalized patients, a team of researchers reports that routine imaging scans used to help diagnose heart attacks generated "incidental findings" (IFs) in more than half of these patients. The investigators say only about 7 percent of these IFs were medically significant and urged imaging experts and hospitals to explore ways to safely reduce the added costly -- and potentially risky -- days in the hospital the IFs generate. "Incidental findings present clinical and financial challenges," says Venkat Gundareddy, M.D., M.P.H., a director of the Collaborative Inpatient Medicine Service at Johns Hopkins Bayview Medical Center in Baltimore. "In our new study, we saw an association between the presence of incidental findings and longer length of stay in the hospital, in some cases because of further tests to explore those findings." "Because this was an observational study, we can't conclusively attribute the added hospital days to one case, but we believe we have added to evidence that IFs are a factor," he adds. It's long been the case, Gundareddy notes, that people experiencing chest pain are usually admitted to a hospital and undergo CT or other forms of imaging. In their review, they discovered that findings unrelated to chest pain kept patients in the hospital an average of 26 percent longer than people without IFs. Results of the retrospective study appear in the May issue of the Journal of Hospital Medicine. The higher sensitivity and accuracy of X-rays, MRIs, ultrasound examinations, and especially CT scans, has led to more incidental findings such as kidney cysts, renal stones, thyroid nodules, enlarged lymph nodes, bone lesions, lung nodules and masses. Unexpected incidental findings are very common in patients hospitalized with chest paint thought to be cardiac related, the investigators say. Chest CT scans done to image the heart can end up showing lung or thyroid nodules or enlarged lymph nodes. Chest X-rays often show more than heart size, when bone lesions and arthritic changes are noted. The new study analyzed the medical records of 376 patients admitted to Johns Hopkins Bayview Medical Center, an urban academic medical center, over a two-year timeframe. Some 197 of them had unexpected incidental findings in diagnostic images, findings that were not related to their chest pain complaints. Fifty percent of the unexpected findings were deemed medically minor, 42 percent moderate and seven percent of major clinical significance. The unexpected findings are associated with a 26 percent increase in length of hospital stay. When unexpected findings such as nodules or bone lesions are discovered after diagnostic imaging, further tests are generally ordered. If the finding was of major clinical significance, often that workup takes place during the same hospitalization, increasing the length of stay, adding to provider workload, and increasing expenses for testing, imaging, surveillance, consults and labor. Clearly, the researchers say, such additional time and costs are needed for some patients, but nationwide efforts to reduce unnecessary costs could benefit from closer study of and attention to the best setting for dealing with incidental findings. "Choosing wisely what tests are needed for each patient, based on presenting complaints and pertinent history, would prevent unnecessary use of imaging and detection of incidental findings," notes Gundareddy. "Establishing a robust outpatient care pathway to further workup incidental findings, as needed, would also decrease inpatient length of stay," he adds. Gundareddy says radiologists' groups and associations already have some guidance related to follow up for certain incidental findings, such as the American College of Radiology's guidance on managing incidental findings from abdominal CT scans. However, no clear follow up guidelines exist for most incidental findings appearing in hospitalized patients. "It's important for patients and providers to understand that as imaging gets more sensitive, it will pick up more things that are unrelated to the main problem for which imaging is done," Gundareddy says. "These findings might or might not be clinically significant, and although they may need attention, they don't necessarily need inpatient hospital attention." Other authors on this paper include Nisa M. Maruthur, M.D., M.H.S. (co-first author), Abednego Chibungu, M.D., Regina Landis, M.S., and Shaker M. Eid, M.D., M.B.A., of The Johns Hopkins University; and Preetam Bollampally, M.D., of Saint Vincent Hospital.
Bailey B.A.,East Tennessee State University |
Kuriacose R.,East Tennessee State University |
Copeland R.J.,East Tennessee State University |
Manning T.,Medicine Service |
Peiris A.N.,East Tennessee State University
Journal of the American Medical Directors Association | Year: 2011
Objectives: Peripheral arterial disease (PAD) is a common and often overlooked entity responsible for considerable morbidity and mortality. Recent evidence suggests that nontraditional risk factors such as vitamin D may contribute to atherosclerosis. We hypothesized that vitamin D status was associated with cardiovascular risk factors and that vitamin D deficiency (25(OH)D <20 ng/mL) enhanced the risk of amputation. Design: We reviewed medical records of 1435 veterans between 2000 and 2008 in Tennessee via retrospective chart analysis using correlations, logistic regressions, t tests, and χ2 analyses. Results: Vitamin D status was significantly and inversely correlated with body mass index (BMI), glucose, and triglyceride values. Hypertension and diabetes but not smoking also emerged as significantly associated. Of the sample population, 5.2% (n = 75) had an amputation performed. Those individuals who were vitamin D deficient had a significantly higher amputation rate (6.7%) compared with patients who were nondeficient (4.2%). BMI, triglyceride, total cholesterol, hypertension, and diabetes were found to account for 5.7% of the variation in amputation status. Vitamin D concentration and deficiency status accounted for a nonsignificant amount of additional variance. Conclusions: We conclude that vitamin D deficiency is closely linked to increased adiposity, triglyceride, and glucose measurements. Vitamin D deficiency was associated with an increased amputation risk in veterans with PAD and appears to mediate its effects through traditional risk factors. © 2011.
Chumbler N.R.,Indiana University – Purdue University Indianapolis |
Chumbler N.R.,Regenstrief Institute |
Chumbler N.R.,VA HSR and D Stroke Quality Enhancement Research Initiative Program |
Williams L.S.,Indiana University |
And 16 more authors.
Neuroepidemiology | Year: 2010
Aims: We derived and validated a clinical prediction rule that can be used to predict post-stroke pneumonia. Methods: We conducted a retrospective cohort study of patients admitted to hospital with a stroke. The cohort was subdivided into a derivation group and a validation group. Within the derivation group, a point scoring system was developed to predict pneumonia based on a logistic regression model. The point scoring system was then tested within the validation group. Results: Of the 1,363 patients with stroke, 10.5% of patients experienced new pneumonia. The most points were assigned for abnormal swallowing result and history of pneumonia (4 points), followed by greater NIHSS score (3 points), patient being 'found down' at symptom onset (3 points), and age >70 years (2 points). A 3-level classification system was created denoting low, medium and high risks of pneumonia, which accurately predicted pneumonia in the validation group. The discriminatory accuracy of the 3-level clinical prediction rule exceeded the acceptable range in both the derivation group (c statistic: 0.78) and validation group (c statistic: 0.76). Conclusion: A simple scoring system was derived and validated. This clinical scoring system may better identify stroke patients who are at high risk of developing new pneumonia. Copyright © 2010 S. Karger AG, Basel.
News Article | February 15, 2017
Allegheny Health Network (AHN) has opened western Pennsylvania’s first after-hours clinic for cancer patients, designed specifically to address their unique needs outside the emergency room setting. With the opening of Allegheny Health Network Cancer Institute Extended Hours Oncology Clinic, AHN is at the forefront of an emerging national trend of expanded, after-hours care for cancer patients, many of whom will visit an emergency room at some point during their treatment or recovery. These patients need timely care in the appropriate clinical setting in order to maintain their wellness and quality of life, and optimize their symptom management. Embedded in the West Penn Hospital’s Mellon Pavilion Medical Oncology Clinic in Pittsburgh’s Bloomfield neighborhood, the clinic will initially be open Monday through Friday from 3 p.m. to 11 p.m. and staffed by a certified registered nurse practitioner, a registered nurse and a medical assistant, all trained in oncology-specific protocols and working under the direction of an oncologist. “The side effects of treatment can pose considerable difficulty for cancer patients. In 2014, western Pennsylvania emergency rooms logged nearly 3,000 visits from cancer patients,” said David Parda, MD, Chair, Allegheny Health Network Cancer Institute. “With the opening of the Extended Hours Oncology Clinic, AHN is filling a gap in the continuum of care for one of our most vulnerable populations.” Side effects can significantly decrease quality of life for cancer patients. These symptoms – many of which worsen in the evening hours - may include pain, fever, fatigue, upper respiratory infections, coughing, painful mouth sores that make it difficult to eat, nausea, vomiting, diarrhea, constipation, dehydration and rashes. While a trip to the emergency room will continue to be the best option for cancer patients with life-threatening symptoms such as chest pain or shortness of breath, the ER can be risky for cancer patients, who may have compromised immune systems. Having a designated treatment space for cancer patients is also expected to decrease wait times for treatment. Care for patients doesn’t end with a visit to the extended hours clinic. Clinic caregivers will connect patients with services that will ensure a smooth transition of care from clinic to home and community, services such as AHN’s Healthcare@Home and Supportive Medicine Service. AHN’s philosophy is that all cancer patients should have access to supportive care, regardless of their disease stage. A 48-hour post-discharge follow-up call from a nurse navigator to all patients will ensure that needed services have begun and help facilitate any additional patient needs. “The extended hours clinic for oncology patients is expected to optimize clinical outcomes, reduce hospital admissions and readmissions, expand access to at-home, supportive and palliative care, and enhance the patient experience while reducing the cost of care,” Dr. Parda said. “It is a positive step forward for healthcare in western Pennsylvania, and most importantly, for our patients.” Alex Brennsteiner, Clinical Program Manager, Highmark Home and Community Services; Crystal Costanza Ross, Director of Program Development, Allegheny Health Network Cancer Institute, and Marjie Leslie, Director of Clinical Services for Allegheny Clinic Medical Oncology played leading roles in the planning and development of the oncology after-hours clinic. The Allegheny Health Network Cancer Institute Extended Hours Oncology Clinic can be accessed via the Mellon Pavilion entrance at 4815 Liberty Ave. or the parking garage at the corner of Liberty Avenue and South Millvale Street. A staff member will escort patients to the clinic. The clinic is open only to patients being treated for cancer at Allegheny Health Network. Appointments are required and can be made only through designated oncologists. Those wanting more information about the Extended Hours Clinic may contact Joann Straessley at 412-359-3559. About Allegheny Health Network Allegheny Health Network is a western Pennsylvania-based integrated healthcare system that serves patients from across a five state region that includes Pennsylvania, Ohio, West Virginia, Maryland and New York. The Network’s Cancer Institute offers a complete spectrum of oncology care, including access to state-of-the-art technologies and new therapies being explored in clinical cancer trials. The Network’s radiation oncology program is the largest in the country and is accredited by the American College of Radiology. AHN also has a formal affiliation with the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, one of the nation’s 41 comprehensive cancer centers designated by the National Cancer Institute, for research, medical education and clinical services.
Mortensen E.M.,VERDICT Research Program |
Mortensen E.M.,Veterans Health Care System |
Garcia S.,Medicine Service |
Garcia S.,University of Texas Health Science Center at San Antonio |
And 5 more authors.
American Journal of the Medical Sciences | Year: 2010
Background: Previous research has shown that hypoglycemia is associated with worse outcomes for the elderly, in sepsis, and in children with pneumonia. The purpose of this study was to examine whether hypoglycemia (<70 mg/dL) is associated with increased 30-day mortality, after adjusting for potential confounders, for adults hospitalized with pneumonia. Methods: A retrospective cohort study conducted at 2 tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, and had a chest x-ray consistent with, community-acquired pneumonia. Our primary analysis was a multivariable logistic regression with the dependent variable of 30-day mortality and with independent variable of hypoglycemia, diabetes, severity of illness determined using the pneumonia severity index, and pneumonia-related processes of care. Results: Data were abstracted on 787 subjects at the 2 hospitals. Mortality was 8.1% at 30 days. At presentation, 55% of subjects were at low risk, 33% were at moderate risk, and 12% were at high risk. In our cohort, 2.8% (n = 22) had hypoglycemia at presentation. Unadjusted mortality for those who were hypoglycemic was 27.3% versus 8.6% for those who were not (P = 0.0003). In the multivariable analysis, hypoglycemia (odds ratio: 4.1, 95% confidence interval: 1.4-11.7) was significantly associated with 30-day mortality. Conclusions: After adjusting for severity of illness and other potential confounders, hypoglycemia is significantly associated with 30-day mortality for patients hospitalized with pneumonia. Patients with hypoglycemia should be placed in closely monitored settings even when by pneumonia specific risk systems they would normally be discharged. © Copyright 2010 Southern Society for Clinical Investigation.
Zeliadt S.B.,VA Health Services Research and Development Service |
Zeliadt S.B.,University of Washington |
Zeliadt S.B.,Fred Hutchinson Cancer Research Center |
Hoffman R.M.,Medicine Service |
And 5 more authors.
Journal of General Internal Medicine | Year: 2010
BACKGROUND: The occurrence and timing of prostate biopsy following an elevated prostate-specific antigen (PSA) test varied considerably in randomized screening trials. OBJECTIVE: Examine practice patterns in routine clinical care in response to an elevated PSA test (=4 ng/μl) and determine whether time to biopsy was associated with cancer stage at diagnosis. DESIGN: Retrospective cohort study. PARTICIPANTS: All veterans (n=13,591) in the Pacific Northwest VA Network with a PSA=4 ng/μl between 1998 and 2006 and no previous elevated PSA tests or prostate biopsy. MAIN MEASURES: We assessed follow-up care including additional PSA testing, urology consults, and biopsies. We compared stage at diagnosis for men who were biopsied within 24 months vs. those men biopsied and diagnosed >24 months after the elevated PSA test. KEY RESULTS: Two-thirds of patients received follow- up evaluation within 24 months of the elevated PSA test: 32.8% of men underwent a biopsy, 15.5% attended a urology visit but were not biopsied, and 18.8% had a subsequent normal PSA test. Younger age, higher PSA levels, more prior PSA tests, no copayment requirements, existing urologic conditions, low body mass index, and low comorbidity scores were associated with more complete follow-up. Among men who underwent radical prostatectomy, a delayed diagnosis was not significantly associated with having a pathologically advanced-stage cancer (T3/T4), although we found an increased likelihood of presenting with stage T2C relative to stage T2A or T2B cancer. CONCLUSIONS: Follow-up after an elevated PSA test is highly variable with more than a third of men receiving care that could be considered incomplete. A delayed diagnosis was not associated with poorer prognosis. © Society of General Internal Medicine 2010.
Elgendy I.Y.,Florida South Georgia Veterans Health System Malcom Randall Veterans Administration Medical Center |
Huo T.,Harvard University |
Bhatt D.L.,Medicine Service |
Bavry A.A.,Florida South Georgia Veterans Health System Malcom Randall Veterans Administration Medical Center
Circulation: Cardiovascular Interventions | Year: 2015
Background-It is unclear whether intravenous glycoprotein IIb/IIIa inhibitors or ischemic time might modify any clinical benefits observed with aspiration thrombectomy before primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction. Methods and Results-Electronic databases were searched for trials that randomized ST-segment-elevation myocardial infarction patients to aspiration thrombectomy before PCI versus conventional PCI. Summary estimates were constructed using a DerSimonian-Laird model. Seventeen trials with 20 960 patients were available for analysis. When compared with conventional PCI, aspiration thrombectomy was not associated with a significant reduction in the risk of mortality 2.8% versus 3.2% (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.76-1.04; P=0.13), reinfarction 1.3% versus 1.4% (RR, 0.93; 95% CI, 0.73-1.17; P=0.52), the combined outcome of mortality or reinfarction 4.1% versus 4.6% (RR, 0.90; 95% CI, 0.79-1.02; P=0.11), or stent thrombosis 0.9% versus 1.2% (RR, 0.82; 95% CI, 0.62-1.08; P=0.15). Aspiration thrombectomy was associated with a nonsignificant increase in the risk of stroke 0.6% versus 0.4% (RR, 1.45; 95% CI, 0.96-2.21; P=0.08). Meta-regression analysis did not identify a difference for the log RR of mortality, reinfarction, and the combined outcome of mortality or reinfarction with intravenous glycoprotein IIb/IIIa inhibitors (P=0.17, 0.70, and 0.50, respectively) or with ischemic time (P=0.29, 0.66, and 0.58, respectively). Conclusions-Aspiration thrombectomy before primary PCI is not associated with any benefit on clinical end points and might increase the risk of stroke. Concomitant administration of intravenous glycoprotein IIb/IIIa inhibitors and ischemic time did not seem to influence any potential benefits observed with aspiration thrombectomy. © 2015 American Heart Association, Inc.