Optical coherence tomography predictors of clinical outcomes after stent implantation: the ILUMIEN IV trial.

Background And Aims: Observational registries have suggested that optical coherence tomography (OCT) imaging-derived parameters may predict adverse events after drug-eluting stent (DES) implantation. The present analysis sought to determine the OCT predictors of clinical outcomes from the large-scale ILUMIEN IV trial.

Methods: ILUMIEN IV was a prospective, single-blind trial of 2487 patients with diabetes or high-risk lesions randomized to OCT-guided versus angiography-guided DES implantation.

OCT-Guided vs Angiography-Guided Coronary Stent Implantation in Complex Lesions: An ILUMIEN IV Substudy.

Background: ILUMIEN IV was the first large-scale, multicenter, randomized trial comparing optical coherence tomography (OCT)-guided vs angiography-guided stent implantation in patients with high-risk clinical characteristics and/or complex angiographic lesions.

Objectives: The authors aimed to specifically examine outcomes in the complex angiographic lesions subgroup.

Methods: From the original trial population (N = 2,487), high-risk patients without complex angiographic lesions were excluded (n = 514).

Ventricular assist device using a thoracotomy-based implant technique: Multi-Center Implantation of the HeartMate 3 in Subjects With Heart Failure Using Surgical Techniques Other Than Full Median Sternotomy (HM3 SWIFT).

Objectives: The HeartMate 3 (Abbott) left ventricular assist device provides substantial improvement in long-term morbidity and mortality in patients with advanced heart failure. The Implantation of the HeartMate 3 in Subjects With Heart Failure Using Surgical Techniques Other Than Full Median Sternotomy study compares thoracotomy-based implantation clinical outcomes with standard median sternotomy.

Methods: We conducted a prospective, multicenter, single-arm study in patients eligible for HeartMate 3 implantation with thoracotomy-based surgical technique (bilateral thoracotomy or partial upper sternotomy with left thoracotomy).

Optical Coherence Tomography-Guided versus Angiography-Guided PCI.

Background: Data regarding clinical outcomes after optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) as compared with angiography-guided PCI are limited.

Methods: In this prospective, randomized, single-blind trial, we randomly assigned patients with medication-treated diabetes or complex coronary-artery lesions to undergo OCT-guided PCI or angiography-guided PCI. A final blinded OCT procedure was performed in patients in the angiography group.

Learning optimal opioid prescribing and monitoring: a simulation study of medical residents.

Objective: Hospitalized patients often receive opioids. There is a lack of consensus regarding evidence-based guidelines or training programs for effective management of pain in the hospital. We investigated the viability of using an Internet-based opioid dosing simulator to teach residents appropriate use of opioids to treat and manage acute pain.

Characterizing the pain score trajectories of hospitalized adult medical and surgical patients: a retrospective cohort study.

Pain care for hospitalized patients is often suboptimal. Representing pain scores as a graphical trajectory may provide insights into the understanding and treatment of pain. We describe a 1-year, retrospective, observational study to characterize pain trajectories of hospitalized adults during the first 48 hours after admission at an urban academic medical center.

Association of the position of a hospital-acquired condition diagnosis code with changes in medicare severity diagnosis-related group assignment.

Context: Incentives to improve quality include paying less for adverse events, including the Centers for Medicare and Medicaid Services' policy to not pay additionally for events classified as hospital-acquired conditions (HACs). This policy is controversial, as variable coding practices at hospitals may lead to differences in the inclusion and position of HACs in the list of codes used for Medicare Severity Diagnosis-Related Group (MS-DRG) assignment.

Objective: Evaluate changes in MS-DRG assignment for patients with an HAC and test the association of the position of an HAC in the list of International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes with change in MS-DRG assignment.

Effects of explicit teacher-implemented phoneme awareness instruction in 4-year-olds.

The purpose of this study was to determine whether gains would be observed in an integrated group of 4-year-olds when phoneme awareness skills were explicitly taught by trained early childhood educators. In a quasi-experimental design with a delayed treatment approach, one classroom (N = 14) was randomly assigned to receive the instructional program in fall, while a second classroom (N = 10) served as a control and subsequently received the program in spring. Baseline assessment of speech and language skills indicated there were four participants with speech and/or language impairments.

An exploratory analysis of the correlation of pain scores, patient satisfaction with relief from pain, and a new measure of pain control on the total dose of opioids in pain care.

Objective: We explored the associations between opioid dose and multiple measures of pain.

Study Design And Measures: Thirty-two consecutive patients admitted solely for an acute exacerbation of cancer-related pain or for surgery were followed for their entire hospital stay (115 days of pain). For each hospital day, we collected pain scores, the number of pain scores, trends in pain scores, the percentage of time patients had 100% acceptable relief from pain, and the number of times patients were asked about acceptable pain relief.

Cost and quality implications of discrepancies between admitting and discharge diagnoses.

Background: Presenting and discharge diagnoses of hospitalized patients may differ as a result of patient complexity, diagnostic dilemmas, or errors in clinical judgment at the time of primary assessment. When diagnoses at admission and discharge are not in agreement, this discrepancy may indicate more complex processes of care and resultant costs. It is unclear whether surrogate measures reflecting quality of care are impacted by discrepant diagnoses.

Hospital care may not affect the risk of readmission.

Background: : Thirty-day readmissions have become a focal point for reducing health care spending, because they are viewed as a marker of the quality of hospital care. However, if increased time in the hospital is associated with better care, attempts to shorten length of stay (LOS) may result in increased rates of readmission. As such, we sought to explore the association of an incremental added day in LOS with the rate of readmission.

Change in MS-DRG assignment and hospital reimbursement as a result of Centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality?

Context: In October 2008, the Centers for Medicare & Medicaid Services reduced payments to hospitals for a group of hospital-acquired conditions (HACs) not documented as present on admission (POA). It is unknown what proportion of Medicare severity diagnosis related group (MS-DRG) assignments will change when the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code for the HAC is not taken into account even before considering the POA status.

Objectives: The primary objectives were to estimate the proportion of cases that change MS-DRG assignment when HACs are removed from the calculation, the subsequent changes in reimbursement to hospitals, and the attenuation in changes in MS-DRG assignment after factoring in those that may be POA.

Discrepancy between admission and discharge diagnoses as a predictor of hospital length of stay.

Context: The addition of clinical data or present on admission (POA) codes to administrative databases improves the accuracy of predicting clinical outcomes, such as inpatient mortality. Other POA information may also explain variation in hospital outcomes, such as length of stay (LOS), but this potential has not been previously explored.

Objectives: To assess whether a discrepancy between the diagnosis coded at the time of admission and the diagnoses coded at discharge independently explains variation in LOS for general internal medicine patients.

Effects of training on a simulator of pain care on the quality of pain care for patients with cancer-related pain.

Context: A computer simulator of pain care provided an environment for residents to learn to (1) rapidly induce pain relief; (2) measure pain scores at appropriate time intervals; (3) use induction doses to estimate, early in care, the long-acting pain medication requirements; and (4) escalate long-acting agents to ensure a smooth and nonvarying pain-control curve. We studied whether lessons learned on the simulator translated into improved pain control for patients with cancer-related pain crises.

Study Design And Measures: We compared pain scores for 48 hours in 2 groups: 20 patients admitted consecutively, solely because of an acute exacerbation of pain, prior to training our residents on a simulator and 20 patients post-training.

Computer-based simulation as a teaching tool for residents treating patients with cancer-related pain crises.

Context: Residents often fail to escalate narcotics to ensure pain relief in patients with cancer because of fear of overdose. A computer simulation of patients in pain may provide a way to improve management without fear of harm. We developed a pain care simulation to train residents.

Introduction to thoracic endografting: imaging, guidewires, guiding catheters, and delivery sheaths.

Purpose: With the recent approval of the first thoracic endoprosthesis in the United States for the treatment of isolated descending thoracic aortic aneurysms, there has been a dramatic increase in the number of physicians interested in getting involved in this emerging technology. However, many of these physicians do not have extensive endovascular experience, are not familiar with the catheters and guidewires used for thoracic endografting procedures, or do not have access to a full complement of endovascular resources.

Description: We discuss the basics of catheters, guidewires, and balloons necessary to perform thoracic endovascular procedures.

Differences in triage thresholds for patients presenting with possible acute coronary syndromes: more than meets the eye.

Background: Many studies have shown differences in cardiac care by racial/ethnic groups without accounting for institutional factors at the location of care.

Objective: Exploratory analysis of the effect of hospital funding status (public vs private) on emergency department (ED) triage decision making for patients with symptoms suggestive of acute coronary syndromes (ACSs) and on the likelihood of ED discharge for patients with confirmed ACS.

Study Design And Setting: Secondary analysis of data from a randomized controlled trial of 10,659 ED patients with possible ACS in five urban academic public and five private hospitals.

Organizational and cultural changes for providing safe patient care.

Objective: To describe an approach and experience with fostering a culture of patient safety.

Methods: (1) Organizational Change-The Department of Medicine established a patient safety committee (PSC) and charged it with reviewing adverse events. (2) Cultural Change-PSC sponsors and participants work to promote a culture of collaboration, study, learning, and prevention versus a culture of blame.