The Effect of Model Fidelity on Learning Outcomes of a Simulation-Based Education Program for Central Venous Catheter Insertion.

Introduction: Simulation-based education for central venous catheter (CVC) insertion has been repeatedly documented to improve performance, but the impact of simulation model fidelity has not been described. The aim of this study was to examine the impact of the physical fidelity of the simulation model on learning outcomes for a simulation-based education program for CVC insertion.

Methods: Forty consecutive residents rotating through the medical intensive care unit of an academic medical center completed a simulation-based education program for CVC insertion.

Estimation of Drug Effectiveness by Modeling Three Time-dependent Covariates: An Application to Data on Cardioprotective Medications in the Chronic Dialysis Population.

In a population of chronic dialysis patients with an extensive burden of cardiovascular disease, estimation of the effectiveness of cardioprotective medication in literature is based on calculation of a hazard ratio comparing hazard of mortality for two groups (with or without drug exposure) measured at a single point in time or through the cumulative metric of proportion of days covered (PDC) on medication. Though both approaches can be modeled in a time-dependent manner using a Cox regression model, we propose a more complete time-dependent metric for evaluating cardioprotective medication efficacy. We consider that drug effectiveness is potentially the result of interactions between three time-dependent covariate measures, current drug usage status (ON versus OFF), proportion of cumulative exposure to drug at a given point in time, and the patient's switching behavior between taking and not taking the medication.

Relationship between stroke and mortality in dialysis patients.

Background And Objectives: Stroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood.

Design, Setting, Participants, & Measurements: A large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival.

Antihypertensive medication exposure and cardiovascular outcomes in hemodialysis patients.

Background/aims: Our understanding of the effectiveness of cardioprotective medications in maintenance dialysis patients is based upon drug exposures assessed at a single point in time. We employed a novel, time-dependent approach to modeling medication use over time to examine outcomes in a large national cohort.

Methods: We linked Medicaid prescription claims with United States Renal Data System registry data and Medicare claims for 52,922 hypertensive maintenance dialysis patients.

Derivation and validation of a formula to estimate risk for 30-day readmission in medical patients.

Objective: To create a simple readmission risk-prediction tool that can be generated easily at the bedside by physicians, nurses, care coordinators and discharge planners.

Design: Retrospective cohort study.

Setting: Tertiary academic medical center.

Race, ethnicity, and state-by-state geographic variation in hemorrhagic stroke in dialysis patients.

Background And Objectives: Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown.

Design, Setting, Participants, & Measurements: Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients.

Development of an ambulatory geriatrics knowledge examination for internal medicine residents.

Background: The number of older adults needing primary care exceeds the capacity of trained geriatricians to accommodate them. All physicians should have basic knowledge of optimal outpatient care of older adults to enhance the capacity of the system to serve this patient group. To date, there is no knowledge-assessment tool that focuses specifically on geriatric ambulatory care.

Applying the milestones in an internal medicine residency program curriculum: a foundation for outcomes-based learner assessment under the next accreditation system.

In 2010, University of Kansas Medical Center internal medicine residency program leaders concluded that their competency-based curriculum and evaluation system was not sufficient to promote accurate assessment of learners' performance and needed revision to meet the requirements of the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System (NAS). Evaluations of learners seldom referenced existing curricular goals and objectives and reflected an "everyone is exceptional, no one is satisfactory" view.The authors identified the American Board of Internal Medicine and ACGME's Developmental Milestones for Internal Medicine Residency Training as a published standard for resident development.

Medical ICU admissions during weekday rounds are not associated with mortality: a single-center analysis.

This study investigated whether intensive care unit (ICU) admissions to the research team's tertiary care academic hospital during morning rounds was associated with increased mortality. Discharge data were analyzed on 1912 patients admitted to the ICUs between July 2007 and June 2011. Measures included discharge disposition, time of admission to the ICU, source of admission, and expected mortality score.

Stroke and the "stroke belt" in dialysis: contribution of patient characteristics to ischemic stroke rate and its geographic variation.

Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. ESRD is a potent risk factor for stroke, but whether regional variations in stroke risk exist among dialysis patients is unknown. Medicare claims from 2000 to 2005 were used to ascertain ischemic stroke events in a large cohort of 265,685 incident dialysis patients.

Impact of admission blood glucose level on outcomes in community-acquired pneumonia in older adults.

Background: Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in older adults. Although diabetes mellitus is a risk factor for pneumonia, the clinical impact of blood glucose level at the time of admission is not clear. Our goal was to examine the association between admission hyperglycemia and subsequent mortality, length of stay, and readmission outcomes in older adults with CAP.

Fracture risk in nursing home residents initiating antipsychotic medications.

Objectives: To determine whether antipsychotic medication initiation is associated with subsequent fracture in nursing home residents, whether fracture rates differ between users of first- and second-generation antipsychotics, and whether fracture rates differ between users of haloperidol, risperidone, olanzapine, and quetiapine.

Design: Time-to-event analyses were conducted in a retrospective cohort using linked Medicaid; Medicare; Minimum Data Set; and Online Survey, Certification, and Reporting data sets.

Setting: Nursing homes in California, Florida, Missouri, New Jersey, and Pennsylvania.

Impact of a modified data capture period on Liu comorbidity index scores in Medicare enrollees initiating chronic dialysis.

Background: The Liu Comorbidity Index uses the United States Renal Data System (USRDS) to quantify comorbidity in chronic dialysis patients, capturing baseline comorbidities from days 91 through 270 after dialysis initiation. The 270 day survival requirement results in sample size reductions and potential survivor bias. An earlier and shorter time-frame for data capture could be beneficial, if sufficiently similar comorbidity information could be ascertained.

Impact of race on cumulative exposure to antihypertensive medications in dialysis.

Background: Racial minorities typically have less exposure than non-minorities to antihypertensive medications across an array of cardiovascular conditions in the general population. However, cumulative exposure has not been investigated in dialysis patients.

Methods: In a longitudinal analysis of 38,381 hypertensive dialysis patients, prescription drug data from Medicaid was linked to Medicare data contained in United States Renal Data System core data, creating a national cohort of dialysis patients dually eligible for Medicare and Medicaid services.

Atrial fibrillation and risk of stroke in dialysis patients.

Purpose: Both stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF.

Methods: A cohort of dually eligible (Medicare and Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate.

Documented consent process for implantable cardioverter-defibrillators and implications for end-of-life care in older adults.

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at risk for life-threatening heart arrhythmias, and their use is increasingly common. However, these devices also confer risk for delivery of unexpected painful shocks during the dying process, thus reducing the quality of palliative care at the end of life. This scenario can be avoided by ICD deactivation in appropriate circumstances but patients will remain unaware of this option if not informed about it.

Association of race with cumulative exposure to statins in dialysis.

Background: Patients on dialysis have high rates of cardiovascular disease and are frequently treated with HMG-CoA reductase inhibitors. Given that these patients have insurance coverage for medications as well as regular contact with health care providers, differences by race in exposure to statins over time should be minimal among patients who are candidates for the drug.

Methods: We created a cohort of incident dialysis patients who were dually eligible for Medicare and Medicaid services.

Geographic variation in HMG-CoA reductase inhibitor use in dialysis patients.

Background: Despite uncertainty about their effectiveness in chronic dialysis patients, statin use has increased in recent years. Little is known about the demographic, clinical, and geographic factors associated with statin exposure in end-stage renal disease (ESRD) patients.

Objective: To analyze the demographic, clinical, and geographic factors associated with use of statins among chronic dialysis patients.

The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients.

Atrial fibrillation is an important comorbidity with substantial therapeutic implications in dialysis patients but its prevalence varies in different studies. We used a database that includes patients in the United States on hemodialysis who were eligible for government assistance with prescription drugs. We then used ICD-9 codes from billing claims in this database to identify patients with chronic atrial fibrillation.

Transient impact of automated glomerular filtration rate reporting on drug dosing for hospitalized older adults with concealed renal insufficiency.

Background: Older adults with concealed renal insufficiency are at risk of medication dosing errors. It is not known whether automated estimated glomerular filtration rate (eGFR) reporting is associated with reduced dosing errors in this population.

Objective: The goal of the present study was to examine the impact on prescribing patterns in older adults with concealed renal insufficiency for a variety of renally cleared medications before and after the addition of automated eGFR reporting.

Geographic variation in cardioprotective antihypertensive medication usage in dialysis patients.

Background: Despite their high risk of adverse cardiac outcomes, persons on long-term dialysis therapy have had lower use of antihypertensive medications with cardioprotective properties, such as angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β-blockers, and calcium channel blockers, than might be expected. We constructed a novel database that permits detailed exploration into the demographic, clinical, and geographic factors associated with the use of these agents in hypertensive long-term dialysis patients.

Study Design: National cross-sectional retrospective analysis linking Medicaid prescription drug claims with US Renal Data System core data.

Quality of monitoring for metabolic effects associated with second generation antipsychotics in patients with schizophrenia on public insurance.

Second generation antipsychotics (SGA) are associated with new onset diabetes, dyslipidemia and significant weight gain. Patients with schizophrenia are also at an increase risk of developing metabolic disorders, making routine metabolic monitoring important in patients with schizophrenia. The objective of our study was to identify glucose and lipid monitoring rates in Kansas Medicaid beneficiaries with schizophrenia who received long-term SGA therapy both before and after metabolic concerns of SGA had been introduced in the medical literature and after publication of metabolic monitoring guidelines from professional organizations in 2004.

Pharmacy students' knowledge of black box warnings.

Objective: To evaluate the progression of pharmacy students' knowledge of black box warnings across 3 years of didactic training, and to determine how they stay current with new warnings.

Methods: A cross-sectional survey instrument was administered to pharmacy students in their first (P1), second (P2), and third (P3) professional years. The survey assessed student awareness of medications possessing a black box warning and familiarity with the warning content for 20 medications (15 with and 5 without warnings).

Considering health insurance: how do dialysis initiates with Medicaid coverage differ from persons without Medicaid coverage?

Background: Type of health insurance is an important mediator of medical outcomes in the United States. Medicaid, a jointly sponsored Federal/State programme, is designed to serve medically needy individuals. How these patients differ from non-Medicaid-enrolled incident dialysis patients and how these differences have changed over time have not been systematically examined.