2009 February 23

Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.

Feb 232009

Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials.

JAMA. 2009 Feb 11;301(6):603-18

Authors: Peikes D, Chen A, Schore J, Brown R

CONTEXT: Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication. OBJECTIVE: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. DESIGN, SETTING, AND PATIENTS: Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. INTERVENTIONS: Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. MAIN OUTCOME MEASURES: Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. RESULTS: Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], -0.283 to -0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (-$84; 90% CI, -$171 to $4; P=.12; -$358; 90% CI, -$934 to $218; P=.31; and -$112; 90% CI, -$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. CONCLUSIONS: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00627029.

PMID: 19211468 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Staphylococcus aureus bacteraemia with known sources.

Int J Antimicrob Agents Start a Discussion »

Feb 232009

Staphylococcus aureus bacteraemia with known sources.

Int J Antimicrob Agents. 2008 Nov;32 Suppl 1:S18-20

Authors: Rubinstein E

Meticillin-resistant Staphylococcus aureus (MRSA), both hospital-acquired and community-acquired MRSA (CA-MRSA) strains, have increased in frequency in the last few years, reaching epidemic dimensions. This review discusses several clinical forms of staphylococcal infection leading to bacteraemia in a high proportion of cases. Staphylococcal (MRSA) bacteraemic pneumonia is predominantly seen in hospital-acquired pneumonia and ventilator-associated pneumonia, reaching a frequency of 8.4% of all bacteraemias, 30% of all nosocomial bacteraemias and 68% of all bacteraemias of patients hospitalised in Intensive Care Units. In patients with CA-MRSA pneumonia, the rate of bacteraemia is as high as 62%. Whereas in nosocomial bacteraemic pneumonia blood cultures become positive on the ninth day of pneumonia, in CA-MRSA bacteraemic pneumonia positive blood cultures appear early in the course of the infection. The pneumonia has a stormy course with the development of abscesses, empyema and extensive pulmonary damage. Vertebral osteomyelitis commonly occurs during intravenous catheter use, causing local thrombophlebitis that will seed to vertebral bodies and disks and may cause secondary sustained bacteraemia. Non-vertebral osteomyelitis is also on the increase, with a frequency that has doubled in recent years, mainly due to MRSA. Patients with haematological malignancies are particularly prone to this complication, usually following line infections. Epidural abscess is the most serious consequence of staphylococcal bacteraemia, leading to permanent neurological damage if not diagnosed early enough.

PMID: 18715760 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

New antibiotic agents for bloodstream infections.

Int J Antimicrob Agents Start a Discussion »

Feb 232009

New antibiotic agents for bloodstream infections.

Int J Antimicrob Agents. 2008 Nov;32 Suppl 1:S60-5

Authors: Vergidis PI, Falagas ME

Infections due to multidrug-resistant pathogens have shown a dramatic worldwide increase in prevalence. Bloodstream infections (BSIs) represent an important cause of morbidity and mortality in hospitalised patients. Research in the field led to the introduction of several novel antibiotic agents in the fight against bacterial pathogens. New antibiotics used against Gram-positive bacteria, mainly meticillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, include daptomycin, linezolid, quinupristin/dalfopristin and semisynthetic lipoglycopeptides. Among the Gram-negative bacteria, extended-spectrum beta-lactamase-producing Enterobacteriaceae as well as highly resistant Pseudomonas and Acinetobacter isolates are of particular concern. Doripenem is a recently approved carbapenem. Polymyxins are reconsidered as valuable therapeutic options for Gram-negative infections. Tigecycline, a glycylcycline, and ceftobiprole, a novel cephalosporin under investigation, have activity both against Gram-positive and Gram-negative organisms. In addition to the above agents, alternative treatment approaches that require further investigation have also been introduced into clinical practice. These include antibiotic lock therapy and continuous intravenous administration of antibiotics. In this article, we review the above treatment options for BSIs based on current clinical evidence. Comparative trials specifically focusing on patients with bacteraemia were generally not performed; however, a proportion of patients from the reported studies did have bacteraemia.

PMID: 18723329 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Risk of intravascular cardiac device infections in patients with bacteraemia: impact on device removal.

Int J Antimicrob Agents Start a Discussion »

Feb 232009

Risk of intravascular cardiac device infections in patients with bacteraemia: impact on device removal.

Int J Antimicrob Agents. 2008 Nov;32 Suppl 1:S26-9

Authors: Corey GR, Lalani T

The risk of intravascular cardiac device infection (ICDI) has increased significantly over the last decade and is rising faster than the corresponding increase in device implantations. ICDIs may consist of pocket infections, wire infections, wire infections complicated by endocarditis, or combinations of these. In this review, we examine the microbiology of ICDIs, focusing on the risk of developing ICDI following bloodstream infections with key pathogens such as Staphylococcus aureus, coagulase-negative staphylococci, enterococci, etc., as well as the pathophysiology of these infections.

PMID: 18774267 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Gram-negative bloodstream infections.

Int J Antimicrob Agents Start a Discussion »

Feb 232009

Gram-negative bloodstream infections.

Int J Antimicrob Agents. 2008 Nov;32 Suppl 1:S10-4

Authors: Muñoz P, Cruz AF, Rodríguez-Créixems M, Bouza E

Over the last 22 years we have prospectively recorded data for bloodstream infections (BSIs) in our institution. We reflect the experience of a tertiary teaching hospital with 1750-2500 beds that served a population ranging during the study period from 650,000 to 750,000 inhabitants. Definitions and microbiological methods were standard. The microbiological workload of blood cultures was analysed and the evolution of the incidence of BSI episodes, provided as episodes per 1000 admissions and per 100000 inhabitants, is reported. During the study period, our institution had over one million admissions; blood culturing increased from 299 blood cultures/1000 admissions in the year 1985 to 720/1000 admissions in 2006. Overall, there were 65475 blood cultures with recovery of significant microorganisms, representing 27 419 episodes of significant BSI (22626 patients). The present paper describes the Gram-negative organisms recovered from the blood cultures and discusses their clinical significance.

PMID: 18775648 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Bloodstream infections in cancer patients with febrile neutropenia.

Int J Antimicrob Agents Start a Discussion »

Feb 232009

Bloodstream infections in cancer patients with febrile neutropenia.

Int J Antimicrob Agents. 2008 Nov;32 Suppl 1:S30-3

Authors: Feld R

Bloodstream infections (bacteraemia) account for approximately 25-30% of febrile episodes in patients with febrile neutropenia (FN). In developed countries, Gram-positive pathogens predominate. Mortality is higher in Gram-negative bacteraemia. A recent study involving 2142 patients with FN was reviewed, including 168 patients with Gram-negative bacteraemia (mortality 18%), 283 patients with Gram-positive bacteraemia (mortality 5%) and 48 patients with polymicrobial bacteraemia (mortality 13%). Among patients who received prophylactic antibiotics, Gram-positive bacteraemia was far more common than Gram-negative bacteraemia (75% vs. 25%), compared with approximately 50% of each in patients without prophylactic antibiotics. Patients with a Multinational Association for Supportive Care in Cancer (MASCC) score <15 had a 36% mortality compared with 3% if the MASCC score was >21. The MASCC score may help risk stratification of patients with FN and bacteraemia, although these data require confirmation. In two series of patients from developing countries (Lebanon and Malaysia), Gram-negative bacteraemia was more common and mortality was higher. In developing countries, Gram-negative bacteraemia may be more frequent due to less use of prophylactic antibiotics and central lines. Laboratory markers may have predictive and prognostic value for bacteraemia in patients at the onset of FN, including mannose-binding lectin, interleukin (IL)-6, IL-8 and procalcitonin, but further studies are required before they can be recommended. New therapies are required to lower the mortality in patients with FN with a high risk for bacteraemia.

PMID: 18778919 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Older Entries

February 2009
M	T	W	T	F	S	S
« Jan				Mar »
						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28