Mayo Clinic proceedings. Innovations, quality & outcomes最新文献

Value-based health care has been accelerated by alternative payment models and has catalyzed the redesign of care delivery across the nation. Lifestyle medicine (LM) is one of the fastest growing medical specialties and has emerged as a high-value solution for root cause treatment of chronic disease. This review detailed a large integrated health care delivery system’s value transformation efforts in the nonoperative treatment of musculoskeletal (MSK) conditions by placing patient-centric, team-based, lifestyle-focused care at the foundation. With an economic and treatment imperative to reimagine care, recognizing more intervention is not always better, a collaborative approach was designed, which placed functional improvement of the patient at the center. This article described the process of implementing LM into an MSK model of care. The change management process impacted clinical, operational, and benefit plan design to facilitate an integrated care model. A new understanding of patients’ co-occurring physical impairments, medical comorbidities, and behavioral health needs was necessary for clinicians to make the shift from a pathoanatomic, transactional model of care to a biopsychosocial, longitudinal model of care. The authors explored the novel intersection of the implementation of a biopsychosocial model of care using LM principles to achieve greater value for the MSK patient population.

Objective

To evaluate prescribing practices for the anti-Xa reversal agent, andexanet alfa, to identify challenges in ordering and administering this medication, and to offer recommendations to improve patient safety.

Patients and Methods

This retrospective study reviewed all adult patients treated with andexanet alfa (AA) at a single institution between January 1, 2018, and March 31, 2020. We identified ordering and administration benchmarks based on recommendations from previous clinical trials on AA. We then reviewed these medical records to determine compliance with these benchmarks. We also collected data related to thrombotic complications and mortality.

Results

Twenty-two AA dosing sets (loading and infusion dose) were given to 20 patients. Eight (36%) dosing sets met our ordering benchmarks regarding appropriate dose, time since last direct oral anticoagulants, urgency of administration, and documentation. Three (14%) dosing sets met the administrative benchmarks of being started within 30 minutes of the initial order, and 13 (59%) dosing sets had timely infusion of the infusion dose after the loading dose. No dosing set met all our administration benchmarks. There was 1 thrombotic event within 24 hours of the correct AA dose and 1 potential death related to AA.

Conclusion

This study highlights challenges in ordering and administering AA at our institution and brings awareness to potential similar concerns at other institutions. These challenges also identified the need for optimized order sets, a streamlined administration process, and frequent provider education to improve patient safety.

Objective

To review the salient features of multimodality cardiovascular imaging in patients with disseminated Mycobacterium chimaera (MC) infections after exposure to contaminated heater-cooler units during cardiopulmonary bypass.

Patients and Methods

Twelve patients with confirmed MC infection were retrospectively identified after a review from January 1, 2010, to April 30, 2021. The electronic medical records were examined with a focus on transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography (CT), cardiac magnetic resonance imaging, and positron emission tomography-CT.

Results

Three (27.3%) patients had diagnostic findings of endocarditis on transthoracic echocardiography, with most patients having nonspecific abnormalities including elevated prosthetic valve gradients or prosthetic leaflet thickening. Transesophageal echocardiography identified 4 (36.7%) patients with vegetations and 3 (27.3%) with aortic root abscess or pseudoaneurysm, with more common findings such as mild aortic root or prosthetic leaflet thickening. Six (50%) patients underwent cardiac CT imaging, which found aortic root pseudoaneurysms or abscesses, prosthetic ring dehiscence, and leaflet thickening. Three (25%) patients underwent cardiac magnetic resonance imaging demonstrating prosthetic valve vegetations, leaflet thickening, and abnormal myocardial delayed enhancement in a noncoronary distribution, suggesting myocarditis. Ten (83%) patients underwent positron emission tomography-CT, 4 (40%) had an abnormal fluorodeoxyglucose uptake around the cardiac prosthetic material, and 7 (70%) had a fluorodeoxyglucose uptake in other organs, suggesting concomitant multiorgan involvement.

Conclusion

Multimodality cardiovascular imaging is central to the management of patients with disseminated MC and can help establish a preliminary diagnosis while awaiting confirmatory microbiological data, potentially reducing the time to diagnosis. Imaging findings are subtle and atypical, not always meeting classically modified Duke’s criteria for infectious endocarditis. Clinicians should have a high index of suspicion for the disease and a low threshold for repeat imaging when initial testing is equivocal.

An estimated 45% of adult Americans currently have high blood pressure (HBP). Effective blood pressure (BP) control is essential for preventing major adverse events from cardiovascular and other vascular-related diseases, such as chronic kidney disease, stroke and dementia. A large and growing number of medical professional societies, health care organizations, and governmental agencies have now endorsed a clinical practice guideline-based target for adequate control of HBP to a systolic BP of less than 130 mm Hg. However, adequate BP control to this goal has been recently estimated to be as low as 30%. The first and most important steps to guide effective BP control include accurate, standardized BP measurement and formal assessment of overall atherosclerotic cardiovascular disease risk. In addition to appropriate pharmacologic treatment, optimal BP management must also include multifaceted guideline-directed lifestyle modifications. High-quality evidence now supports effective uniform HBP control that is consistently achievable for most of people from diverse backgrounds. This can be accomplished through identification and prioritization of social determinants of health enabled by shared decision making that is delivered via team-based care. Such integrated approaches can have a substantial impact for simultaneously reducing several major modifiable atherosclerotic cardiovascular disease risk factors. Hence, moving the “Big Needle” of improved overall cardiovascular, kidney, and brain health of the US population must no longer be solely relegated to primary care and will require a major and coordinated reprioritization of capital and evidence-based human resource allocations by all health care stakeholder organizations.

Objective

To perform a retrospective, multicenter, external validation of the Cleveland Clinic malignancy probability prediction model for incidental pulmonary nodules.

Patients and Methods

From July 1, 2022, to May 31, 2023, we identified 296 patients who underwent tissue acquisition at Mayo Clinic (MC) (n=198) and Loyola University Medical Center (n=98) with histopathology indicating malignant (n=195) or benign (n=101). Data was collected at initial radiographic identification (point 1) and at the time of intervention (point 2). Point 3 represented the most recent data. The areas under the receiver operating characteristics were calculated for each model per time point. Calibration was evaluated by comparing the predicted and observed rates of malignancy.

Results

The areas under the receiver operating characteristics at time points 1, 2, and 3 for the MC model were 0.67 (95% CI, 0.61-0.74), 0.67 (95% CI, 0.58-0.77), and 0.70 (95% CI, 0.63-0.76), respectively. The Cleveland Clinic model (CCM) was 0.68 (95% CI, 0.61-0.74), 0.75 (95% CI, 0.65-0.84), and 0.72 (95% CI, 0.66-0.78), respectively. The mean ± SD estimated probability for malignant pulmonary nodules (PNs) at time points 1, 2, and 3 for the CCM was 64.2±25.9, 65.8±24.0, and 64.7±24.4, which resembled the overall proportion of malignant PNs (66%). The mean estimated probability of malignancy for the MC model at each time point was 38.3±27.4, 36.2±24.4, and 42.1±27.3, substantially lower than the observed proportion of malignancies.

Conclusion

The CCM found discrimination similar to its internal validation and good calibration. The CCM can be used to augment clinical and shared decision-making when evaluating high-risk PNs.