BACKGROUND:Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA). METHODS:We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers). RESULTS:Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs. CONCLUSION:This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.

BACKGROUND:Demand for joint replacement is increasing, with many patients receiving postsurgical physical therapy (PT) in non-inpatient settings. Clinicians need a reliable tool to guide decisions about the appropriate PT setting for patients discharged home after surgery. We developed and validated a model to predict PT location for patients in our health system discharged home after total knee arthroplasty.METHODS:We analyzed data for patients who completed a preoperative total knee risk assessment in 2017 (model development cohort) or during the first 6 months of 2018 (model validation cohort). The initial total knee risk assessment, to guide rehabilitation disposition, included 28 variables in mobility, social, and environment domains, and on patient demographics and comorbidities. Multivariable logistic regression was used to identify factors that best predict discharge to home health service (HHS) vs home with outpatient PT. Model performance was assessed by standard criteria.RESULTS:The development cohort included 259 patients (19%) discharged to HHS and 1129 patients (81%) discharged to home with outpatient PT. The validation cohort included 609 patients, with 91 (15%) discharged to HHS. The final model included age, gender, motivation for outpatient PT, and reliable transportation. Patients without motivation for outpatient PT had the highest probability of discharge to HHS, followed by those without reliable transportation. Model performance was excellent in the development and validation cohort, with c-statistics of 0.91 and 0.86, respectively.CONCLUSION:We developed and validated a predictive model for total knee arthroplasty PT discharge location. This model includes 4 variables with accurate prediction to guide patient-clinician preoperative decision making.

OBJECTIVESTo examine the effect of pre- and postoperative care management on weight loss following bariatric surgery.STUDY DESIGNWe conducted a retrospective cohort study supplemented by cross-sectional surveys across 9 bariatric surgery centers.METHODSBased on the intensity of patient contact, care management intensity (CMI) was defined as high, moderate, or low for preoperative programs, and high or low for postoperative programs. Multivariable linear regression assessed 1- and 2-year post operative weight loss as a function of CMI.RESULTSIn the 9 centers, 4433 individuals underwent Roux-en-Y gastric bypass or adjustable gastric band placement between 2005 and 2009. Two sites had low, 5 had moderate, and 2 had high preoperative CMI; 5 sites had low and 4 had high postoperative CMI. In analyses stratified by procedure and adjusted for multiple covariates including site, we found no statistically significant associations between either preoperative or postoperative CMI and post operative change in body mass index at year 1 or year 2. Results were limited by heterogeneity of care management across sites and an inability to assess adherence to care management programs.CONCLUSIONSProspective investigations that incorporate quantifiable measures of CMI and measure individual adherence to components of care management programs are needed to more accurately determine the effect of care management on weight loss. Additional investigations should examine the effect of CMI on other relevant outcomes, such as nutritional status and quality of life, that may be more directly affected by care management.

Background— To determine whether a pharmacist-led, Heart360-enabled, home blood pressure monitoring (HBPM) intervention improves blood pressure (BP) control compared with usual care (UC). Methods and Results— This randomized, controlled trial was conducted in 10 Kaiser Permanente Colorado clinics. Overall, 348 patients with BP above recommended levels were randomized to the HBPM (n=175) or UC (n=173) groups. There were no statistically significant differences in baseline characteristics between the groups; however, there was a trend toward a higher baseline BP for the HBPM group compared with the UC group (148.8 versus 145.5 mm Hg for systolic BP; 89.6 versus 88.0 mm Hg for diastolic BP). At 6 months, the proportion of patients achieving BP goal was significantly higher in the HBPM group (54.1%) than in the UC group (35.4%; P <0.001). Compared with the UC group, the HBPM group experienced a −12.4-mm Hg larger (95% confidence interval, −16.3 to −8.6) reduction in systolic BP and a −5.7-mm Hg larger (95% confidence interval, −7.8 to −3.6) reduction in diastolic BP. The impact of the intervention on BP reduction was even larger for the subgroup of patients with diabetes mellitus or chronic kidney disease. The HBPM group had more e-mail and telephone contacts and greater medication regimen intensification. The proportion of patients reporting high satisfaction with hypertension care was significantly greater in the HBPM group (58%) than in the UC group (42%), P <0.001. Conclusions— A pharmacist-led, Heart360-supported, home BP monitoring intervention led to greater BP reductions, superior BP control, and higher patient satisfaction than UC. Clinical Trial Registration— URL: http://www.clinicaltrials.gov/ct2/show/NCT01162759 . Unique identifier: NCT01162759.

Background: Blood pressure (BP) control among coronary artery disease (CAD) patients is sub-optimal in clinical practice and may be due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships are limited. Methods: We assessed BP trajectories among managed care patients with hypertension and incident CAD. Patients were stratified by target BP goal (<140/90 or <130/80 among those with diabetes or renal disease) and BP trajectories were modeled over the year following CAD diagnosis. Treatment intensification (increase in BP therapies in the setting of an elevated BP) and medication adherence (percentage of days covered with BP therapies) were evaluated in multivariable models adjusting for patient variables. Results: 2763 patients had a <140/90 BP goal and 9890 had a <130/80 BP goal. Within each BP goal group, four trajectories were identified - persistently uncontrolled (Group 1), uncontrolled to controlled (Group 2), controlled to uncontrolled (Group 3), and persistently controlled (Group 4). In multivariable models comparing Group 2 to Group 1, treatment intensification was associated with improved BP control over the year for both groups (OR for <140/90 BP goal 0.75, 95% CI 0.66, 0.84; OR for <130/80 BP goal 0.93, 95% CI 0.89, 0.98). Medication adherence was associated with improved BP control among the 130/80 target BP group only (OR for <140/90 BP goal 0.79, 95% CI 0.38, 1.69; OR for <130/80 BP goal 0.66, 95% CI 0.49, 0.9). Conclusions: In this managed care patient population, treatment intensification and medication adherence significantly affect BP trajectories in the year following CAD diagnosis.

Background Cross-sectional assessments of hemoglobin (Hb) are associated with mortality in patients with heart failure (HF). Our objectives were to characterize patterns of change in Hb over time in patients with HF and to evaluate the relationship between longitudinal measures of Hb and adverse outcomes.Methods The study included 2,478 patients with a primary discharge diagnosis of HF from January 2001 to December 2006. Outcomes included time to death and time to death or HF hospitalization. The association between baseline Hb and outcomes was evaluated using multivariable Cox regression. The longitudinal association was evaluated using a time-dependent Hb predictor variable and using anemia trajectory groups.Results For a median of 475 days, baseline Hb was associated with a trend toward increased mortality (hazard ratio [HR] 1.02, 95% CI 0.99-1.06 per g/dL decline). With a time-dependent approach, the magnitude of the association was greater (HR 1.35, 95% CI 1.30-1.39 per g/dL decline). In trajectory analysis, 35% of the cohort had variable patterns of anemia. Persistently low Hb (HR 1.65, 95% CI 1.27-2.14) and a progressive decline in Hb (HR 1.54, 95% CI 1.16-2.05) were associated with increased mortality risk. Patients with recovery of anemia had similar outcomes as those patients who are persistently nonanemic. Results were similar for the composite of death or HF hospitalization.Conclusions Variability in Hb over time is common in patients with HF, and declining Hb is associated with a poor prognosis. Longitudinal characterization of Hb levels has greater prognostic significance than a single measurement. Systematic surveillance of Hb levels may help identify high-risk patients with heart failure. (Am Heart J 2010; 159: 81-9.)

Colleen Ross, MS1, Thomas Maddox, MD2, Ella Lyons, MS1, Heather Tavel, BS1 and David Magid, MD, MPH1 1Kaiser Permanente Colorado; 2Denver VA Medical Center

Background— Blood pressure (BP) control among coronary artery disease patients remains suboptimal in clinical practice, potentially due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships and outcomes are limited. Methods and Results— We assessed BP trajectories among health maintenance organization patients with hypertension and incident coronary artery disease. BP trajectories were modeled over the year after coronary artery disease diagnosis, stratified by target BP goal. Treatment intensification (increase in BP therapies in the setting of an elevated BP), medication adherence (percentage of days covered with BP therapies), and outcomes (all-cause mortality, myocardial infarction, and revascularization) were evaluated in multivariable models: 9569 patients had a <140/90 mm Hg BP target and 12 861 had a <130/80 mm Hg BP target. Within each group, 4 trajectories were identified: good, borderline, improved, and poor control. After adjustment, increasing BP treatment intensity was significantly associated with better BP trajectories in both groups. Medication adherence had inconsistent effects. There were no significant differences in combined outcomes by BP trajectory, but among the diabetes and renal disease cohort, borderline control patients were less likely to have myocardial infarction (odds ratio, 0.61; 95% confidence interval, 0.40–0.93), and good control patients were less likely to have myocardial infarction (odds ratio, 0.53; 95% confidence interval, 0.34–0.84) or a revascularization procedure (odds ratio, 0.66; 95% confidence interval, 0.47–0.93) compared with poor control patients. Conclusions— In this health maintenance organization population, treatment intensification but not medication adherence significantly affects BP trajectories in the year after coronary artery disease diagnosis. Better BP trajectories are associated with lower rates of myocardial infarction and revascularization.

Copyright © 2009 American Heart Association. All rights reserved. Print ISSN: 1941-7705. Online 7272 Greenville Avenue, Dallas, TX 72514 Circulation: Cardiovascular Quality and Outcomes is published by the American Heart Association. DOI: 10.1161/CIRCOUTCOMES.108.839605 2009; 2009;2;421-428; originally published online Aug 4, Circ Cardiovasc Qual Outcomes W. Groeneveld Raina M. Merchant, Lance B. Becker, Benjamin S. Abella, David A. Asch and Peter Cost-Effectiveness of Therapeutic Hypothermia After Cardiac Arrest http://circoutcomes.ahajournals.org/cgi/content/full/2/5/421 located on the World Wide Web at: The online version of this article, along with updated information and services, is

BACKGROUND Little is known about the association between exercise capacity and nonfatal cardiac events in patients referred for exercise treadmill testing (ETT). Our objective was to determine the prognostic importance of exercise capacity for nonfatal cardiac events in a clinical population. METHODS A cohort study was performed of 9191 patients referred for ETT. Median follow-up was 2.7 years. Exercise capacity was quantified as the proportion of age- and sex-predicted metabolic equivalents achieved and categorized as less than 85%, 85% to 100%, and greater than 100%. Individual primary outcomes were myocardial infarction, unstable angina, and coronary revascularization. All-cause mortality was a secondary outcome. RESULTS Patients with lower exercise capacity were more likely to be female (55.38% vs 42.62%); to have comorbidities such as diabetes (23.16% vs 9.61%) and hypertension (59.43% vs 44.05%); and to have abnormal ETT findings such as chest pain on the treadmill (12.09% vs 7.63%), abnormal heart rate recovery (82.74% vs 64.13%), and abnormal chronotropic index (32.89% vs 12.20%). In multivariable analysis, including other ETT variables, lower exercise capacity (<85% of predicted) was associated with increased risk of myocardial infarction (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.55-3.60), unstable angina (HR, 2.39; 95% CI, 1.78-3.21), coronary revascularization (HR, 1.75; 95% CI, 1.46- 2.08), and all-cause mortality (HR, 2.90; 95% CI, 1.88-4.47) compared with exercise capacity greater than 100% of predicted. CONCLUSION Adjusting for patient characteristics and other ETT variables, reduced exercise capacity was associated with both nonfatal cardiovascular events and mortality in patients referred for ETT.

Ella E. Lyons, MS, Frederick Masoudi, MD, MSPH, Christina Clarke, BS, Christina Adams, MD, Pamela Peterson, MD and David Magid, MD, MPH Ella E. Lyons, MS, Institute for Health Research – Kaiser Permanente Colorado; Frederick Masoudi, MD, MSPH, Denver Health and University of Colorado at Denver and Health Sciences Center; Christina Clarke, BS, Institute for Health Research – Kaiser Permanente Colorado; Christina Adams, MD, University of Colorado at Denver and Health Sciences Center; Pamela Peterson, MD, Denver Health; David Magid, MD, MPH, Institute for Health Research – Kaiser Permanente Colorado and University of Colorado at Denver and Health Sciences Center

BACKGROUND:Although it is known that reperfusion therapy for ST-elevation myocardial infarction (STEMI) is underused, the reasons for the failure to provide this potentially life-saving treatment are not well described.METHODS:In a cohort of 2215 consecutive patients presenting with acute myocardial infarction to 5 emergency departments in Colorado and California between 2000 and 2002, patients with ischemic symptoms and ST-segment elevation on electrocardiogram without documented guideline-based contraindications to therapy were identified as eligible reperfusion candidates. Multivariable logistic models were constructed to identify factors associated with the failure to receive reperfusion. The emergency department records of patients not receiving reperfusion were reviewed to categorize the reasons therapy was not provided.RESULTS:Of 460 eligible patients, 102 (22%) did not receive reperfusion therapy. Patient factors associated with failure to receive reperfusion therapy included older age, peripheral vascular disease, and absence of chest pain; patients seen by both resident and attending physicians were more likely to receive treatment than those seen by an attending alone. In cases where reperfusion was not provided, ST-segment elevation was not identified in 34% (n = 35), left bundle-branch block was not considered as an indication in 13% (n = 13), there was documentation of a reason for withholding therapy not supported by guidelines in 34% (n = 35), and there was no documentation of reasons for withholding reperfusion in 19% (n = 19).CONCLUSIONS:Initiatives to improve electrocardiogram interpretation and evidence-based patient selection may reduce gaps in the delivery of reperfusion therapy to eligible candidates and thereby potentially improve STEMI outcomes.

Background: Patients often have chest pain during exercise treadmill testing (ETT). However, the evidence supporting chest pain as an independent adverse prognostic factor during ETT has been inconsistent. The objective of this study was to determine the importance of chest pain during ETT in predicting future nonfatal cardiac hospitalizations.Methods: This was a prospective cohort study of all patients undergoing ETT between July 2001 and June 2004 in a large managed care organization. The primary outcome of interest was nonfatal cardiac hospitalizations including myocardial infarction and unstable angina. Multivariable Cox proportional hazards regression assessed the independent association between chest pain during ETT and subsequent nonfatal cardiac hospitalizations, adjusting patient, clinical and other treadmill variables.Results: Of the 8,459 patients undergoing ETT, 697 (8.2%) patients had chest pain during the test. Patients with chest pain during ETT had more nonfatal cardiac hospitalizations compared to patients without chest pain (11.9% vs. 2.6%; p < 0.0001). In multivariable Cox regression analysis, patients with chest pain during ETT remained at significantly increased risk of nonfatal cardiac hospitalizations (HR 3.44; 95% CI 2.60-4.56). The association between chest pain and adverse outcomes was consistent among prespecified subgroups including patients without ST-segment changes and with good functional capacity on ETT.Conclusions: Chest pain during ETT, even without ECG changes, predicts subsequent cardiac hospitalizations. Future studies should evaluate whether aggressive management of such patients can prevent subsequent hospitalizations.

STUDY OBJECTIVE:To determine whether an electronic tool effectively increases the percentage of patients receiving laboratory monitoring during ongoing drug therapy. DESIGN:Randomized trial. SETTING:Outpatient medical offices of a group model health maintenance organization. PATIENTS:A total of 9,139 patients prescribed ongoing therapy with any of 14 drugs, resulting in 4,871 patient-drug combinations in the intervention group and 4,780 in the usual-care (control) group. INTERVENTION:Physicians and pharmacists jointly developed monitoring guidelines based on published recommendations. Pharmacists were electronically alerted to missing laboratory results and then ordered tests, reminded patients to undergo tests, and reviewed and managed abnormal results. MEASUREMENTS AND MAIN RESULTS:In the intervention group, 64% of patientdrug combinations were monitored, whereas in the usual-care group 58% were monitored (p < 0.001). Differences in monitoring were observed in the intervention versus usual-care groups for amiodarone (71% vs 55%, p<0.01), theophylline (54% vs 28%, p<0.001), carbamazepine (49% vs 32%, p<0.001), lithium (42% vs 28%, p<0.01), phenytoin (44% vs 33%, p<0.001), and metformin (72% vs 67%, p<0.001). Of 1981 laboratory tests ordered, 1,472 (74%) were completed. The tests revealed 181 serum drug concentrations outside the therapeutic range and 126 abnormal serum creatinine, alanine aminotransferase, aspartate aminotransferase, and thyroid-stimulating hormone levels, and complete blood counts. CONCLUSION:A computerized tool plus collaboration of health care professionals effectively increased the number of patients who received laboratory safety monitoring of drug therapy.

Background: Errors involving medication use are common. Computerized physician order entry (CPOE) can improve prescribing practices. Few studies have examined the effect of CPOE in combination with decision support tools on prescribing practices in the outpatient setting. Less is known about prescribers' adherence to laboratory monitoring recommendations.Objective: To evaluate if reminders presented during CPOE for medications would increase physicians' compliance with guidelines for laboratory monitoring at initiation of therapy.Study Design: Randomized prospective intervention study.Methods: Two hundred seven primary care physicians in a group-model managed care organization were randomized to receive or not receive drug laboratory monitoring alerts within the CPOE system. Adherence to laboratory monitoring recommendations for patients prescribed selected medications was compared between physician groups.Results: There was no significant difference between the control and intervention group physicians in the overall rate of compliance with ordering the recommended laboratory monitoring for patients prescribed study medications. Laboratory monitoring was performed as recommended 56.6% of the time in the intervention group compared with 57.1% of the time in the control group (P = .31). In cases in which a statistically significant difference was demonstrated, improved compliance favored the intervention group (eg, 7, 1.2% vs 62.3% [P = .003] for gernfibrozil and 75.7% vs 73.9% IP = .051 for statins).Conclusions: As CPOE becomes more prevalent, additional research is needed to determine effective decision support tools. These findings then should be communicated to the developers and users of computerized medical record systems.

Background: Exercise capacity on exercise treadmill testing (ETT) predicts mortality, but little is known about the association between exercise capacity and non-fatal cardiac events. Furthermore, the prognostic value of exercise capacity independent of a broad range of contemporary ETT variables has not been evaluated. Methods: This cohort study enrolled 9,569 consecutive patients referred for ETT in a large HMO. The outcomes of interest were myocardial infarction, unstable angina, and coronary revascularization. Secondary outcomes included cardiac and all cause mortality. The primary predictor variable was exercise capacity as measured by metabolic equivalents (METs). Cox proportional hazards regression assessed the association between exercise capacity and the outcomes, adjusting for demographic, clinical, and ETT variables. Results: The median length of follow-up was 2.7 years. Patients with lower exercise capacity were older, more likely to be female and had more co-morbid conditions compared to those with greater exercise capacity. In addition, patients with poor exercise capacity were more likely to have chest pain with exercise, ST segment changes, abnormal heart rate recovery, and an abnormal chronotropic index. In adjusted models, lower exercise capacity remained strongly and independently associated with increased risk of myocardial infarction, unstable angina and all-cause mortality, with a trend towards increased risk of cardiovascular mortality and revascularization (Table). Conclusion: Independent of patient characteristics and other ETT parameters, reduced exercise capacity is a powerful predictor of both nonfatal cardiovascular events and mortality. Given the magnitude of the association, further evaluation of the benefits of aggressive diagnostic and therapeutic strategies specifically directed at preventing cardiovascular events in patients with reduced exercise tolerance is warranted.