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News Article | December 7, 2016
Site: www.businesswire.com

NEW YORK--(BUSINESS WIRE)--Fitch Ratings has affirmed the 'A+' rating on the following bonds issued by the Berks County Municipal Authority on behalf of the Reading Hospital and Medical Center Project (RHMC): RHMC also has outstanding approximately $44.7 million in 2012 series C and approximately $175.1 million in 2016 series A-D variable rate revenue bonds, which are privately placed with commercial banks and not rated by Fitch. Bondholders have a lien on and a security interest in the gross revenues of the obligated group, which includes Reading Health System (RHS; parent) and Reading Hospital. IMPROVED PERFORMANCE IN FISCAL YEAR (FY) 2016: Growth in RHS' volumes and rates, as well as ongoing implementation of its Performance Improvement Plan (PIP) in FY 2016 has reversed a three-year trend of very weak profitability. For fiscal 2016, RHS exceeded its targeted PIP improvements by more than $5 million and achieved a 1.2% operating margin, compared to -5.3% in fiscal 2015 and -3.4% in fiscal 2014. RHS is targeting a 1.1% operating margin for fiscal 2017. STABLE CORE OPERATIONS: RHS' underlying operations remain sound despite the financial volatility of the past few years, which had been driven by persistent revenue cycle issues from its IT conversion launched in February 2013. Core operations are supported by a solid employed physician base, steady growth in utilization across clinical lines and a primary service area (PSA) market share that has been steady at around 62% for several years. JOINT VENTURE WITH UPMC HEALTH PLAN: RHS has entered into a joint venture with the UPMC Health Plan to form a provider-payor insurance plan, effective in 2017. Fitch generally views this alliance with a strategic regional partner, as well as the added benefits of revenue diversification, brand connectivity and further build-out of its integrated delivery model, as credit positive for RHS. SOLID LIQUIDITY: RHS' liquidity position remains robust for the rating despite some recent declines from weak cash flows and heightened capital spending. Liquidity is expected to weaken further in 2017 as a period of heavy capital spending comes to a close. Fitch believes there is sufficient room to absorb planned capital demands at the 'A+' rating. LARGE CAPITAL PROJECT NEARING COMPLETION: Capital projects are proceeding as planned, with $125 million of expenditures budgeted for fiscal 2017 primarily to complete construction of a new surgical tower, which is expected to be fully operational by January 2017. RHS expects to fund the entire project using internal equity. CONTINUED RECOVERY: Fitch expects Reading Health System (RHS) to sustain its operational improvement and meet its budgeted profitability of 1.1% operating margin in fiscal 2017. PROJECT EXECUTION: Fitch expects RHS to meet its current budget and timeline for its new surgical tower. Material cost overruns or operational delays could lead to negative rating pressure; however, this is unlikely, as construction is very nearly complete and the tower is expected to be fully operational by January 2017. Reading Health System comprises the parent organization and various subsidiaries including Reading Hospital (713 operated-bed acute care hospital located in Reading, PA, Reading Health Partners, The Highlands at Wyomissing (a continuing care retirement community), Reading Health Physician Network (a physician group with 357 employed physicians), and RHS Foundation. Total operating revenue was $978.5 million in the fiscal year ended June 30, 2016. The obligated group comprised 89% of the consolidated entity's total revenue in 2016. Fitch's analysis is based on the consolidated entity, RHS. Volume and rate growth, as well as RHS' ongoing implementation of its PIP in FY 2016 has reversed a three-year trend of very weak profitability (after write-downs), which had been driven by persistent revenue cycle issues from the Epic conversion launched in February 2013. In FY 2016, RHS achieved PIP improvements of $47.4 million, exceeding targeted improvements of $42.3 million by more than $5 million. Operating margin has improved to 1.2% in FY 2016 from -5.3% in FY 2015 and -3.4% in FY 2014. Affirmation of the 'A+' rating reflects Fitch's expectation that RHS will sustain its operational improvements and meet or exceed its FY 2017 budget. For fiscal 2017, RHS is targeting an additional $32.3 million in PIP improvements and is budgeting a 1.1% operating margin. Through the first quarter of 2017 (quarter ended Sept. 30), RHS is on budget. Over the longer term, upward rating movement would be contingent on achieving sustained operating EBITDA margins consistent with the higher rating category and further strengthening of balance sheet liquidity from higher cash flow and moderating capital spending. RHS' operating platform includes an extensive delivery network that has remained solid through the recent period of financial volatility. RHS experienced modest growth in its utilization trends for 2016 and inpatient market share has been stable at around 62% in the PSA and 8% in the secondary service area for several years. A large part of RHS' market strength is supported by Reading Health Physician Network, an extensive employed physician network that has grown to 357 physicians from 329 in 2015. Further, RHS created Reading Health Partners, a joint venture with the medical staff aimed to create a clinically integrated network among both employed and non-employed physicians at RHS. Management is in the process of updating its three-year strategic plan, which is expected to be implemented by March 2017. Generally, RHS' operational strategies continue to include pursuing partnerships to expand its market and diversify lines of business; growing clinical service lines to mitigate outmigration; further collaboration with its network of physicians; capital investments; maintaining excellence in quality outcomes; and improving operating performance. In November 2016, RHS announced that it has finalized an agreement with UPMC Health Plan to form a provider-payor joint venture. The new health plan will commence operations in January 2017, beginning with providing Third Party Administrator (TPA) and FSA Spending Account (FSA) administrative services to employees of RHS and expanding throughout the year to include a full suite of health insurance plans, including Medicare Advantage and Children's Health Insurance Program (CHIP). Health plan operations are expected to have a neutral effect on RHS' overall profitability; however, RHS' operating profile and market footprint should benefit from this alliance with a strategic regional partner. Additionally, the JV structure of the health plan is expected to offer RHS the strategic benefits of provider-payor insurance plans, such as revenue diversification, brand connectivity and build-out of its integrated delivery network, while mitigating some of their operational and financial risks, such as scalability and the need to fund risk-based capital requirements. Fitch generally views this alliance with the UPMC Health Plan as a credit positive for RHS. In September 2013, RHS broke ground on a new surgical tower that will house 24 surgical suites with updated technological capabilities, expanded emergency rooms, and 150 private beds. Construction and operation of the new surgical tower continues as planned. The tower commenced surgical services in October 2016 and is expected to begin inpatient services in January 2017. The project is expected to cost approximately $343 million, with $246.2 million already spent. RHS has budgeted to spend the remaining $99.8 million in FY 2017. Combined with other routine and project spending, total capital expenditure is estimated at $125 million for FY 2017, which is approximately 163% of depreciation. All of the capital spending is expected to be funded from cash flow and equity. As a result, liquidity decline is inevitable in the near term. However, Fitch believes projected capital demands are manageable at the 'A+' rating and expects RHS' balance sheet to recover as profitability stabilizes. Fitch calculates unrestricted cash and investments totaling $885.1 million as of Sept. 30, 2016, compared to a level that had been above $1 billion as recently as 2014. The decline was partly attributable to weaker cash flows, but was more heavily affected by heightened capital spending that has averaged 171.8% of depreciation since fiscal 2014. Nevertheless, days cash on hand of 345.9, 25.6x cushion ratio and 151.4% cash-to-debt compare favorably against the respective 'A' category medians of 215.5 days, 19.4x and 148.6%. At FYE 2016, long-term debt totaled $580.9 million with 46% underlying fixed rate and 54% underlying variable rate. Underlying variable-rate bonds consist of $91.8 million in publicly traded FRNs and $220 million in privately placed indexed loans all with initial terms in 2022 and 2023. Debt service is relatively level at around $25 million to $27 million through 2022, then increases to over $34 million with maximum annual debt service (MADS) of $34.6 million. During FY 2016, RHS refinanced $174.2 million of its 2012 series D bonds, originally a direct placement with RBC, as 2016 series A-D with four other banks (Santander, J.P. Morgan, Northern Trust, and Barclays). The refinancing is expected to generate $0.9 million in annual interest expense savings and mitigated the risk of a 30-day redemption event by lowering the event ratings trigger to below either 'BBB' or 'BBB-' from below 'A' previously. Although the total amount of debt has declined consistently, debt ratios are weak for the rating category due to the financial deterioration experienced in recent years. MADS equated to 3.5% of 2016 revenues, debt-to-EBITDA was 4.2x and debt-to-capitalization was 44.8%, compared to the respective 'A' category medians of 2.7%, 2.9x and 36.0%. MADS coverage improved from 3.0x in FY 2015 to 4.0x in FY 2016, which is more in line with RHS' historic average of 4.0x to 5.0x, but remains unfavorable to Fitch's 'A' category median of 4.5x. RHS has several swaps outstanding, but collateral posting requirements are only triggered if the rating is downgraded below 'A-'. 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Apfel C.C.,University of California at San Francisco | Heidrich F.M.,TU Dresden | Jukar-Rao S.,University of California at San Francisco | Jalota L.,Reading Hospital | And 4 more authors.
British Journal of Anaesthesia | Year: 2012

Background: In assessing a patient's risk for postoperative nausea and vomiting (PONV), it is important to know which risk factors are independent predictors, and which factors are not relevant for predicting PONV. Methods: We conducted a systematic review of prospective studies (n>500 patients) that applied multivariate logistic regression analyses to identify independent predictors of PONV. Odds ratios (ORs) of individual studies were pooled to calculate a more accurate overall point estimate for each predictor. Results: We identified 22 studies (n=95 154). Female gender was the strongest patient-specific predictor (OR 2.57, 95% confidence interval 2.32-2.84), followed by the history of PONV/motion sickness (2.09, 1.90-2.29), non-smoking status (1.82, 1.68-1.98), history of motion sickness (1.77, 1.55-2.04), and age (0.88 per decade, 0.84-0.92). The use of volatile anaesthetics was the strongest anaesthesia-related predictor (1.82, 1.56-2.13), followed by the duration of anaesthesia (1.46 h-1, 1.30-1.63), postoperative opioid use (1.39, 1.20-1.60), and nitrous oxide (1.45, 1.06-1.98). Evidence for the effect of type of surgery is conflicting as reference groups differed widely and funnel plots suggested significant publication bias. Evidence for other potential risk factors was insufficient (e.g. preoperative fasting) or negative (e.g. menstrual cycle). Conclusions: The most reliable independent predictors of PONV were female gender, history of PONV or motion sickness, non-smoker, younger age, duration of anaesthesia with volatile anaesthetics, and postoperative opioids. There is no or insufficient evidence for a number of commonly held factors, such as preoperative fasting, menstrual cycle, and surgery type, and using these factors may be counterproductive in assessing a patient's risk for PONV. © 2012 The Author [2012].


Davis T.,University of Pennsylvania | Jones P.,Reading Hospital
Dimensions of Critical Care Nursing | Year: 2012

Increased anxiety levels are a common problem for mechanically ventilated patients. Heightened anxiety and lack of effective treatment options result in negative patient outcomes. Music therapy has been documented as an effective nursing intervention to manage anxiety in ventilator-dependent patients. Seven studies examining the effectiveness of music therapy in ventilator-dependent patients are reviewed in this literature review. Copyright © 2012 Lippincott Williams & Wilkins.


Slotkin E.M.,Reading Hospital | Patel P.D.,Cleveland Clinic | Suarez J.C.,Cleveland Clinic
Journal of Arthroplasty | Year: 2015

Acetabular component malposition contributes to increased complications and early revision. Supine positioning during direct anterior approach (DAA) THA facilitates the use of fluoroscopy to improve component positioning. This study evaluated the accuracy of acetabular component orientation using intraoperative fluoroscopy in DAA THA. A total of 780 surgeries by two surgeons were retrospectively reviewed over a 3-year period. Ranges for abduction (30°-50°) and version (5°-250) were employed. Overall, 92% fell within the targeted abduction range, 93% fell within the targeted anteversion range, and 88% met both criteria. The accuracy of component positioning for combined abduction and anteversion improved yearly (79.2%, 2011; 90.9%, 2012; and 95.6%, 2013). Fluoroscopy in DAA THA is a useful tool to improve acetabular component orientation, though a learning curve exists with its interpretation. © 2015 Elsevier Inc..


Cheatle M.D.,University of Pennsylvania | Cheatle M.D.,Reading Hospital | Savage S.R.,Dartmouth College | Savage S.R.,Dartmouth Center on Addiction Recovery and Education | Savage S.R.,Manchester Veterans Administration Medical Center
Journal of Pain and Symptom Management | Year: 2012

Most patients receiving opioids for the spectrum of pain disorders tolerate opioids well without major complications. However, a subset of this population encounters significant difficulties with opioid therapy (OT). These problems include protracted adverse effects, as well as misuse, abuse, and addiction, which can result in significant morbidity and mortality and make informed consent an important consideration. Opioid treatment agreements (OTAs), which may include documentation of informed consent, have been used to promote the safe use of opioids for pain. There is a debate regarding the effectiveness of OTAs in reducing the risk of opioid misuse; however, most practitioners recognize that OTAs provide an opportunity to discuss the potential risks and benefits of OT and establish mutually agreed-on treatment goals, a clear plan of treatment, and circumstances for continuation and discontinuation of opioids. Informed consent is an important component of an OTA but not often the focus of consideration in discussions of OTAs. This article examines the principles, process, and content of informed consent for OT of pain in the context of OTAs. © 2012 U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved.


Le B.H.,Reading Hospital | Sandusky M.,Brown University
Brain Pathology | Year: 2010

Glioblastoma, the most common primary brain tumor, is a highly infiltrative, malignant astrocytic neoplasm that demonstrates a wide spectrum of morphologic heterogeneity. Cases with a primitive neuroectodermal tumor (PNET)-like component are rare, but are being increasingly recognized and studied. The primitive component typically shows immunohistochemical features that are indicative of potential for divergent differentiation along glial and neuronal pathways; when present, the entire neuraxis may be at risk for involvement, portending a particularly poor prognosis. Recently, data from the largest case series studying malignant gliomas with a PNET-like component suggest that the primitive component likely arises from the malignant glial component. This report presents an example of glioblastoma with a prominent primitive neuroectodermal-like component in an 81 year-old male who, during the course of concurrent chemotherapy and radiation therapy, died five weeks following initial diagnosis. © 2009 International Society of Neuropathology.


Preskorn S.H.,University of Kansas | Kane C.P.,Pfizer | Kane C.P.,Reading Hospital | Lobello K.,Pfizer | And 5 more authors.
Journal of Clinical Psychiatry | Year: 2013

Objective: Determine the point prevalence of phenoconversion to cytochrome P450 2D6 (CYP2D6) poor metabolizer status in clinical practice. Method: This multicenter, open-label, single-visit naturalistic study was conducted from October 2008 to July 2009 in adult patients (≥ 18 years) who had been receiving venlafaxine extended-release (ER) (37.5-225 mg/d) treatment for up to 8 weeks. A 15-mL blood sample was drawn 4 to 12 hours after patients' last venlafaxine ER dose. Plasma O-desmethylvenlafaxine and venlafaxine concentrations were determined for each patient. CYP2D6 poor metabolizer phenotype was defined as O-desmethylvenlafaxine to venlafaxine ratio < 1 based on published data. CYP2D6 genotype was determined for each patient; patients were classified as poor metabolizer, intermediate metabolizer, extensive metabolizer, and ultrarapid metabolizer. Agreement between poor metabolizer phenotype and genotype classifications was assessed using the McNemar test. Results: Phenoconversion to CYP2D6 poor metabolizer status occurred in 209 of 865 individuals (24%) with a CYP2D6 non-poor metabolizer genotype. The incidence of CYP2D6 poor metabolizer status based on phenotype was almost 7 times higher than that expected based on genotype: only 4% (35/900) of patients were genotypic CYP2D6 poor metabolizers, but 27% (243/900) were phenotypic CYP2D6 poor metabolizers (McNemar test, P < .0001). Conclusions: CYP2D6 phenotype conversion is common in patients being treated for depression. These results are important because differences in CYP2D6 drug metabolic capacity, whether genetically determined or due to phenoconversion, can affect clinical outcomes in patients treated with drugs substantially metabolized by CYP2D6. These results demonstrate that personalized medicine based solely on genetics can be misleading and support the need to consider drug-induced variability as well. © 2013 Copyright Physicians Postgraduate Press, Inc.


Strauss S.,Reading Hospital | Bourbeau P.P.,BD Diagnostics
Journal of Clinical Microbiology | Year: 2015

This study compared results from plating urine specimens with the BD InoqulA instrument using a 10-μl inoculum with results from cultures plated manually with a 1-μl loop for comparable 2-month periods. The positivity rates, turnaround times for positive cultures, and BD Phoenix identification and antimicrobial susceptibility test results were comparable for both time periods. We experienced no problems with culture interpretation as the result of moving to the 10-μl inoculum. Copyright © 2015, American Society for Microbiology. All Rights Reserved.


With an upcoming publication in the Worldwide Leaders in Healthcare, Joy K. Darkes, RN, BSN, joins the prestigious ranks of the International Nurses Association. Joy is a Registered Nurse with 46 years of experience in her field and an extensive expertise in all facets of nursing, especially pediatric nursing and school nursing. Joy is currently working at King’s Academy in Mohrsville, Pennsylvania. Joy received her hospital-based Nursing Degree in 1970 from Reading Hospital. An advocate for continuing education, she graduated with her Bachelor of Science Degree in Nursing at Kutztown University of Pennsylvania in 1990. Joy is a National Certified School Nurse, as well as an inductee of Sigma Theta Tau International Honor Society of Nursing, and keeps up to date in her field through her professional membership with the National Association of School Nurses. Joy attributes her great success to always wanting to be a nurse, feeling that nursing was her calling in life. When she is not working, Joy dedicates her free time to swimming. Learn more about Joy K. Darkes here: http://inanurse.org/network/index.php?do=/4133323/info/ and be sure to read her upcoming publication in the Worldwide Leaders in Healthcare.


With an upcoming publication in the Worldwide Leaders in Healthcare, Joy K. Darkes, RN, BSN, joins the prestigious ranks of the International Nurses Association. Joy is a Registered Nurse with 46 years of experience in her field and an extensive expertise in all facets of nursing, especially pediatric nursing and school nursing. Joy is currently serving patients at King’s Academy in Mohrsville, Pennsylvania, and is also Elementary Principal at Ephrata Area School District. Joy received her hospital-based Nursing Degree in 1970 from Reading Hospital. An advocate for continuing education, she graduated with her Bachelor of Science Degree in Nursing at Kutztown University of Pennsylvania in 1990. Joy is a National Certified School Nurse, as well as an inductee of Sigma Theta Tau International Honor Society of Nursing, and keeps up to date in her field through her professional membership with the National Association of School Nurses. Joy attributes her great success to always wanting to be a nurse, feeling that nursing was her calling in life. When she is not working, Joy dedicates her free time to swimming. Learn more about Joy K. Darkes here and be sure to read her upcoming publication in the Worldwide Leaders in Healthcare.

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