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Three patients (11%) required surgery 1 patient rebled following embolization and required operative management, and 2 underwent upfront operative management. The mortality rate attributable to hemorrhage from a VA-PSA in the setting of necrotizing pancreatitis was 14% (4 of 28 patients). Conclusion In this study, VA-PSA occurred in 4.3% of patients with necrotizing pancreatitis. Percutaneous angioembolization effectively treated most cases; however, mortality from VA-PSA was high (14%). A high degree of clinical suspicion remains critical for early diagnosis of this potentially fatal problem.Background For the management of distal radius fractures, surgical decision-making depends on radiographic measurements of indicators including radial inclination (RI), ulnar variance (UV) and radial tilt (RT). Evaluation of the inter- and intrarater reliability of surgeons' measurements of these criteria has been limited. Methods Twelve physicians were invited to participate in this study. Anonymously, they measured RI, UV and RT on 30 digitally stored radiographs of distal radius fractures on 3 occasions, each at least 1 week apart, using online measuring tools. After taking the third set of measurements, the participants were given a tutorial by the senior author (G.J.) on a single technique to measure all 3 indicators. The participants then took 3 more sets of measurements using only the technique they had been taught. Intraclass correlation coefficients (ICCs) were used to evaluate interrater reliability each week. Multiple logistic regression was used to calculate the effect of the tutorial, controlling for week of study along with reader (participant) and patient variance. Results The ICCs indicated that the participants' measurement precision improved promptly after the tutorial, and this improvement was sustained through subsequent readings. The odds of an "accurate" measurement (within 2° of the senior author's measurements for RI, 1 mm for UV and 4° for RT) was 1.7 times higher for RI, 2.7 times higher for UV and 2.3 times higher for RT after the tutorial; all of these results were statistically significant. Conclusion Surgeons ought to be familiar with a method to reproducibly measure the indicators used in the published guidelines for surgical intervention. The tutorial on a single standardized technique for online measurement of RI, UV and RT in distal radius fractures improved measurement precision.Objectives To implement a project of linked pharmacist-provider new patient visits and then evaluate the impact on the productivity of the provider and pharmacist. Study design A clinical pharmacist was integrated into the workflow at 2 sites (sites A and B) of Henry J. Austin Health Center, a federally qualified health center, so that new patients were scheduled to see the pharmacist in a 15-minute encounter immediately before a 15-minute encounter with the primary care provider. Methods Reports generated in the electronic health record were downloaded into Microsoft Excel for statistical analysis. Two-sample 2-tailed t tests assuming unequal variances were used to evaluate changes in the mean number of appointments checked in and canceled before and after the project's implementation to study provider productivity, the primary study outcome. Descriptive statistics were used to report the pharmacist's productivity. Results Statistically significant increases in the number of checked-in new patient visits and in all visits of any type were observed at site A; however, these changes were not observed at site B. Conclusions The linked visits between the pharmacist and provider allowed for increased provider productivity at 1 of the sites. Based on these results and provider feedback from both sites, this project was viewed as a positive initiative. Scheduling challenges were a barrier to project success at site B.Objectives This study assessed rates of ambulatory care-sensitive condition (ACSC) admissions within a healthcare system to identify areas for intervention. Study design This was a multiyear cross-sectional study using the data warehouse of Clalit Health Services (Clalit), the largest payer/provider healthcare system in Israel, with complete clinical records for more than 4 million members. All admissions from 2009 to 2014 were included in the study. Discharge diagnoses were identified using International Classification of Diseases, Ninth Revision codes. Methods We provide adjusted rates (per 100,000 Clalit population adjusted by age and sex to the 2005 Organisation for Economic Co-operation and Development population) for all admissions, by discharge diagnoses, for each year. We identify the highest adjusted rates (relative and absolute) by both catchment area and hospital affiliation (Clalit or non-Clalit). Results ACSC-related admissions made up 16.2% of all admissions for the 5 years studied, and the overall rate increased by 26.8% from 2009 to 2014. The conditions with the highest admission rates in all years and all catchment areas were pneumonia and congestive heart failure. There was extreme variation among catchment areas for hypertension-related admissions. Within the Clalit hospitals, ACSCs accounted for 20.5% of admissions; within non-Clalit hospitals, ACSCs accounted for 13.6% of admissions. Conclusions In evaluating the rates of ACSC-related admissions, this study demonstrates the contribution of a single, longitudinal benchmark. This study also suggests that hypertension, congestive heart failure, and pneumonia may be areas for future intervention in Clalit.Objectives Exacerbations account for the greatest proportion of costs associated with chronic obstructive pulmonary disease (COPD). Here we aimed to evaluate, from the US payer perspective, the costs associated with moderate and severe COPD exacerbation events for patients treated with fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) compared with FF/VI or UMEC/VI. Study design This post hoc, within-trial economic analysis used data derived from the InforMing the PAthway of COPD Treatment (IMPACT) study (NCT02164513). Methods Treatment groups within the IMPACT trial received either triple therapy with FF/UMEC/VI (100/62.5/25 mcg) or dual therapy (FF/VI [100/25 mcg] or UMEC/VI [62.5/25 mcg]). The primary end point for this IMPACT post hoc analysis was cost differences between the treatment arms related to 1-year on-treatment combined moderate and severe COPD exacerbation events. Results The final study sample for this within-trial analysis consisted of 10,355 patients, 49% of whom experienced an on-treatment moderate or severe exacerbation during the study. The mean 1-year on-treatment cost estimate associated with combined moderate and severe exacerbations was highest with UMEC/VI and lowest with FF/UMEC/VI ($6205 vs $4913, respectively). Mean cost differences were statistically significant for all pairwise comparisons of FF/UMEC/VI with FF/VI or UMEC/VI (-$549 [95% CI, -$565 to -$533] and -$1292 [95% CI, -$1313 to -$1272], respectively; both P less then .0001). Conclusions Treatment with FF/UMEC/VI compared with FF/VI or UMEC/VI in the US healthcare system resulted in lower exacerbation-related costs for combined moderate/severe exacerbation events, as well as moderate and severe exacerbations separately.Objectives To examine healthcare resource utilization (HRU) and costs in a population of managed care enrollees who experienced an osteoporotic fracture. Study design Retrospective cohort study using the Optum Research Database (January 2007 to May 2017). Methods All-cause and osteoporosis-related HRU and costs were analyzed in patients 50 years and older with a qualifying index fracture and continuous enrollment with medical and pharmacy benefits for 12 months preindex (baseline period). Results Of 1,841,263 patients with fractures during the identification period, 302,772 met eligibility criteria. Two-thirds (66.6%) were 65 years and older, 71.6% were women, and 41.2% were commercial (not Medicare Advantage) enrollees. The most common fracture sites were spine (21.9%), radius/ulna (19.5%), and hip (13.7%). Mean (SD) total all-cause healthcare cost was $34,855 ($56,094), with most paid by health plans ($31,863 [$55,025]) versus patients ($2992 [$2935]). Most healthcare costs were for medical ($31,766 [$54,943]) versus pharmacy ($3089 [$6799]) services. https://www.selleckchem.com/products/ly3039478.html Approximately 75% of patients received rehabilitation services (mean [SD] cost = $18,025 [$41,318]). Diagnosis of index fracture during an inpatient stay versus an outpatient visit (cost ratio, 2.16; 95% CI, 2.13-2.19) and fractures at multiple sites (cost ratio, 1.23; 95% CI, 1.21-1.26) were the leading predictors of cost. Kaplan-Meier estimated cumulative second-fracture rates were 6.6% at 1 year, 12.3% at 2 years, 16.9% at 3 years, and 20.9% at 4 years after index fracture. Conclusions These findings suggest a significant economic burden associated with fractures, including a high total all-cause cost of care. Early identification and treatment of patients at high risk of fractures are of paramount importance to reduce fracture risk and associated healthcare costs.Specific measures using a Six Sigma approach led to sustained reduction of door-to-balloon times among patients with ST-segment elevation myocardial infarction (STEMI) in a community setting.Because hospitals and health systems sponsored the majority of new accountable care organizations (ACOs) from 2010 to 2015, they influenced priorities and strategies of the policies designed to drive ACO adoption. In recent years, however, the majority of new ACOs have been sponsored by physician groups. This shift means that policies need to be developed with the characteristic strengths and weaknesses of physician-led ACOs in mind. Using data from the Leavitt Partners ACO database, we analyzed the types of providers becoming ACOs over time to look at their numbers and market potential. Because the market potential for further growth of physician group-led ACOs is much stronger than for hospital- or health system-led ACOs, policy makers need to create programs and policies that facilitate physician-led ACOs' success by helping them develop the capacity to take on risk, finance investments in high-value healthcare, and partner with other organizations to provide the full spectrum of care.Objectives To assess the effect of medical home enrollment on acute care use and healthcare spending among Medicaid beneficiaries with mental and physical illness. Study design Retrospective cohort analysis of administrative data. Methods We used 2007-2010 Medicaid claims and state psychiatric hospital data from a sample of 83,819 individuals diagnosed with schizophrenia or depression and at least 1 comorbid physical condition. We performed fixed-effects regression analysis at the person-month level to examine the effect of medical home enrollment on the probabilities of emergency department (ED) use, inpatient admission, and outpatient care use and on amount of Medicaid spending. Results Medical home enrollment had no effect on ED use in either cohort and was associated with a lower probability of inpatient admission in the depression cohort (P less then .05). Medical home enrollees in both cohorts experienced an increase in the probability of having any outpatient visits (P less then .05). Medical home enrollment was associated with an increase in mean monthly spending among those with schizophrenia ($65.