Saturday, July 16, 2016

NEJM report on ACOs

Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics...


Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was −$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only −$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others.


The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.

So as far as cost savings go these results were modest and somewhat mixed. I have to wonder if the effects of ACOs on costs will mirror what happened in the mid 90s with the wave of managed care, when there was an initial slash in costs but the “success” was short lived, as the reductions were not sustainable. I put very little stock in the statement that there was partial improvement in quality, since quality really means the weak and unproven surrogate of performance.

Wednesday, July 13, 2016

Higher prevalence of pancreatic cancer in patients newly diagnosed with type 2 diabetes

This is an association that has long been suspected. Additional evidence for the association was found in this study.

Tuesday, July 12, 2016

The effect of high flow nasal oxygen post-extubation, in patients at low risk

Importance Studies of mechanically ventilated critically ill patients that combine populations that are at high and low risk for reintubation suggest that conditioned high-flow nasal cannula oxygen therapy after extubation improves oxygenation compared with conventional oxygen therapy. However, conclusive data about reintubation are lacking.

Objective To determine whether high-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy for preventing reintubation in mechanically ventilated patients at low risk for reintubation.

Design, Setting, and Participants Multicenter randomized clinical trial conducted between September 2012 and October 2014 in 7 intensive care units (ICUs) in Spain. Participants were 527 adult critical patients at low risk for reintubation who fulfilled criteria for planned extubation. Low risk for reintubation was defined as younger than 65 years; Acute Physiology and Chronic Health Evaluation II score less than 12 on day of extubation; body mass index less than 30; adequate secretions management; simple weaning; 0 or 1 comorbidity; and absence of heart failure, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, and prolonged mechanical ventilation.

Interventions Patients were randomized to undergo either high-flow or conventional oxygen therapy for 24 hours after extubation.

Main Outcomes and Measures The primary outcome was reintubation within 72 hours, compared with the Cochran-Mantel-Haenszel χ2 test. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis and multiorgan failure, ICU and hospital length of stay and mortality, adverse events, and time to reintubation.

Results Of 527 patients (mean age, 51 years [range, 18-64]; 62% men), 264 received high-flow therapy and 263 conventional oxygen therapy. Reintubation within 72 hours was less common in the high-flow group (13 patients [4.9%] vs 32 [12.2%] in the conventional group; absolute difference, 7.2% [95% CI, 2.5% to 12.2%]; P = .004). Postextubation respiratory failure was less common in the high-flow group (22/264 patients [8.3%] vs 38/263 [14.4%] in the conventional group; absolute difference, 6.1% [95% CI, 0.7% to 11.6%]; P = .03). Time to reintubation was not significantly different between groups (19 hours [interquartile range, 12-28] in the high-flow group vs 15 hours [interquartile range, 9-31] in the conventional group; absolute difference, −4 [95% CI, −54 to 46]; P = .66]. No adverse effects were reported.

Conclusions and Relevance Among extubated patients at low risk for reintubation, the use of high-flow nasal cannula oxygen compared with conventional oxygen therapy reduced the risk of reintubation within 72 hours.

Monday, July 11, 2016

Hepatitis B and C associated glomerular diseases

From a recent review:

The most common histopathologic presentation of HBV-GN is HBV-associated membranous nephropathy, which usually manifests clinically with varying grades of proteinuria and microscopic hematuria. The pathogenesis is likely to be immune complex mediated; however, other host and viral factors have been implicated. The treatment of HBV-GN revolves around antiviral therapy. Various histologic types of glomerular diseases are reported in association with HCV infection, the most frequent being Type 1 membranoproliferative glomerulonephritis, usually in the context of Type 2 mixed cryoglobulinemia. The pathogenesis of HCV-GN can be attributed to glomerular deposition of cryoglobulins or noncryoglobulin-immune complexes. Cryoglobulins typically comprised immunoglobulin Mκ with rheumatoid factor activity. Clinically, patients may present with proteinuria, microscopic hematuria, hypertension, and acute nephritic and/or nephrotic syndrome. The treatment of HCV-GN, especially cryoglobulinemic membranoproliferative glomerulonephritis, encompasses various options including contemporary antiviral therapy with or without conventional and novel immunomodulatory agents.

Mentioned in the body of the paper are several other glomerular diseases that have been associated with hep B as well as polyarteritis nodosa which, though not a cause of glomerulonephritis, can cause renal damage as part of the vasculitis.

Sunday, July 10, 2016

How to work up hematuria

This topic was recently reviewed in Advances in Chronic Kidney Disease. From the body of the paper:

On finding a urine dipstick positive for blood, the test should be repeated after several days, to account for any transient causes of MH, such as physical activity, sexual intercourse, or menstruation. If the dipstick remains positive, urine microscopy should be performed to identify RBCs and to define their morphology (dysmorphic or isomorphic)..For our purposes, we define MH as 3 or more RBC/hpf. If no RBCs are visualized, patients should be evaluated for alternative causes of a positive dipstick, such as myoglobinuria. We agree with the CUA guidelines 2 and Huussen and colleagues, 35 who suggest that urologic imaging and cystoscopy may not be required if dysmorphic cells or RBC casts are seen, suggesting a glomerular etiology. Such findings should, however, prompt assessment of kidney function and urinary protein excretion. If the patient has a reduced GFR or proteinuria, referral to nephrology is warranted and a kidney biopsy should be considered. For those individuals with isolated glomerular MH, a clinician should assess these patients annually for kidney function changes and/or the development of albuminuria or proteinuria. If isomorphic RBCs are seen on urine microscopy, the clinician should confirm with the patient whether possible benign causes of MH such as recent physical activity or trauma, sexual activity, menstrual bleeding, viral symptoms, or urethral instrumentation may account for these findings. If a benign cause is present, a repeat urinalysis should be done in several weeks to ensure resolution. If the earlier mentioned causes are not identified, imaging of the GU tract is indicated. Although CTU has demonstrated the best testing characteristics, we emphasize the importance of limiting cumulative doses of radiation exposure, especially in younger individuals..alternative imaging modalities should be considered, including US or MR...

If no parenchymal lesion is detected on imaging, the clinician should assess the patient's GU cancer risk factor profile. If risk factors are present, they should be promptly referred to urology for cystoscopy. If a patient has no such risk factors, age should be considered before undergoing cystoscopic evaluation. We consider the evidence presented in the 2012 AUA guidelines inadequate to support cystoscopy for anyone with asymptomatic MH younger than 40 years. Patients with asymptomatic MH aged 50 years or older have sufficient cancer risk to warrant cystoscopy, regardless of risk factor profile. 6 For patients aged 40 to 49 years, the data are unclear; if no risk factors are present, clinical judgment for cystoscopy referral is advised.