A physician led bedside wound care program in post acute care reduces wound related hospitalizations, infections, and amputations over 85% and saves Medicare over $19,000 per patient.
Making the case for cost-effective wound managementGNEAUPP.
This document discusses cost-effective wound management and making the case for it. It begins by explaining the challenges in wound management, including increasing prevalence of wounds and difficulty collecting data on clinical efficacy, effectiveness, and costs. It then discusses common myths around cost-effectiveness, clarifying that cost-effective does not mean cheaper but provides benefits at a reasonable cost compared to alternatives. The document outlines different types of economic analyses used in healthcare, particularly cost-effectiveness analysis, and discusses understanding costs from various perspectives.
The Woundontology Consortium is a semi-open, international, virtual community of practice devoted to advancing the field of research in non-invasive wound assessment by image analysis, ontology and semantic interpretation and knowledge extraction (content–based visual information retrieval).
This document describes the implementation of a wound care program across multiple hospital sites to standardize practices and improve outcomes. An initial assessment found clinical wound care was inconsistent, outdated, and costly. A collaborative was formed to develop evidence-based guidelines and address barriers like resistance to change. Techniques to spread adoption like appointing a program manager and local committees helped standardize processes. Compliance with guidelines improved significantly for leg ulcers, though complete adherence remained low. Early results showed potential for improved healing times and decreased costs as standardized practices increased. The program aimed to empower clinicians and improve patient outcomes and quality of life through evidence-based wound care.
Seeking patient feedback an important dimension of quality in cancer careAgility Metrics
1) A patient satisfaction survey was conducted with cancer outpatients to identify areas for improvement. Wait times and contacting healthcare providers by telephone received the lowest satisfaction ratings, despite prior interventions to address wait times.
2) Patients followed by a nurse navigator reported higher satisfaction with wait times than those without a nurse navigator.
3) The survey found overall high satisfaction rates, but identified wait times and telephone contact as ongoing priorities for enhancing the patient experience.
The document discusses improving patient safety in intensive care medicine. It describes launching a major initiative through the European Society of Intensive Care Medicine (ESICM) to bring together representatives from critical care societies around the world. The goal is to pledge efforts to improving patient care and outcomes. Key areas of focus include changing medical culture and priorities to better address patient safety issues, and evaluating patient safety at both the individual patient level and collective level to maximize benefits and minimize harms. The initiative aims to raise awareness of patient safety and help transform daily practice to improve quality of care for all patients.
This document provides guidelines for the use of topical antiseptic and antimicrobial agents in wound management. It was developed by a multidisciplinary group of experts and is intended to help clinicians determine when, why, and how to appropriately use these agents. The document discusses the need to use antimicrobials in a targeted manner for short durations based on clinical signs of infection rather than arbitrary timelines. It also addresses issues like antibiotic resistance and the role of antiseptics in wound healing.
This study evaluated the effectiveness of a regenerating matrix therapy (RGTA/CACIPLIQ20) for treating chronic wounds. 16 patients with 22 chronic wounds received twice weekly applications of CACIPLIQ20 for up to 4 weeks. Wound size and pain were measured before, during, and after treatment. The results showed that CACIPLIQ20 significantly reduced wound size by 15-18% and pain levels by 60-70% within 4 weeks. Patient and clinician satisfaction with the treatment also remained high. The therapy may help facilitate wound healing and alleviate wound-related pain.
A randomized controlled trial tested the effects of a palliative care intervention on clinical outcomes in 322 patients with advanced cancer. The intervention consisted of 4 weekly educational sessions and monthly follow-up sessions led by advanced practice nurses, focusing on problem solving, communication, symptom management, and advance care planning. Compared to usual care, the intervention led to higher quality of life and mood scores but did not significantly reduce symptom intensity or hospital resource use. The intervention helped improve patients' well-being and engagement in their care near the end of life.
Making the case for cost-effective wound managementGNEAUPP.
This document discusses cost-effective wound management and making the case for it. It begins by explaining the challenges in wound management, including increasing prevalence of wounds and difficulty collecting data on clinical efficacy, effectiveness, and costs. It then discusses common myths around cost-effectiveness, clarifying that cost-effective does not mean cheaper but provides benefits at a reasonable cost compared to alternatives. The document outlines different types of economic analyses used in healthcare, particularly cost-effectiveness analysis, and discusses understanding costs from various perspectives.
The Woundontology Consortium is a semi-open, international, virtual community of practice devoted to advancing the field of research in non-invasive wound assessment by image analysis, ontology and semantic interpretation and knowledge extraction (content–based visual information retrieval).
This document describes the implementation of a wound care program across multiple hospital sites to standardize practices and improve outcomes. An initial assessment found clinical wound care was inconsistent, outdated, and costly. A collaborative was formed to develop evidence-based guidelines and address barriers like resistance to change. Techniques to spread adoption like appointing a program manager and local committees helped standardize processes. Compliance with guidelines improved significantly for leg ulcers, though complete adherence remained low. Early results showed potential for improved healing times and decreased costs as standardized practices increased. The program aimed to empower clinicians and improve patient outcomes and quality of life through evidence-based wound care.
Seeking patient feedback an important dimension of quality in cancer careAgility Metrics
1) A patient satisfaction survey was conducted with cancer outpatients to identify areas for improvement. Wait times and contacting healthcare providers by telephone received the lowest satisfaction ratings, despite prior interventions to address wait times.
2) Patients followed by a nurse navigator reported higher satisfaction with wait times than those without a nurse navigator.
3) The survey found overall high satisfaction rates, but identified wait times and telephone contact as ongoing priorities for enhancing the patient experience.
The document discusses improving patient safety in intensive care medicine. It describes launching a major initiative through the European Society of Intensive Care Medicine (ESICM) to bring together representatives from critical care societies around the world. The goal is to pledge efforts to improving patient care and outcomes. Key areas of focus include changing medical culture and priorities to better address patient safety issues, and evaluating patient safety at both the individual patient level and collective level to maximize benefits and minimize harms. The initiative aims to raise awareness of patient safety and help transform daily practice to improve quality of care for all patients.
This document provides guidelines for the use of topical antiseptic and antimicrobial agents in wound management. It was developed by a multidisciplinary group of experts and is intended to help clinicians determine when, why, and how to appropriately use these agents. The document discusses the need to use antimicrobials in a targeted manner for short durations based on clinical signs of infection rather than arbitrary timelines. It also addresses issues like antibiotic resistance and the role of antiseptics in wound healing.
This study evaluated the effectiveness of a regenerating matrix therapy (RGTA/CACIPLIQ20) for treating chronic wounds. 16 patients with 22 chronic wounds received twice weekly applications of CACIPLIQ20 for up to 4 weeks. Wound size and pain were measured before, during, and after treatment. The results showed that CACIPLIQ20 significantly reduced wound size by 15-18% and pain levels by 60-70% within 4 weeks. Patient and clinician satisfaction with the treatment also remained high. The therapy may help facilitate wound healing and alleviate wound-related pain.
A randomized controlled trial tested the effects of a palliative care intervention on clinical outcomes in 322 patients with advanced cancer. The intervention consisted of 4 weekly educational sessions and monthly follow-up sessions led by advanced practice nurses, focusing on problem solving, communication, symptom management, and advance care planning. Compared to usual care, the intervention led to higher quality of life and mood scores but did not significantly reduce symptom intensity or hospital resource use. The intervention helped improve patients' well-being and engagement in their care near the end of life.
This research proposal aims to study how strengthening patient-agency, or a patient's ability to manage their own healthcare, can improve outcomes for veterans. The proposal outlines three areas of focus: 1) Developing a standardized method to measure patient-agency in VA settings, 2) Explaining how stressors impact changes in patient-agency over time, and 3) Evaluating how VA programs affect veterans' physical, psychological and economic restoration by changing patient-agency. The goal is to help VA better support veterans' transitions after service by empowering them to direct their own healthcare and treatment.
- The document discusses evidence from systematic reviews and meta-analyses on the use of advanced wound dressings and antimicrobial dressings for chronic wounds such as diabetic foot ulcers, pressure ulcers, and venous leg ulcers.
- The evidence is generally of low quality, and there is insufficient evidence to conclude that any advanced or antimicrobial dressing is more effective for wound healing compared to other dressings.
- Dressing selection should be based on individual clinical assessment and cost-effectiveness considerations. Silver dressings should only be used when there are signs of infection.
Evaluation of the Inpatient Hospital Experience while on PrecautionsKathryn Cannon
This study assessed patient satisfaction of those under contact/airborne isolation precautions versus those not under precautions at Yale-New Haven Hospital. 87 patients were interviewed using a survey measuring satisfaction with communication, treatment explanations, help from staff, pain control, and overall experience. Small variations were found between groups in nurse communication, timely help, pain control, and overall satisfaction. No significant difference was seen in doctor communication, but those under precautions expressed higher satisfaction with treatment explanations. The study aimed to understand differences to improve hospital processes and performance under new CMS reimbursement policies tied to patient satisfaction.
This document discusses issues with patient misidentification in healthcare and proposes solutions. It notes that patient misidentification can lead to medical errors and harm patients. Interventions like using two patient identifiers, barcoding systems, and staff education on safety protocols may help reduce errors related to improper identification. The importance of ensuring patients receive the correct treatments and medications is emphasized.
This document describes several programs from Innovent Oncology aimed at improving cancer care quality and managing costs:
1) Level I Pathways provide evidence-based treatment guidelines developed by community oncologists to standardize care and limit unnecessary variation.
2) Advance Care Planning facilitates discussions around end-of-life care preferences to reduce futile treatment and increase patient/family satisfaction.
3) Patient Support Services provide disease management education and support to improve adherence, reduce emergency visits, and increase satisfaction.
This document discusses patient-reported outcome measures (PROMs) and their importance in drug development and clinical trials for Duchenne muscular dystrophy (DMD). It outlines how multistakeholder meetings including patients, regulators, industry, researchers, and clinicians can provide input to help develop DMD-specific PROMs and guidelines. It also describes the development of the Performance of Upper Limb module, a DMD-specific PROM created with input from DMD patients to measure important functional outcomes.
This document summarizes a patient satisfaction survey conducted at the Massachusetts General Hospital Cancer Center. It provides background on the importance of measuring patient satisfaction and assessing the interpersonal aspects of care delivery. The literature review discusses factors that influence patient satisfaction, such as health status, age, sex, and specific care experiences. It also describes common treatments for breast cancer and the challenges patients face. The document outlines the study's method, results, and discussion sections to evaluate patient satisfaction at the MGH Cancer Center clinic.
This study evaluated the implementation of a value-driven outcomes tool at University of Utah Health Care to measure costs, quality, and outcomes at the individual patient level. The tool identified high variability in costs for certain conditions like sepsis and joint replacements. For three clinical projects using the tool (total joint replacement, hospitalist laboratory testing, and sepsis management), costs decreased 7-11% and quality improved. The tool was associated with reduced costs and better outcomes when used to provide clinicians information on resource use and performance for defined patient populations.
This research article examines the ethical dilemmas faced by palliative care physicians through surveys and interviews with 30 palliative care specialists in Mexico.
The study identified 113 common dilemmas, most frequently regarding sedation, home administration of opioids, and institutional regulations. It was observed that truth-telling and bidirectional trust between patients and providers are core to palliative medicine ethics. The most prominent virtues among participants were justice and professional humility. Physicians in palliative care see themselves most importantly as educators and advisers who provide medical assistance.
The research aims to better understand the values that guide decision-making in palliative care in order to improve care for patients at the end of life. It finds rediscovering virtues in clinical practice can
Rischio Radiologico (Ernesto Mola e Giorgio Visentin)csermeg
1) The document discusses the responsibilities of family doctors in regards to justification and optimization of medical imaging according to the European BSS 2013 guidelines. It describes how family doctors can contribute to ensuring imaging examinations are justified based on clinical need and protocols are optimized to reduce radiation exposure.
2) The document outlines various ways family doctors can help with risk assessment, communication, and management including sharing guidelines, communicating with specialists, collecting patient exposure histories, and involving patients in decision making.
3) WONCA commits to cooperation across stakeholders to promote radiation protection culture through education and establish clear justification processes and clinical imaging guidelines.
This study examined the core predictors of "hassles" experienced by patients with multiple chronic conditions (multimorbidity) in primary care. The researchers surveyed 486 patients with multimorbidity across four general practices in the UK. They found that the most commonly reported hassles related to lack of information about conditions/treatments, poor communication among providers, and poor access to specialists. Having more conditions, symptoms of anxiety/depression, younger age, employment, and no recent discussion with their GP predicted greater hassles. The study highlights key hassles that should be addressed and patient groups most at risk to help design improved models of care for multimorbidity.
This research poster presentation examines the impact of increased protein intake on pressure ulcer prevalence in nursing home patients aged 65 and older with Braden Scale scores between 15-18. The study aims to decrease pressure ulcer rates by providing an extra 30g of protein in a daily smoothie to the sample population. Skin assessments using the Braden Scale will be conducted before and after the 6-week intervention to evaluate changes in pressure ulcer risk levels. The poster outlines the background, PICO question, literature review supporting the benefits of protein supplementation, methods of implementation, and plans for data analysis to determine if the intervention is effective in reducing pressure ulcer prevalence.
The Effect of Protocol of Nursing Intervention on Quality of Care in Minor In...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care.
Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice
This document provides an overview of transitions of care, including definitions, models, and best practices. It describes transitions as the movement of patients between healthcare settings or providers. Poor transitions can lead to adverse outcomes for patients and increased costs. Several evidence-based models are described that aim to improve transitions through elements like medication reconciliation, discharge planning, and post-discharge follow up. These models have demonstrated reductions in readmissions and healthcare utilization. The document provides resources for additional information on improving the quality of patient transitions.
This document discusses the growing recognition of integrating patients and families into healthcare planning and delivery through a model of patient- and family-centered care. It provides examples from individual hospitals and healthcare systems that are partnering with patients at all levels from direct care to policy-making and education. The key aspects of patient- and family-centered care involve dignity and respect, information sharing, participation in decision-making, and collaboration between patients, families and healthcare providers.
The document proposes implementing color-coordinated fall risk identifiers for patients at risk of falls at the Manhattan VA Hospital to potentially decrease falls. It reviews literature finding single interventions like signs or bracelets are less effective than multiple reminders. The proposal is to randomly assign patients scoring high on the Morse Fall Scale to either bright yellow socks/bracelets or a red dot outside their room. Incidences of falls will be compared over 3 months between the two groups to evaluate if color-coordinated identifiers reduce falls more than the current program.
This document summarizes evidence from randomized controlled trials on the use of complementary health approaches for pain management in the United States. It examines trials of acupuncture, massage therapy, osteopathic manipulative therapy, relaxation techniques, natural supplements, tai chi, and yoga for managing chronic low back pain, osteoarthritis, neck pain, and headaches. The trials generally found modest benefits of these approaches for pain relief and functional improvement compared to usual care or placebo, with few reported adverse effects. Larger and longer trials are still needed to provide more definitive evidence.
Wound image analysis classifier for efficient tracking of wound healing statussipij
Wounds are evolved by increase in number of damage tissues. The traditional way of assessing the wound
healing status is to periodic measure of the area covered by the wound. This technique is tedious to
measure and periodic assessment is cumbersome. Basically healing status of the wound can be classified
as contact methods and non contact methods. The purpose of this research work is to accurately assess the
healing status of the wound .To accurately assess the wound, capturing of the wound images are the first
task to be performed. There are various tools like the photographic wound assessment tool (PWAT) to
acquire efficient wound images. Since the characteristics of different types of wounds (venous, pressure,
diabetic, and arterial ulcers) vary markedly, determining the reliability and validity of using the PWAT to
assess wound appearance for both chronic pressure ulcers and leg ulcers due to vascular insufficiency is
important. Segmenting the area of the wound from the wound image using efficient segmentation
techniques and preprocessing the segmented wound to reduce the noise using efficient filters and efficient
denoising techniques. Efficient classifiers are needed to classify the wound images. One among the
classifiers are the Wound Image Analysis Classifier (WIAC). Experimental evaluation has been made on
comparing various classifiers like SVM, KNN, WIAC.
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...CHC Connecticut
Anuj K Dalal presents information on a PCORI research grant: Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.
Integrated Cancer Solutions - Cancer Care PathwaysKirby Ryan, Jr.
This document describes an integrated cancer solutions program from Innovent Oncology that addresses the primary cost drivers of cancer care. It consists of three main components: Level I Pathways to standardize treatment selection and reduce variability, Patient Support Services to improve health status between treatments through disease management, and Advance Care Planning to improve end of life care and reduce unnecessary interventions. The goal is more consistent, predictable care that improves outcomes and the experience for patients, payers, and providers.
* Patient-level & wound-level parameters influencing wound
healing were identified from prior research and clinician input
* Probability of wound healing can be predicted with reasonable
accuracy in real-world data from EMRs
The document discusses efforts by the US Department of Health and Human Services (HHS) to address the growing challenges posed by multiple chronic conditions. HHS released a 2010 strategic framework with 4 goals: 1) foster health system changes like accountable care organizations and medical homes, 2) empower individuals through self-management programs, 3) equip clinicians with guidelines and training, and 4) enhance research. Since then, HHS has made progress in areas like expanding self-management programs, testing new care models, establishing payments for non-face-to-face care management, and increasing focus on comorbidities in clinical trials and guidelines. However, more accelerated efforts are still needed across all goals to better meet the needs of the growing multiple
This research proposal aims to study how strengthening patient-agency, or a patient's ability to manage their own healthcare, can improve outcomes for veterans. The proposal outlines three areas of focus: 1) Developing a standardized method to measure patient-agency in VA settings, 2) Explaining how stressors impact changes in patient-agency over time, and 3) Evaluating how VA programs affect veterans' physical, psychological and economic restoration by changing patient-agency. The goal is to help VA better support veterans' transitions after service by empowering them to direct their own healthcare and treatment.
- The document discusses evidence from systematic reviews and meta-analyses on the use of advanced wound dressings and antimicrobial dressings for chronic wounds such as diabetic foot ulcers, pressure ulcers, and venous leg ulcers.
- The evidence is generally of low quality, and there is insufficient evidence to conclude that any advanced or antimicrobial dressing is more effective for wound healing compared to other dressings.
- Dressing selection should be based on individual clinical assessment and cost-effectiveness considerations. Silver dressings should only be used when there are signs of infection.
Evaluation of the Inpatient Hospital Experience while on PrecautionsKathryn Cannon
This study assessed patient satisfaction of those under contact/airborne isolation precautions versus those not under precautions at Yale-New Haven Hospital. 87 patients were interviewed using a survey measuring satisfaction with communication, treatment explanations, help from staff, pain control, and overall experience. Small variations were found between groups in nurse communication, timely help, pain control, and overall satisfaction. No significant difference was seen in doctor communication, but those under precautions expressed higher satisfaction with treatment explanations. The study aimed to understand differences to improve hospital processes and performance under new CMS reimbursement policies tied to patient satisfaction.
This document discusses issues with patient misidentification in healthcare and proposes solutions. It notes that patient misidentification can lead to medical errors and harm patients. Interventions like using two patient identifiers, barcoding systems, and staff education on safety protocols may help reduce errors related to improper identification. The importance of ensuring patients receive the correct treatments and medications is emphasized.
This document describes several programs from Innovent Oncology aimed at improving cancer care quality and managing costs:
1) Level I Pathways provide evidence-based treatment guidelines developed by community oncologists to standardize care and limit unnecessary variation.
2) Advance Care Planning facilitates discussions around end-of-life care preferences to reduce futile treatment and increase patient/family satisfaction.
3) Patient Support Services provide disease management education and support to improve adherence, reduce emergency visits, and increase satisfaction.
This document discusses patient-reported outcome measures (PROMs) and their importance in drug development and clinical trials for Duchenne muscular dystrophy (DMD). It outlines how multistakeholder meetings including patients, regulators, industry, researchers, and clinicians can provide input to help develop DMD-specific PROMs and guidelines. It also describes the development of the Performance of Upper Limb module, a DMD-specific PROM created with input from DMD patients to measure important functional outcomes.
This document summarizes a patient satisfaction survey conducted at the Massachusetts General Hospital Cancer Center. It provides background on the importance of measuring patient satisfaction and assessing the interpersonal aspects of care delivery. The literature review discusses factors that influence patient satisfaction, such as health status, age, sex, and specific care experiences. It also describes common treatments for breast cancer and the challenges patients face. The document outlines the study's method, results, and discussion sections to evaluate patient satisfaction at the MGH Cancer Center clinic.
This study evaluated the implementation of a value-driven outcomes tool at University of Utah Health Care to measure costs, quality, and outcomes at the individual patient level. The tool identified high variability in costs for certain conditions like sepsis and joint replacements. For three clinical projects using the tool (total joint replacement, hospitalist laboratory testing, and sepsis management), costs decreased 7-11% and quality improved. The tool was associated with reduced costs and better outcomes when used to provide clinicians information on resource use and performance for defined patient populations.
This research article examines the ethical dilemmas faced by palliative care physicians through surveys and interviews with 30 palliative care specialists in Mexico.
The study identified 113 common dilemmas, most frequently regarding sedation, home administration of opioids, and institutional regulations. It was observed that truth-telling and bidirectional trust between patients and providers are core to palliative medicine ethics. The most prominent virtues among participants were justice and professional humility. Physicians in palliative care see themselves most importantly as educators and advisers who provide medical assistance.
The research aims to better understand the values that guide decision-making in palliative care in order to improve care for patients at the end of life. It finds rediscovering virtues in clinical practice can
Rischio Radiologico (Ernesto Mola e Giorgio Visentin)csermeg
1) The document discusses the responsibilities of family doctors in regards to justification and optimization of medical imaging according to the European BSS 2013 guidelines. It describes how family doctors can contribute to ensuring imaging examinations are justified based on clinical need and protocols are optimized to reduce radiation exposure.
2) The document outlines various ways family doctors can help with risk assessment, communication, and management including sharing guidelines, communicating with specialists, collecting patient exposure histories, and involving patients in decision making.
3) WONCA commits to cooperation across stakeholders to promote radiation protection culture through education and establish clear justification processes and clinical imaging guidelines.
This study examined the core predictors of "hassles" experienced by patients with multiple chronic conditions (multimorbidity) in primary care. The researchers surveyed 486 patients with multimorbidity across four general practices in the UK. They found that the most commonly reported hassles related to lack of information about conditions/treatments, poor communication among providers, and poor access to specialists. Having more conditions, symptoms of anxiety/depression, younger age, employment, and no recent discussion with their GP predicted greater hassles. The study highlights key hassles that should be addressed and patient groups most at risk to help design improved models of care for multimorbidity.
This research poster presentation examines the impact of increased protein intake on pressure ulcer prevalence in nursing home patients aged 65 and older with Braden Scale scores between 15-18. The study aims to decrease pressure ulcer rates by providing an extra 30g of protein in a daily smoothie to the sample population. Skin assessments using the Braden Scale will be conducted before and after the 6-week intervention to evaluate changes in pressure ulcer risk levels. The poster outlines the background, PICO question, literature review supporting the benefits of protein supplementation, methods of implementation, and plans for data analysis to determine if the intervention is effective in reducing pressure ulcer prevalence.
The Effect of Protocol of Nursing Intervention on Quality of Care in Minor In...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care.
Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice
This document provides an overview of transitions of care, including definitions, models, and best practices. It describes transitions as the movement of patients between healthcare settings or providers. Poor transitions can lead to adverse outcomes for patients and increased costs. Several evidence-based models are described that aim to improve transitions through elements like medication reconciliation, discharge planning, and post-discharge follow up. These models have demonstrated reductions in readmissions and healthcare utilization. The document provides resources for additional information on improving the quality of patient transitions.
This document discusses the growing recognition of integrating patients and families into healthcare planning and delivery through a model of patient- and family-centered care. It provides examples from individual hospitals and healthcare systems that are partnering with patients at all levels from direct care to policy-making and education. The key aspects of patient- and family-centered care involve dignity and respect, information sharing, participation in decision-making, and collaboration between patients, families and healthcare providers.
The document proposes implementing color-coordinated fall risk identifiers for patients at risk of falls at the Manhattan VA Hospital to potentially decrease falls. It reviews literature finding single interventions like signs or bracelets are less effective than multiple reminders. The proposal is to randomly assign patients scoring high on the Morse Fall Scale to either bright yellow socks/bracelets or a red dot outside their room. Incidences of falls will be compared over 3 months between the two groups to evaluate if color-coordinated identifiers reduce falls more than the current program.
This document summarizes evidence from randomized controlled trials on the use of complementary health approaches for pain management in the United States. It examines trials of acupuncture, massage therapy, osteopathic manipulative therapy, relaxation techniques, natural supplements, tai chi, and yoga for managing chronic low back pain, osteoarthritis, neck pain, and headaches. The trials generally found modest benefits of these approaches for pain relief and functional improvement compared to usual care or placebo, with few reported adverse effects. Larger and longer trials are still needed to provide more definitive evidence.
Wound image analysis classifier for efficient tracking of wound healing statussipij
Wounds are evolved by increase in number of damage tissues. The traditional way of assessing the wound
healing status is to periodic measure of the area covered by the wound. This technique is tedious to
measure and periodic assessment is cumbersome. Basically healing status of the wound can be classified
as contact methods and non contact methods. The purpose of this research work is to accurately assess the
healing status of the wound .To accurately assess the wound, capturing of the wound images are the first
task to be performed. There are various tools like the photographic wound assessment tool (PWAT) to
acquire efficient wound images. Since the characteristics of different types of wounds (venous, pressure,
diabetic, and arterial ulcers) vary markedly, determining the reliability and validity of using the PWAT to
assess wound appearance for both chronic pressure ulcers and leg ulcers due to vascular insufficiency is
important. Segmenting the area of the wound from the wound image using efficient segmentation
techniques and preprocessing the segmented wound to reduce the noise using efficient filters and efficient
denoising techniques. Efficient classifiers are needed to classify the wound images. One among the
classifiers are the Wound Image Analysis Classifier (WIAC). Experimental evaluation has been made on
comparing various classifiers like SVM, KNN, WIAC.
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...CHC Connecticut
Anuj K Dalal presents information on a PCORI research grant: Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.
Integrated Cancer Solutions - Cancer Care PathwaysKirby Ryan, Jr.
This document describes an integrated cancer solutions program from Innovent Oncology that addresses the primary cost drivers of cancer care. It consists of three main components: Level I Pathways to standardize treatment selection and reduce variability, Patient Support Services to improve health status between treatments through disease management, and Advance Care Planning to improve end of life care and reduce unnecessary interventions. The goal is more consistent, predictable care that improves outcomes and the experience for patients, payers, and providers.
* Patient-level & wound-level parameters influencing wound
healing were identified from prior research and clinician input
* Probability of wound healing can be predicted with reasonable
accuracy in real-world data from EMRs
The document discusses efforts by the US Department of Health and Human Services (HHS) to address the growing challenges posed by multiple chronic conditions. HHS released a 2010 strategic framework with 4 goals: 1) foster health system changes like accountable care organizations and medical homes, 2) empower individuals through self-management programs, 3) equip clinicians with guidelines and training, and 4) enhance research. Since then, HHS has made progress in areas like expanding self-management programs, testing new care models, establishing payments for non-face-to-face care management, and increasing focus on comorbidities in clinical trials and guidelines. However, more accelerated efforts are still needed across all goals to better meet the needs of the growing multiple
Running head McVeigh– Defensive Medicine Essay 1 1 .docxcowinhelen
Running head: McVeigh– Defensive Medicine Essay 1
1
It has been said that the fear of medical liability drives healthcare providers, particularly
physicians, to unnecessarily order diagnostic tests and to perform treatments and procedures
that may not be necessary, simply to ensure that nothing is left undone. Is this in fact the case?
Defend position on this premise using literature.
Langley McVeigh, MHA, FACHE
May 23, 2017
McVeigh - Defensive Medicine 2
Yes, defensive medicine is practiced in the United States. However, it is important to
understand: (1) what impact it has on healthcare expenditures (2) to what degree does it occur
(prevalence) and (3) if so, what can be done to prevent it?
As an emergency services administrator for a Level 1 trauma center, experience has led
me to understand the dynamic influencing physicians in their clinical decision making process.
Ideally, this process should be void of non-clinical bias or influence. However, this is not the
case in many circumstances. Physicians are considering risk and liability when ordering tests
and procedures. This risk management, or risk mis-management, phenomenon is called
defensive medicine. By definition, these occurrences are medical practices intended to
exonerate practitioners from liability with limited or without medical benefit to the patient
(Sethi et al, 2012). Physicians have been directed by health policy to provide value based care,
but defensive medicine practice works against this care model.
There have been studies conducted measuring physician attitudes towards tort reform
and defensive medicine practices. While studies show physicians, especially high risk medical
specialists, regularly practicing defensive medicine, the cost implications are unclear.
Furthermore, proposed reforms to the medical tort system must be investigated. Some have
proposed to completely do away with the medical tort litigation and insurance system,
replacing it with a system similar to workman’s compensation models. While it may be a reflex
mechanism to use cost as a metric to measure results of defensive medicine practices, patient
outcomes and quality of life implications must also be measured. The patient is the one who is
being subjected to additional and unwarranted procedures.
McVeigh - Defensive Medicince 3
According to a survey of 2000 orthopedic surgeons in 2010 (Sethi et al, 2012), of the
1214 respondents, 96% admitted to have practiced defensive medicine by ordering labs,
imaging studies, specialist referrals, and inpatient admissions. Many surgeons confided this was
done to avoid malpractice claims. These prescriptions offered little no benefit to patient
outcomes, and contrary to the current posture of value based practice in our health care
system. This additional intervention is costly, at an inconvenience to the patient, and may carry
additional health risk. As a reflex, one may think of ...
The document summarizes an evidence based project presentation on negative pressure wound therapy (NPWT) for diabetic foot ulcers (DFU). It includes objectives of the presentation, background information on evidence based nursing practice and DFUs. It also outlines the research question comparing NPWT to standard moist wound therapy for healing diabetic foot ulcers over 60 days. A literature review was conducted and findings from 5 systematic reviews showing NPWT increases healing rates for DFUs are summarized. National guidelines also support the use of NPWT for DFUs.
This document discusses the costs of medical errors and efforts to reduce preventable hospital-acquired conditions (HACs). It notes that medical errors may cause up to 98,000 deaths per year costing up to $29 billion annually. Hospitals have little incentive to improve safety due to externalizing most error costs. In response, policies began denying Medicare/Medicaid payments for treatments from certain HACs considered preventable. This policy was expanded in 2012/2015 and may reduce payments to hospitals with the highest rates of HACs. The goal is to incentivize greater patient safety.
Running Head ARTICLE CRITIQUERESEARCH ARTICLE CRITIQUE2.docxtoddr4
The two articles discuss the prevalence of pressure ulcers in hospital and skilled nursing facility patients. The first article finds that using prophylactic foam dressings on high-risk patients in hospitals significantly reduced pressure injury rates. The second article finds that regular assessment and preventative measures like hydropolymer foam dressings eliminated pressure ulcers in a long-term care facility. Both articles indicate that protecting bony areas from pressure and friction can reduce or eliminate pressure ulcers.
An enhanced care management program achieved lower health care costs through broader outreach, personalized health coaching, and engagement of higher-risk populations. A randomized controlled trial of 175,000 individuals found that the enhanced program led to a $7.96 lower average monthly medical cost per member and over a 4:1 return on investment. Key aspects of the enhanced program included targeting a wider range of chronic and preference-sensitive conditions, more frequent outreach, and deeper health coaching relationships.
A collaborative organization structure is beneficial toward improving quality and patient satisfaction for wound care billing services than a fragmented organizational structure.
Rehabilitation for and Stroke Patients.docxwrite22
This document discusses a proposed change to address the high prevalence of pressure ulcers among hospitalized post-surgical and stroke patients. It proposes implementing a multifaceted educational intervention for nurses to enhance their knowledge and confidence in caring for patients with or at risk of pressure ulcers. This is aimed to reduce ulcer incidence by improving nursing care. The effectiveness will be measured by decreased pressure ulcer cases, deaths, and readmissions post-implementation. However, reluctance to change and lack of funding could hinder the plan.
Article Type: Editorial
Title: Patient Safety: Paradigm shift of modern healthcare delivery and research
Year: 2022; Volume: 2; Issue: 1; Page No: 1 – 2
Author: Dr. Mohammed Imran
10.55349/ijmsnr.20222112
Affiliation: Associate Professor, Medical Pharmacology, College of Medicine and Health Sciences, Sohar, National University of Science and Technology, Sultanate of Oman.
Email ID: imran@nu.edu.om
Article Summary:
Submitted : 10-February-2022
Revised : 26-February-2022
Accepted : 12-March-2022
Published : 31-March-2022
Impact Of Improved Documentation On An Academic Neurosurgical PracticeAntoinette Williams
This document discusses the impact of an educational intervention on documentation accuracy at an academic neurosurgery department. The intervention provided training to physicians on properly documenting patient comorbidities. After the intervention, measures of case complexity including severity of illness, risk of mortality, and case mix index all significantly increased, reflecting more accurate documentation. As a result, the average margin per discharge improved by 42.2%, showing the financial impact of improved documentation. The study demonstrates that targeted training can meaningfully improve documentation quality and its effects on quality metrics and revenue.
DN 703 Identifying a Target Population Research Paper.docxwrite5
The target population is adult patients who return to the emergency department within 72 hours of being discharged. This population often returns due to an inability to understand discharge instructions and access follow-up care. The paper will analyze the cultural, psychosocial, environmental, and demographic factors of this population and propose an intervention involving nurses providing detailed discharge explanations and ensuring effective communication through the use of interpreters if needed. It will also discuss developing a discharge checklist and establishing reliable post-discharge contact to address patient concerns without returning to the emergency department.
Resource Nurse Program.A Nurse-Initiated, Evidence-Based Program to Eliminate...GNEAUPP.
✔ El programa Enfermera de Recursos alienta al personal de enfermería a explorar los factores causales relacionados con el desarrollo de la PU.
✔ enseñanza / aprendizaje de igual a igual es una estrategia efectiva para llegar a las enfermeras de cabecera.
✔ Las enfermeras de recursos tienen el poder de cambiar la práctica.
✔ El programa de la enfermera de recursos es una manera rentable de reducir Hapus.
When developing a business strategy centered on the patient, organizations must adapt and implement programs that foster information sharing and collaboration while providing faster and greater access to life-changing products.
jlme article final on NGS coverage n reimb issues w pat deverkaJennifer Dreyfus
The document discusses the challenges of obtaining coverage and reimbursement for clinical next generation sequencing (NGS) from both public and private health payers. It outlines the evidentiary standards payers use to evaluate new diagnostic tests, including requirements for analytic validity, clinical validity, and clinical utility. However, establishing these standards is difficult for NGS given limitations in analytical validation methods, lack of proficiency testing, and the technology's rapid advancement. Additionally, while regulatory approval for market entry requires less evidence than reimbursement decisions, demand for NGS often outpaces evidence development. The document argues more collaboration is needed between developers and payers to strengthen evidence standards and facilitate clinical integration of NGS.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
Comment1Nursing practice has changed in how nurses handle and ca.docxdivinapavey
Comment1
Nursing practice has changed in how nurses handle and care for central lines as well as how central lines are inserted specifically peripherally inserted central catheters. The reduction of CLABSI’s (central line associated blood stream infection) and the use of an insertion bundle have greatly improved patient outcomes in the last many years. These practice changes have reduced patient mortality and decreased the length of patient stay in the ICU. Through these studies and by implementation of new processes brings awareness to nursing staff on what needs to be done to better care and protect our patients. The findings have changed my overall view of central lines. When I cared for central lines I was more careful at assessing, accessing, documenting and advocating for earlier removal of these devices when no longer needed in my patient. At the hospital where I work, dressing changes of central lines are a two person process and the use of CUROS caps to cover needless connectors or injectable ports on tubing is required to prevent infection. The insertion bundle is utilized by our PICC team who do their part in following strict guidelines when placing the central line catheter.
Comment2
Hospital Acquired Pressure Ulcers (HAPU) is a topic of great concern in health care delivery due health impact and complications on affected patients, as well as the cost and reimbursement issues. The costs of pressure ulcers are extremely high. Patients die from sepsis related to pressure ulcers that become chronic. According to National Pressure Ulcer Advisory Panel 2017, more than 2.5 million patients develop pressure injury (PI) a year, national incidence rate of 2.5% in hospitals, and 60, 000 death a year (William Padula, John Hopkins University). PI injury cost US Health system $9-11 billion a year. In an effort to prevent HAPU, death caused by sepsis related to pressure ulcers, Stage II and III pressure Ulcers are among the eight preventable conditions identified by Medicare and Medicaid which extra payment are eliminated. Medicare and Medicaid stop reimbursing hospitals for certain hospital-acquired conditions considered preventable in the hospital setting, private insurance also follow this step. Pressure ulcers are a potential complication of prolonged bed rest and are included in the category of hospital-acquired conditions. Incontinent patients are especially prone to pressure ulcers if moisture is not managed adequately. The key to prevent pressure entails is to first identify patients at risk; and second implementing strategies for all patients who are identified at risk. Health care delivery has the duty to focus patient care to prevent PI by inspecting skin daily, managing moisture on skin, conducting a pressure ulcer admission assessment for all patients, minimizing pressure, optimizing nutrition and hydration, reassessing risk for all patients daily. Following these steps help improving patient care and prevent in ...
This document describes a study protocol to evaluate the effectiveness of a planned teaching program for preventing pressure ulcers among fracture patients in a selected hospital in Bangalore. The study aims to provide patients and their family members with health education to improve knowledge on preventing pressure ulcers. A literature review found that pressure ulcer incidence is high for immobile patients like those with orthopedic fractures. Studies show prevention is better than treatment and nurses play a key role in educating patients and monitoring skin integrity. The planned teaching program aims to reduce pressure ulcer rates by empowering patients with knowledge on prevention.
Value in healthcare aims to improve patient outcomes while lowering costs. It rewards providers for quality rather than quantity of care. While some progress has been made through examples like integrated systems in India and Germany that lower costs through better processes, value-based care has not been widely adopted due to barriers like entrenched financial incentives that prioritize volume over value. Fully realizing value-based care requires health informatics to track outcomes, benchmarking to share best practices, alternative payment models, and delivery innovations to better coordinate care.
The article discusses how the Comprehensive Care Physicians (CCP) model proved to improve patient care and reduce utilization for patients at increased risk for hospitalization.
- Video recording of this lecture in English language: https://youtu.be/RvdYsTzgQq8
- Video recording of this lecture in Arabic language: https://youtu.be/ECILGWtgZko
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
Congestive Heart failure is caused by low cardiac output and high sympathetic discharge. Diuretics reduce preload, ACE inhibitors lower afterload, beta blockers reduce sympathetic activity, and digitalis has inotropic effects. Newer medications target vasodilation and myosin activation to improve heart efficiency while lowering energy requirements. Combination therapy, following an assessment of cardiac function and volume status, is the most effective strategy to heart failure care.
Gene therapy can be broadly defined as the transfer of genetic material to cure a disease or at least to improve the clinical status of a patient.
One of the basic concepts of gene therapy is to transform viruses into genetic shuttles, which will deliver the gene of interest into the target cells.
Safe methods have been devised to do this, using several viral and non-viral vectors.
In the future, this technique may allow doctors to treat a disorder by inserting a gene into a patient's cells instead of using drugs or surgery.
The biggest hurdle faced by medical research in gene therapy is the availability of effective gene-carrying vectors that meet all of the following criteria:
Protection of transgene or genetic cargo from degradative action of systemic and endonucleases,
Delivery of genetic material to the target site, i.e., either cell cytoplasm or nucleus,
Low potential of triggering unwanted immune responses or genotoxicity,
Economical and feasible availability for patients .
Viruses are naturally evolved vehicles that efficiently transfer their genes into host cells.
Choice of viral vector is dependent on gene transfer efficiency, capacity to carry foreign genes, toxicity, stability, immune responses towards viral antigens and potential viral recombination.
There are a wide variety of vectors used to deliver DNA or oligo nucleotides into mammalian cells, either in vitro or in vivo.
The most common vector system based on retroviruses, adenoviruses, herpes simplex viruses, adeno associated viruses.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14...Donc Test
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition (Hinkle, 2017) Verified Chapter's 1 - 73 Complete.pdf
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Pharmacology of 5-hydroxytryptamine and Antagonist
Physician led bedside wound care
1. 32 OSTOMY WOUND MANAGEMENT SEPTEMBER 2010 www.o-wm.com
FEATURE
A Retrospective Comparison of Clinical
Outcomes and Medicare Expenditures in
Skilled Nursing Facility Residents with
Chronic Wounds
Joan E. DaVanzo, PhD, MSW; Audrey M. El-Gamil; Allen Dobson, PhD; and
Namrata Sen, MHSA
Abstract
Medicare skilled nursing facility (SNF) residents with chronic wounds require more resources and have relatively high health-
care expenditures compared to Medicare patients without wounds. A retrospective cohort study was conducted using 2006
Medicare Chronic Condition Warehouse claims data for SNF, inpatient, outpatient hospital, and physician supplier settings
along with 2006 Long-Term Care Minimum Data Set (MDS) information to compare Medicare expenditures between two
groups of SNF residents with a diagnosis of pressure, venous, ischemic, or diabetic ulcers whose wounds healed during
the 10-month study period. The study group (n = 372) was managed using a structured, comprehensive wound management
protocol provided by an external wound management team. The matched comparison group consisted of 311 SNF residents
who did not receive care from the wound management team. Regression analyses indicate that after controlling for resident
comorbidities and wound severity, study group residents experienced lower rates of wound-related hospitalization per day
(0.08% versus 0.21%, P <0.01) and shorter wound episodes (94 days versus 115 days, P <0.01) than comparison group
patients. Total Medicare costs were $21,449.64 for the study group and $40,678.83 for the comparison group (P <0.01) or
$229.07 versus $354.26 (P <0.01) per resident episode day. Additional studies including wounds that do not heal are war-
ranted. Increasing the number of SNF residents receiving the care described in this study could lead to significant Medicare
cost savings. Incorporating wound clinical outcomes into a pay-for-performance measures for SNFs could increase broader
SNF adoption of comprehensive wound care programs to treat chronic wounds.
Key Words: Medicare, long-term care, wounds, injury, cost
Index: Ostomy Wound Management 2010;56(9):xx–xx
Potential Conflicts of Interest: This study was conducted by The Lewin Group and Dobson DaVanzo & Associates, LLC,
with funding and guidance from Vohra Wound Management. Vohra Wound Management helped identify the study group
residents and determine study objectives and outcomes to be measured. Opinions expressed are those of the authors,
not the companies they are affiliated with nor the project sponsor. None of the authors has any financial interest, relation-
ship, or affiliation with Vohra Wound Management beyond the contract of the study funding.
Dr. DaVanzo is Chief Executive Officer, Dobson DaVanzo & Associates, LLC, Vienna, VA. At the time of the study, Ms. El-Gamil was an Associate at The Lewin
Group, Falls Church, VA. She now is a Senior Associate at Dobson DaVanzo & Associates. Dr. Dobson is President at Dobson DaVanzo & Associates. Ms. Sen is
a Senior Consultant, The Lewin Group. Please address correspondence to: Audrey M. El-Gamil, Dobson DaVanzo & Associates, LLC, 440 Maple Avenue East,
Suite 203, Vienna, VA 22180; email: Audrey.el-gamil@dobsondavanzo.com.
Earn CEUs for studying this article.
Visit www.numedix.com.
2. SEPTEMBER 2010 OSTOMY WOUND MANAGEMENT 33www.o-wm.com
REDUCING MEDICARE EXPENDITURES AND IMPROVING OUTCOMES
Healthcare reform has long been debated with emphasis on
big picture aspects such as population coverage, insurance
market structures with or without a public plan, system fi-
nance, provider payment systems, and benefit designs. Evi-
dence-based clinical guidelines, quality measurements, and
pay-for-performance have become important parts of the dis-
cussion in the move toward healthcare reform implementa-
tion. Ultimately, healthcare reform can succeed only if care
delivery is rationalized and costs are controlled, which will re-
quire the identification of cost-effective systems of care for
common chronic conditions.
This study focuses on the treatment of Medicare benefici-
ary lower extremity chronic wounds managed in the Medicare
skilled nursing facility (SNF) setting. Lower extremity ulcers,
including pressure, venous, ischemic, and diabetic ulcers, are
a common and costly problem in all institutional healthcare
settings.1 Pressure ulcer prevalence may range from 2.2% to
23.9% in the SNF setting and is particularly problematic for
older Medicare SNF residents.2,3 In 2004, of 1.5 million US
nursing home residents, approximately 159,000 (11%) had
pressure ulcers (any stage) — Stage II ulcers were the most
common (5% of residents) and account for 50% of all pres-
sure ulcers.4 Results of a retrospective cohort study5 from 2000
showed that venous ulcer prevalence in long-term care set-
tings at admission is 2.5%, with an incidence for patients ad-
mitted without a venous ulcer ranging from 1.0% to 2.2%
within 90 to 365 days from admission.
With the availability of wound care guidelines for treating
and preventing chronic wounds (including pressure, venous,
and diabetic ulcers),6-9 the Centers for Medicare and Medicaid
Services (CMS) has included wound care as a quality measure
for nursing homes. In the SNF environment, the Design for
Nursing Home Compare Five-Star Quality Rating System:
Technical User Guide10 (the Guide) includes the “percent of
high risk residents who have pressure sores” as one of its five
long-stay quality measures. The Guide indicates that pressure
ulcer prevalence can be influenced by nursing home care prac-
tices such as, “frequent scheduling of assessments for suspi-
cious skin areas, observations on the environmental
assessments of residents, and care practices related to how the
nursing home manages clinical, psychosocial, and nutritional
complications.”10 Like many aspects of healthcare, much of
successful wound care is based on basic clinical principles.11
Additionally, several state quality improvement organiza-
tions (QIOs) have developed initiatives to prevent and treat
pressure ulcers and other chronic ulcers. For example, the New
Jersey Hospital Association created a Pressure Ulcer Collabo-
ration that used evidence-based guidelines to develop stan-
dards of quality care for pressure ulcers across all provider
settings. In this initiative, SNFs represented 21% of the par-
ticipating organizations.12 A Texas QIO also was able to im-
prove quality of care and prevent pressure ulcers in SNFs.13
In order to heal an ulcer as fast and cost-efficiently as possi-
ble, providers at long-term care facilities often use a multidis-
ciplinary approach,including nursing,physical therapy,dietary,
pharmacy, and occupational therapy.14 A pseudo-randomized
pragmatic cluster trial15 conducted in 2007 to determine the ef-
fectiveness of providing multidisciplinary wound management
using standard modern wound care protocols concluded that
treatment of chronic wounds in nursing homes by trained mul-
tidisciplinary wound care teams using modern wound care pro-
tocols is cost-effective compared to “usual” wound care, which
is classified as care providedby healthcare professionals without
wound care training and without pharmacist involvement in
wound management.Furthermore,the Association for the Ad-
vancement of Wound Care16 (AAWC) notes that the “impor-
tance of communicating through an interdisciplinary approach
is crucial to ensure that patients are receiving care that is timely
and that follows current evidence-based practice.” An interdis-
ciplinary approach includes care from a trained wound special-
ist, a team of healthcare professionals within the SNF,
nutritionists,physical therapists,an internal medicine specialist,
and family education. As demonstrated in the AAWC Concep-
tual Framework of Quality Systems for Wound Care,17 quality
wound care is achieved through the six pillars of quality,includ-
ing safe,effective,patient-centered,efficient,and equitable care.
A risk-based Markov analysis18 conducted in 2004 to sim-
ulate the health and economic outcomes of optimal care of
the diabetic foot in a hypothetical population of patients with
diabetes found that evidence-based chronic foot wound pro-
grams that “included intensive glycemic control, regular foot
examinations, risk stratification, patient education, clinician
education, and multidisciplinary foot care increased life ex-
pectancy and reduced the incidence of foot complications” in
patients with diabetes. A white paper19 developed by the Na-
tional Pressure Ulcer Advancement Panel in 2009 reviewed
the scientific evidence on nutrition and hydration for pressure
ulcer prevention and treatment and concluded that under-nu-
trition may decrease the body’s ability to fight infection and
have a negative effect on pressure ulcer healing. Protein is re-
sponsible for the synthesis of enzymes involved in healing.
SNFs can contract with board-certified physicians and
wound-care specialists to provide services; Lee and Turnbull20
Key Points
• The prevalence, incidence, and costs of care for
skilled nursing facility (SNF) residents with chronic
wounds are high.
• A retrospective analysis of healed wounds using
Medicare and MDS data showed that wound-related
costs were significantly lower in residents whose
wounds were managed using a standardized, multi-
disciplinary protocol of care.
• SNF residents who did not receive the consults and
protocol of care were more likely to be hospitalized
and their wounds took longer to heal.
Ostomy Wound Management 2010;56(9):xx-xx
3. suggested that contracting with a physician to perform de-
bridement services is more cost-effective and results in faster
healing times than applying chemical debridement agents and
other treatments commonly provided by SNFs.Although sev-
eral guidelines have been developed on how to prevent
chronic wounds, a 1997 survey21 of 155 family physicians
found that more than 70% of physicians feel they lack educa-
tion on proper pressure ulcer management. Additionally, the
same study found that physicians attending one or more nurs-
ing homes to provide wound care
were more likely to feel strongly that
it was the physician’s role to provide
care to patients with pressure ulcers
(P <0.01). Given these findings, it is
reasonable to expect that a wound
care expert and a multidisciplinary
team could provide cost-effective
wound care with better clinical out-
comes.
The purpose of this retrospective
cohort study was to compare clinical
outcomes and cost of care between
SNF residents with chronic wounds
receiving a specific structured, com-
prehensive wound management pro-
tocol (study group) to SNF residents
in other mutually exclusive facilities
who receive a range of wound care
treatments (comparison group).
Methods
The study was conducted using
Medicare administrative claims data
from the Centers of Medicare and
Medicaid Services 2006 Medicare
Chronic Condition Warehouse
(CCW) file for SNF, inpatient, outpa-
tient hospital, and physician supplier
settings and from the Long Term
Care Minimum Data Set (MDS).
Study and comparison group resi-
dents were selected based on the pres-
ence of ICD-9-CM and CPT/HCPCS
codes indicating the presence of pres-
sure, venous, ischemic, or diabetic ul-
cers and receipt of wound care
treatment and procedures while re-
siding in a SNF. Wound healing was
not used as a inclusion criteria in this
initial data request (see Table 1).
Wound care. The study group’s
structured, comprehensive wound
care protocol comprises treatment by
Vohra Wound Management, Miami,
FL, and is consistent with modern wound care standards and
an interdisciplinary approach to wound care led by a trained
wound specialist. A provider’s decision to request a consulta-
tion from the wound management team for a SNF resident
and use of the wound care protocol is thought to be essentially
random, thus limiting facility effects. The protocol includes
sharp debridement of nonviable tissue at the bedside and early
aggressive topical treatment of heavily contaminated or in-
fected wounds to prevent the need for systematic treatments.
34 OSTOMY WOUND MANAGEMENT SEPTEMBER 2010 www.o-wm.com
FEATURE
Table 1. Wound-related diagnoses and procedure codes
Wounds included in study
Chronic decubitus (pressure) ulcer
Ulcer of lower limbs, except decubitus
Varicose (venous) ulcer of lower extremities, with
inflammation, and with ulcer and inflammation
Open wound of foot, toes
Unspecified open wounds of lower limbs
Wound-related diagnoses/DRGsa
(unfavorable clinical outcomes)
Wound-related infection
Gangrene
Amputation
Wound-related hospitalization (based on
presence of wound-related DRG)b
Upper limb and toe amputation for circulatory
system disorders
Skin graft and/or debridement for skin ulcer or
cellulitis with or without complications
Skin graft and/or debridement except for skin ulcer
or cellulitis with or without complications
Skin ulcers
Amputation of lower limb for endocrine, nutritional,
and metabolic disorders
Skin grafts and wound debridement for
endocrine, nutritional and metabolic disorders
Wound debridement for injuries
Septicemia
Wound debridement and graft
Wound-related procedures
Wound debridement
Removal of devitalized tissue from wounds,
nonselective or selective
Debridement of infected skin and subcutaneous
tissue/muscle
Excision for various types of pressure ulcers
Amputation
Negative pressure wound therapy
Hyperbaric oxygen therapy
ICD-9-CM
707.0 – 707.09
707.1 – 707.19, 707.8 – 707.9
454.0, 454.1, 454.2
892, 893
894
ICD-9-CM
684
785.4
895 – 897
DRG
114
263 – 264
265 – 266
271
285
287
440
416
217
CPT/HCPCS
97602, 97597 – 97598
11000 – 11044
15920 – 15999
27880 – 27888, 28800 – 28825
97605 – 97606
C1300, 99183
a Diagnoses Related Groups
b Wound-related hospitalization codes are accompanied by additional wound-related procedures to
ensure the patient had a wound
4. SEPTEMBER 2010 OSTOMY WOUND MANAGEMENT 35www.o-wm.com
Furthermore, under the guidance of the wound care specialist
contracted to provide treatment, the SNF team addresses nu-
trition, appropriate support services and wound offloading,
physical therapy, vascular compromise, pain control, diabetes
control, and functional expectations. It is unknown if any care
provided in the comparison group was performed by a wound
care specialist.
Construction of study and comparison group datasets.
Medicare administrative claims data were requested from the
CMS for a specified cohort of 2,010 Medicare beneficiaries
who received the wound protocol in 2006 (study group). The
study group was identified based on the provider number of
thecontractedwoundcarespe-
cialist in thepatient claims.The
comparison group of wound
patients was identified as those
who resided in a SNF in 2006
but did not receive the wound
protocol (ie, did not have
claims from the contracted
wound care specialist and did
not reside in the same SNF as
any of the study group resi-
dents). The comparison group
was selected and matched to
the study group based on age,
gender, and state of residence
(N = 2,010). This method en-
sured that patients in both
groups were within the same
state but not in the same SNF.
Healthcare utilization and
cost. Healthcare utilization
and cost information for
study and comparison group
patients was obtained from
the following CMS CCW files
for 2006: 1) SNF, 2) inpatient
hospital, 3) outpatient hospi-
tal, and 4) physician supplier.
In addition, 2006 MDS assess-
ment data for SNF stays were
obtained. Claims were linked
across all sites of service to
MDS files for each patient in
the database. The first MDS
assessment collected after SNF
admission that contained
wound information was used
to determine wound severity,
recognizing that wound sever-
ity at SNF admission may be
less severe (“back-staged”)
than wound severity before
receiving care in the SNF. Payments for the wound-related
claims (SNF and providers) are based on the Medicare pay-
ment rate attached to each claim for every provider, as pro-
vided by the linked claims files. Therefore, this study measures
payments outside of the SNF Prospective Payment System
(PPS) bundled payment amounts (eg, hospital care).
Construction of episode. Only wounds documented in the
claims that had a corresponding wound assessment in the
MDS were included in this analysis. The MDS is considered a
reliable way to measure nursing home patient characteristics22
and has been used to validate the clinical accuracy of Medicare
administrative data.23 Due to the statistical limitations of using
REDUCING MEDICARE EXPENDITURES AND IMPROVING OUTCOMES
Table 2. Dependent and independent variables used in the regression analyses
Dependent variable
Clinical outcomes
Medicare expenditures
Independent variable
Patient demographics
Type of ulcer
Conditions/comorbidities
Description
Wound infection
Gangrene
Amputation
Hospitalization with wound
diagnosis related group (DRG)
Medicare expenditures per episode
Description
Age
Gender
Period of treatment
Chronic decubitus ulcer
Ulcer of the lower leg
Venous ulcer
Foot wound
Ischemic heart
Congestive heart failure
Diabetes
Atrial fibrillation
Lower extremity Neuropathy
Peripheral arterial disease
Alzheimer’s Disease
Cataract
Chronic kidney disease
Chronic obstructive pulmonary
disease (COPD)
Glaucoma
Depression
Hip Fracture
Osteoporosis
Stroke
Cancer
Gangrene in the pre-treatment
phase
Amputation in the pre-treatment
phase
Value
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Logarithm of Medicare
expenditures per episode
Value
Continuous variable
Dichotomous variable
Continuous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable
Dichotomous variable; only
for study residents
Dichotomous variable; only
for study residents
5. 36 OSTOMY WOUND MANAGEMENT SEPTEMBER 2010 www.o-wm.com
data without a defined first and last wound-related claim, only
wounds that were first documented and healed during the
study period (February 1, 2006 through November 30, 2006)
were included in the analysis. Wounds with wound-related
claims outside of this study period were excluded because total
episode costs and outcomes could not be determined without
identification of all previous or future treatments and out-
comes. Wounds that were managed and did not fully resolve
also were excluded. Although time to healing cannot be di-
rectly measured using administrative data, this study assumes
the wound is healed once wound-related claims no longer ap-
pear in the claims. MDS assessment data are not able to iden-
tify the exact timing of wound healing, making it difficult to
identify the end of the wound episode using this dataset. Pa-
tients whose wound-related claims stopped due to patient
death were excluded from the analysis because the wound
could not be followed to resolution; however, patients who
died after the cessation of wound-related claims remained in
the study. In addition, only study group and comparison
group residents with a total wound episode >7 days were in-
cluded in the analysis because wounds that heal in <7 days are
demonstrably less severe than the chronic wounds that are the
focus of this study. Adjustments to the data reflecting the
above decisions and definitions reduced the number of resi-
dents included in the study
from 2,010 to 372 for the study
group and from 2,010 to 311
for the comparison group.
Given the resultant data set,
wound care episodes were cre-
ated for study and comparison
group patients. The period
from the first wound-related
claim through the last wound-
related claim is referred to as
the total wound episode for the
study and comparison groups;
this definition serves as the
basis for examining differences
between study and comparison
group wound patients. Within
the total episode for the study
group patients only, wound
care treatment and prevalence
of unfavorable clinical out-
comes due to the study proto-
col are isolated by creating two
components of the total wound
episode. The first component is
the care provided, as well as re-
sulting unfavorable clinical
outcomes, between the first
wound-related claim and the
first 21 days of receiving care
from a study protocol provider (Before Protocol Episode). This
first 21 days of the protocol treatment are included in this seg-
ment because patients often enter the protocol with pre-ex-
isting unfavorable clinical outcomes as a result of their
previous care. Even though the study protocol is administered
at this time, the pre-existing unfavorable clinical outcomes
that occur are likely a result of their previous care. The second
component is the care provided after the first 21 days of care
from the study protocol provider through the last wound-re-
lated diagnosis or procedure code (During Protocol Episode).
These components of the total episode for the study group fa-
cilitate comparison of outcomes between the During Protocol
and Before Protocol time periods during a wound episode.
The comparison group patients are analyzed at the total
wound episode level only because they never received the
study wound care protocol.
In order to conduct a regression analysis to determine
changes in the prevalence of unfavorable clinical outcomes
due to the study protocol (excluding unfavorable clinical out-
comes present before receiving the study protocol), study
group resident data were further differentiated into when they
were first treated by the structured protocol (initial residents)
and after they received care under the protocol for one month
(established residents). The initial portion includes clinical out-
FEATURE
Table 3. Residents with completed wound episode (>7 days): resident and
wound characteristics
Variable
Number of residents
Average wound score at first wound
assessmenta
Demographics
Mean resident age (years)
Percent female
Wound etiology
Chronic decubitus ulcer
Ulcer of the lower leg
Venous ulcer
Foot wound
Comorbidities
Percent diabetic
Percent with Alzheimer’s
(with or without dementia)
Percent with peripheral arterial disease
Percent with lower extremity neuropathy
Percent with depression
Percent with hip fracture
Percent with stroke
Study
group (A)
372
5.8
80.8
43.0%
90.3%
53.0%
7.0%
7.5%
51.3%
27.4%
28.2%
5.4%
47.6%
16.1%
29.0%
Comparison
group (B)
311
5.5
80.9
40.5%
87.1%
67.5%
12.2%
14.8%
51.1%
24.8%
43.4%
8.0%
41.5%
12.5%
27.7%
Percent difference
(A-B)/B
19.6%
6.0%
-0.1%
6.2%
4%
-22%b
-43%b
-49%b
0.4%
10.7%
-35.0%b
-33.1%
14.7%
28.6%
5.0%
a Wound severity score for each resident was constructed by multiplying the wound stage by the number of
wounds, as indicated on the first MDS assessment available during the wound episode that contains wound
information. For example, a resident with two ulcers, one classified as Stage I, and one as Stage II, would
have a total wound score of three [(1 wound * Stage I) + (1 wound * Stage II) = 3]
b P <0.01
6. SEPTEMBER 2010 OSTOMY WOUND MANAGEMENT 37www.o-wm.com
comes present at the onset of the comprehensive protocol.
Clinical outcomes for established study group residents are
compared to the overall comparison group wound episodes.
The rationale for this determination is that the protocol can-
not influence patient outcomes until it is applied.
Construction of dependent variables. Clinical outcomes
for this analysis included wound-related infection, gangrene,
amputation, and wound-related hospitalization (determined
by the presence of specified ICD-9-CM and CPT codes on
physician and hospital claims). Medicare expenditures were
separately calculated for Part A, Part B, and wound-related
hospitalization. Medicare Part A costs include inpatient hos-
pitalizations and SNF care received. Medicare Part B costs in-
clude physician services received during or before a patient’s
SNF stay, hospital outpatient services, and any Medicare-cov-
ered service received after a patient exhausts his/her annual
long-term care limit (100 days).
Clinical outcomes are calculated on a per-day basis in order
to make them comparable across groups with varying lengths
of stay.
Construction of independent variables. Aside from
wound care provision, the independent (explanatory) vari-
ables included resident demographics, comorbidities, a wound
severity score, and a time trend. Resident demographics on
which the study and comparison groups were matched in-
cluded age, gender, and state of res-
idence.
A wound severity score for each
resident, regardless of wound eti-
ology, was constructed by multi-
plying the wound stage by the
number of wounds, which are both
indicated on the first MDS assess-
ment available during the wound
episode that contains wound infor-
mation. For example, a resident
with two ulcers, one Stage I and
one Stage II, would have a total
wound score of three [(one wound
* Stage I) + (one wound * Stage II)
= 3]. This approach allows use of Medicare administrative
claims data to “adjust” for wound severity across the study
and comparison groups because clinical data and medical
records are not available to the study team for these patients.
However, a study that tested the reliability of the MDS in 13
nursing homes in five states concluded that the information
contained in the MDS assessments is reliable for such re-
search.22
Statistical analysis. Dependent variables were cross-tabu-
lated against age, gender, diagnosis (comorbidities), type of
wound, and wound care treatments. T-tests, chi-square tests,
and analysis of variance tests were used to determine the sta-
tistical significance of the differences between the study and
comparison groups (correcting for multiple comparisons). T-
tests were used to test for the differences in patient demograph-
ics, while chi-square tests were used to test for the difference
in prevalence of clinical conditions and comorbidities.
Data for the entire episode of the study group were com-
pared to the comparison group in the statistical analysis of
clinical outcomes and expenditures. The results of the analysis
are presented as the probability of a resident experiencing an
unfavorable clinical outcome per day.
Multivariate techniques were used to control for differences
in patient demographics and comorbidities and the effect of
wound severity on patient outcomes and Medicare expendi-
REDUCING MEDICARE EXPENDITURES AND IMPROVING OUTCOMES
Table 4. Residents with completed wound episode (>7 days): clinical outcomes
Clinical outcomes
Wound infection (%)
Gangrene (%)
Amputation (%)
Wound-related hospitalization (%)
Study group:
total wound
episode
0.38%
0.09%
0.07%
0.08%
Study group:
during protocol
episodea
0.27%
0.06%
0.04%
0.07%
Study group:
before protocol
episodeb
2.13%
0.37%
0.32%
0.66%
Comparison
group
0.39%
0.13%
0.06%
0.21%
Odds ratio: study
group total episode to
comparison group
0.969
0.625
1.165
0.245c
a Clinical outcomes during protocol episode are those associated with care during the structured comprehensive protocol (after first 21 days of first study
group provider encounter)
b Clinical outcomes before the protocol episode are all outcomes starting from the first wound claim through the first 21 days of the protocol episode
c P <0.01
Table 5. Residents with completed wound episode (>7 days):
clinical outcomes odds ratios
Clinical outcomes
Wound infection (yes, no)
Gangrene (yes, no)
Amputation (yes, no)
Wound-related hospitalization
(yes, no)
Odds ratio
1.146
1.639
1.381
1.852
“Initial” study group
protocol residentsa
P value
0.34
0.07
0.36
<0.001
Odds ratio
0.781
1.337
1.549
1.067
“Established” study group
protocol residentsb
P value
0.03
0.19
0.12
0.71
a Clinical outcomes present at the onset of the comprehensive protocol
b Clinical outcomes present after study group residents received care under the comprehensive protocol
7. 38 OSTOMY WOUND MANAGEMENT SEPTEMBER 2010 www.o-wm.com
tures. Multivariate regressions were used to test the hypothesis
that wound protocol residents have better clinical outcomes
and lower Medicare expenditures than comparison group res-
idents, after controlling for resident demographics, comor-
bidities, and wound severity.
Two types of regression models were used. For the dichoto-
mous clinical outcomes (ie, presence of wound infection, gan-
grene,amputation,and wound-related hospitalization),logistic
regression models were estimated. These regressions assess the
association between the dichotomous outcome variable and the
study treatment protocol after controlling for explanatory vari-
ables including time trend and wound severity (see Table 2).
The resultant odds ratios indicate the degree to which study
group wound patients (residents) have higher or lower odds of
unfavorable outcomes than comparison group residents.
For the Medicare expenditure variables, a semi-logarithmic
Ordinary Least Squares (OLS) regression specification was
used. The dependent expenditure outcome variables are
logged and the independent variables are in natural (un-
logged) form. The study group variable (a zero-one dummy
variable) is included to capture the percent increase or de-
crease in Medicare expenditures associated with being in the
study group, while controlling for numerous confounding
(explanatory) variables. The Medicare expenditure dependent
variables are overall Medicare cost per total episode and
Medicare per diem cost per total episode.
Results
Patient characteristics.The study and comparison groups
included 372 and 311 participants, respectively. The average
age of residents in both groups was similar (study group, 80.8
years; comparison group, 80.9 years). The prevalence of co-
morbidities and average wound severity score between the
study group and comparison group were not statistically dif-
ferent, with the exception of peripheral artery disease (47.0%
for comparison group versus 33.8% for study group, P <0.01)
(see Table 3).
The distribution of wound etiologies among the study and
comparison group members showed some statistically signifi-
cant differences.Approximately 90% of the study and compar-
ison groups have chronic decubitus ulcers. The presence of
lower leg ulcers is the next most prevalent wound type among
the study groups. The prevalence of lower leg ulcers is higher
in the comparison group than in the study group (67.5% versus
53.0%, respectively; P <0.01). The prevalence of venous ulcers
and foot wounds is twice as high in the comparison group than
in the study group (14.8% versus 7.5% for venous ulcers; 14.8%
versus 7.5% for foot wounds, P <0.01). Although these differ-
ences are statistically significant,only a relatively small propor-
tion of patients have foot wounds and venous ulcers (see Table
3).
Clinical outcomes. After controlling for covariates, study
group residents had a similar probability of experiencing
wound-related infection, gangrene, and amputation per day
across the total wound episode but had a significantly lower
probability of experiencing wound-related hospitalization (P
<0.01) per day compared to the comparison group. The prob-
ability of experiencing wound-related infection per day was
0.38% in the study group, compared to 0.39% in the compar-
ison group. The probability of experiencing gangrene per day
in the study group was 0.09% (compared to 0.13% in the
comparison group) and the probability of experiencing am-
putation per day in the study group was 0.07%, compared to
0.06% in the comparison group (see Table 4).
After accounting for model covariates, established protocol
patients were 0.781 times less likely to experience a wound-
related infection than residents in the During Protocol episode
(P = 0.03). Initial protocol patients were more likely to expe-
FEATURE
Table 6. Residents with completed wound episode (>7 days): healthcare costs
Variable
Medicare Part A payments (including hospital
inpatient, and skilled nursing facilities)
Medicare Part B payments (including hospital
outpatient, physician carrier and home healtha)
Inpatient Medicare payment for wound-related
hospitalizations
Total Medicare Part A and Part B payment
Average total Medicare payment for outpatient
and inpatient services per day
Average number of days in wound episode
Study group
(total episode)
$26,568.58
$7,270.91
$27,783.70
$21,449.64
$229.07
94
Comparison
group
$32,020.59
$8,658.74
$24,969.86
$40,678.83
$354.26
115
Percent
difference
-17.0%
-16.0%
11.3%
-47.3%
-35.3%
-18.5%
Parameter estimates: study
group total episode to
comparison group
-0.191b
-0.175c
0.107
-0.640b
-0.436b
-0.205b
a Home health services are billed under Medicare Part A and Part B. For the purposes of this analysis, all home health services are classified as Part B.
Home health payments represent services provided to patients during interrupted stay from the skilled nursing facility
b P <0.01
c P <0.05
8. SEPTEMBER 2010 OSTOMY WOUND MANAGEMENT 39www.o-wm.com
REDUCING MEDICARE EXPENDITURES AND IMPROVING OUTCOMES
rience gangrene than comparison group patients (1.639) (P =
0.07). Initial protocol patients were also more likely to expe-
rience a wound-related hospitalization than the comparison
group (1.852) (P <0.001) (see Table 5). However, the proba-
bility of experiencing a wound-related hospitalization de-
creased through continued protocol care. Although the odds
of a wound-related hospitalization were significantly higher
in the initial study period group (1.852, P <0.001), they were
lower in the established period (1.067).
Wound-related costs. After adjusting for covariates, study
group resident total Medicare Part A and B expenditures for the
episode of care were $21,449.64 compared to $40,678.83 for the
comparison group, approximately 47% less (see Table 6).
Medicare expenditures for hospitalizations are a large com-
ponent of total Medicare expenditures.Wound-related hospital-
izations for study group residents cost $2,813 more than the
matched comparisons during the total wound episode after con-
trolling for numerous covariates ($27,783.70 versus $24,969.86);
however, the results are not significantly different statistically.As
noted in Table 4, significantly fewer study group residents were
admitted to the hospital for a wound-related diagnosis.
Compared to the comparison group, total Medicare Part A
payments for the study group protocol were 17% lower
($26,568.58 versus $32,020.59) and total Part B payments were
16% lower ($7,270.91 versus $8,658.74). The predicted values
for all study group dependent variables (total Part A, Part B,
wound-related hospitalization, and total Medicare expendi-
tures) are calculated independently based on the comparison
group costs. As a result, these predicted values do not sum to
the total expenditures (Part A and Part B payment) for the
study group, but 13% of the Medicare Part B expenditures for
the study group were associated with protocol care.
For per diem costs, regression analysis indicates that study
group residents incur 35.3% lower total Medicare episode
costs per day (per diem) over the entire wound care episode
than comparison group residents after controlling for study
covariates ($229.07 versus $354.26) (see Table 6). Per diem is
the average total Medicare payment (total Part A and B) di-
vided by the average number of days in the wound episode
(number of days with wound-related claims). Study group
residents’ per diem cost for the Before Protocol Episode is ap-
proximately $692, compared to $256 during the protocol
episode (data not shown).
In addition to lower costs per day, regression results indi-
cate that study group patients have a 21-day (18.5%) shorter
length of episode than the comparison group (94 versus 115
days) (see Table 6).
Several independent regression variables are significant in
the regression models presented. The likelihood of experienc-
ing unfavorable clinical outcomes in the initial and experi-
enced protocol period is driven by the length of the wound
care episode. The presence of a lower limb ulcer increases the
likelihood of experiencing an infection, while presence of a
venous ulcer increases the likelihood of experiencing a
wound-related hospitalization. The age of a patient also affects
the likelihood of experiencing gangrene and a wound-related
hospitalization. Presence of peripheral arterial disease only af-
fects the likelihood of experiencing gangrene.
Several independent variables influence the cost of total
wound care (total Medicare Part A and B costs) as well as the
cost per day and overall length of the episode. The explanatory
power of the total Medicare costs is driven by the presence of
peripheral arterial disease, ischemic heart disease, chronic kid-
ney disease, chronic obstructive pulmonary disease (COPD),
and chronic pressure and lower limb ulcers. The explanatory
power of the Medicare cost per day is driven by ischemic heart
disease, chronic kidney disease, COPD, and cataracts. The
length of the total wound episode is a factor of the presence
of peripheral arterial disease, osteoporosis, cataracts, and the
presence of chronic decubitus, lower limb, or venous ulcers.
Discussion
The clinical outcomes and drivers of wound healing in the
current study are generally consistent with the results of previ-
ous research. In this study, the only significant difference in co-
morbidities between residents receiving care from the
structured wound protocol specialist (study group) and the
comparison group was the increased prevalence of peripheral
arterial disease in the comparison group patients.Peripheral ar-
terial disease often is considered the leading cause of lower ex-
tremity wounds.A study of the 1999–2000 National Health and
Nutrition Evaluation Survey (NHANES) by the National Cen-
ters for Health Statistics24 found that the prevalence of ulcers is
three times higher for patients with peripheral arterial disease,
peripheral neuropathy, and lower extremity disease. Results of
a retrospective cohort study1 of 397 long-term care residents
with pressure, ischemic, venous, neuropathic, and mixed etiol-
ogy wounds found no effect of peripheral arterial disease on
wound healing. Another retrospective review25 of 400 patients
with either pressure, diabetic, or venous ulcers also found no
strong relationship between comorbid conditions (such as di-
abetes, cardiac disease, pulmonary disease, and endocrine dis-
orders) and wound healing. Thus, study results are not likely
due to “easier” patient selection. If anything, one would expect
the more challenging residents to be included in the study (re-
ferral) group.Comparing the probability of unfavorable clinical
outcomes per day of study group residents before and after re-
ceiving the study group protocol suggests that while the study
group resident wounds were not more severe (based on current
calculations), the increased probability of experiencing an un-
favorable clinical outcome per day suggests that they may not
have received optimal care before referral.
After controlling for covariates, patients receiving the study
group protocol had a similar probability of experiencing
wound-related infection, gangrene, and amputation per day
across the total wound episode but a significantly lower prob-
ability of experiencing wound-related hospitalization (P
<0.01) per day compared to the comparison group.
9. 40 OSTOMY WOUND MANAGEMENT SEPTEMBER 2010 www.o-wm.com
Receiving the study group protocol over time significantly
reduced the odds of having a wound-related hospitalization
and reduced the length of episode days from 115 days to 94
days (18.5%) relative to the comparison group. Furthermore,
treatment using the structured comprehensive wound man-
agement protocol saved Medicare approximately $125 per res-
ident per day of treatment (a 35.3% reduction from the
average cost per diem for the comparison group cost of $354).
SNF residents who received study protocol care also had lower
odds of experiencing a wound-related infection after the pro-
tocol care period was established relative to the comparison
group. It is well known that the faster wounds heal, the lower
the possibility for infection, which can increase treatment
cost.26 Furthermore, faster healing time could facilitate an ear-
lier discharge of the patient from the SNF.
After controlling for resident demographics, comorbidities,
and wound severity, the average Medicare savings based on
the structured protocol for wounds that healed were $19,229
per episode (an approximately 47.3% reduction from the av-
erage cost per episode for the comparison group of $40,678).
This is primarily due to reduced hospitalization rates. These
results are similar to a recent pseudo-randomized pragmatic
cluster trial15 that assessed the cost-effectiveness of a multidis-
ciplinary team in the nursing home. This study concluded that
standardized treatments provided by a trained multidiscipli-
nary wound care team significantly improved healing out-
comes and reduced treatment costs. A 2001 clinical
perspective analysis27 confirms that a multidisciplinary wound
healing center can improve the clinical outcome of treatments
and benefit patients and society.
Prior research has investigated the drivers of wound healing.
Specifically, several studies have measured the effect of age on
wound healing but none have found a statistically significant
correlation between age and wound healing, which is inconsis-
tent with the current finding that age affected the likelihood of
experiencing gangrene and wound-related hospitalizations.1,28,29
Furthermore, studies have found that diabetic and venous ul-
cers are related to longer wound episodes as well as the number
of infections and malnutrition.28 Presence of peripheral vascular
disease and previous stroke have been found to have a signifi-
cant influence on wound healing, while other cardiac condi-
tions (eg, congestive heart failure, renal insufficiency) were not
found to have a significant impact on healing.1
During the 12 months from September 2007 through Au-
gust 2008, the study group protocol was used to treat approx-
imately 16,500 new Medicare SNF residents, an average
resident census of approximately 2,600 residents. This is ap-
proximately 2% of the national prevalence (159,000 patients)4
of SNF residents with wounds. The data strongly suggest that
incorporating this wound care protocol could lead to signifi-
cant Medicare savings.
Limitations
Although a study that uses Medicare administrative data has
limitations in comparison to randomized controlled trials
(RCTs), RCTs have not proven definitive in wound care.30 To
this end,Medicare routinely uses analyses of its statistical system
data to inform its decision-making process,especially when the
statistical systems contain clinical information such as the SNF
MDS, which provides information on the number of wounds
and the severity of each wound at a given point in time.31
Due to the retrospective design of this study, limitations
must be considered. The first limitation is the exclusion of
nonhealing wounds or wounds that did not first appear or
fully heal between February 1, 2006 and November 30, 2006.
Although nonhealing wounds are typically more costly than
wounds that heal, conclusions could not be drawn regarding
the unfavorable clinical outcomes and episode length and cost
without capturing the entire wound episode in the study data-
base in a discrete time period. Also, patients who died during
their wound care episode were excluded from the study. Fu-
ture studies that expand the study window to include wounds
that do not heal during the study period would be warranted.
A second limitation to the study is the information avail-
able to determine wound severity. By using a retrospective de-
sign, the study is dependent on the accuracy, timing, and
completeness of the MDS assessments and the demographic
information contained in the claims data. Having only the
number of wounds by stage for each patient limits the ability
to develop a more clinically precise severity measure, which
could be used to severity-adjust wounds across patients and
track individual wound healing and unfavorable clinical out-
comes. However, it is not clear if the availability of this infor-
mation would produce a measurement bias between the study
and comparison groups. Similarly, claims data can be used to
make covariate adjustments in a quasi-experimental design
framework, but without use of a RCT, the possibility of patient
and perhaps facility selection effects on unmeasured variables
contaminating the study may exist.
However, it is understood that MDS data collection and re-
porting requires providers to “back-stage” or “reverse stage”
wound severity to show patient wound healing while in the
SNF.32 For example, as a wound heals, the provider will track
the wound staging from Stage II to Stage I.Although back-stag-
ing is not an acceptable practice within the clinical commu-
nity,33 back-staging in the MDS allows the study team to
quantify the severity of the wound when the study protocol or
comparison group treatment commences, as opposed to the
maximum severity of the wound when treated in other settings.
Finally, information about the comparison group treat-
ments is limited.Although it is known that comparison group
patients received care in SNFs that were mutually exclusive to
those of study group patients, the exact levels of wound care
received cannot be known. Comparison group facility char-
acteristics such as staff ratios, tenure and certification of staff
members, and availability of specialists including physical
therapists and nutritionists is not known and cannot be com-
pared to the characteristics of the study group facilities. Be-
FEATURE
10. SEPTEMBER 2010 OSTOMY WOUND MANAGEMENT 41www.o-wm.com
cause study group patients received care from the same group
of wound specialists, this standard of care was maintained for
all study patients.Although the wound protocol used does not
differ from existing standards of modern wound care, it em-
phasizes multidisciplinary care and consistently applied treat-
ment from a certified wound care specialist. Thus, these results
should be able to be obtained by a certified wound care
provider with a multidisciplinary team in other SNF settings.
Conclusion
A retrospective cohort study demonstrates that an exter-
nally led structured comprehensive wound management pro-
tocol results in equal, if not improved, clinical outcomes at
significantly lower cost. To this end, strict adherence to com-
prehensive wound care management is cost-effective. A sub-
sequent study could be conducted to determine if the study
group protocol is cost-effective and provides improved clinical
outcomes for all wounds and not just wounds that heal.
The study findings have implications for private and public
payors such as the CMS. Sufficient payment to wound man-
agement specialists will likely encourage the provision of these
services to more SNF residents. One approach might be to
fund demonstration projects that expand this innovative
model of care to additional long-term care facilities. Moreover,
the use of value-based purchasing for long-term care that ad-
dresses pressure ulcers as a core condition may incentivize fa-
cilities to more broadly use comprehensive wound care
programs to treat chronic wounds.
The CMS plans to base several pay-for-performance (P4P)
measures on the following: 1) potentially avoidable hospital-
ization, 2) medical outcomes, 3) survey deficiencies, and 4)
nursing staffing. The SNF P4P initiative could be funded in
part by the savings from fewer wound-related hospitalizations
and reduced wound care expenditures associated with struc-
tured wound care.34
Given the findings of this study, similar studies should be
conducted across a variety of healthcare settings.A next logical
setting would be home care because wound healing and inap-
propriate hospitalization in this setting have recently emerged
as major quality issues. The CMS recently addressed this issue
with two new quality assurance measures for home care: 1)
emergent care for wound infections and 2) improving or de-
teriorating status of wounds,35 potentially creating opportu-
nities for improved outcomes and cost savings for
home-bound patients. I
References
1. Takahashi PY, Kiemele LJ, Chandra A, Taryonski PV. A retrospective co-
hort study of factors that affect healing in long-term care residents with
chronic wounds. Ostomy Wound Manage. 2009;55(1):32–37.
2. Lyder C. Pressure ulcer prevention and management. JAMA.
2003;289(2):223.
3. Brandeis GH, Belowitz DR, Hossain M, Morris JN. Pressure ulcers: the
minimum data set and the resident assessment protocol. Adv Wound
Care. 1995;8(6):18–25.
4. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents:
United States, 2004. Available at:
www.cdc.gov/nchs/data/databriefs/db14.pdf. Accessed August 28,
2010.
5. Wipke-Tevis DD, Rantz MJ, Mehr DR, et al. Prevalence, incidence, man-
agement, and predictors of venous ulcers in the long-term-care popu-
lation using the MDS. Adv Skin Wound Care. 2000;13(5):218–224.
6. Whitney J, Phillips L, Aslam R, et al. Guidelines for the treatment of pres-
sure ulcers. Wound Repair Regen. 2006;14:663–679.
7. Robson MC, Cooper DM, Aslam R, et al. Guidelines for the treatment
of venous ulcers. Wound Repair Regen. 2006;14:649–662.
8. Steed DL, Attinger C, Colaizzi T, et al. Guidelines for the treatment of
diabetic ulcers. Wound Repair Regen. 2006;14:680–692.
9. Pressure ulcers in adults: prediction and prevention. National Guideline
Clearinghouse, 1992. Available at:
www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A4409.
Accessed July 28, 2010.
10. Design for Nursing Home Compare Five-Star Quality Rating System:
Technical Users’ Guide. Centers for Medicare and Medicaid Services.
2009. Available at: www.cms.gov/CertificationandComplianc/Down-
loads/usersguide.pdf. Accessed July 28, 2010.
11. McGlynn EA, Asch SM, Adams J, et al. The quality of health care deliv-
ered to adults in the United States. N Eng J Med. 2003;348(26):2635–
2645.
12. Edelstein T, Holmes A. Achieving results in pressure ulcer prevention
across care settings: lessons from the New Jersey pressure ulcer col-
laborative. New Jersey Hospital Association. June 27, 2007. Available
at: www.nj.gov/health/healthfacilities/documents/lane_webinar.pdf. Ac-
cessed July 28, 2010.
13. Abel RL, Warren K, Bean G, et al. Quality improvement in nursing homes
in Texas: results from a pressure ulcer prevention project. J Am Med Dir
Assoc. 2005;6(3):228–230.
14. Takahashi P, Chandra A, Kiemele L. Wound care technologies: emerging
evidence for appropriate use in long-term care. Ann Long-term Care.
2007;15(11):35–40.
15. Trang V, Harris A, Duncan G, et al. Cost-effectiveness of multidisciplinary
wound care in nursing homes: a pseudo-randomized pragmatic cluster
trial. Fam Pract. 2007;24:372–379.
16. Wallach PM, Roscoe L, Bowden R. The profession of medicine: an in-
tegrated approach to basic principles. Acad Med. 2002;77(11):1168–
1169.
17. Paine TG, Milne CT, Barr JE, et al. AAWC conceptual framework for
quality systems for wound care. Ostomy Wound Manage.
2006;52(11):57–66.
18. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of preven-
tion and treatment of the diabetic foot. Diabetes Care. 2004;27(4):901–
907.
19. Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure
Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel
White Paper. National Pressure Ulcer Advisory Panel. 2009. Available
a t :
www.npuap.org/Nutrition%20White%20%Paper%20Website%20Ver-
sion.pdf. Accessed August 28, 2010.
20. Lee SK, Turnbull GB. Wound care in a PPS environment. Nursing
Homes. 2001;50(3):34–36.
21. Kimura S, Pacala J. Pressure ulcers in adults: family physicians’ knowl-
edge, attitudes, practice preferences, and awareness of AHCPR guide-
lines – Agency for Health Care Policy Research. J Fam Pract.
1997;44(4):361–368.
22. Hawes C, Morris JN, Phillips CD, Mor V, Fries BE, Nonemaker S. Relia-
bility estimates for the minimum data set for nursing home resident as-
sessment and care screening (MDS). Gerontologist.
1995;35(2):172–178.
23. Scinto JD, Sherwin TE, Fowler J. Use of administrative data in measur-
ing quality of care. Available at:
www.health.ri.gov/chic/performance/quality/quality7.pdf. Accessed Au-
gust 28, 2010.
24. Gregg EW, Sorlie P, Paulose-Ram R, et al. Prevalence of lower-extremity
disease in the US adult population >40 years of age with and without
diabetes: 1999-2000 National Health and Nutrition Examination Survey.
Diabetes Care. 2004;27(7):1591–1597.
25. Jones KR, Fennie K, Lenihan A. Chronic wounds: factors influencing
healing within 3 months and non-healing after 5-6 months of care.
Wound Res. 2007;19(3):51–63.
26. Brem H, Lyder C. Protocol for the successful treatment of pressure ul-
cers. Am J Surg. 2004;188(1A suppl):9S–17S.
27. Gottrup F, Holstein P, Jorgensen B, Lohmann M, Karlsmark T. A new
concept of a multidisciplinary wound healing center and a national ex-
pert function of wound healing. Arch Surg. 2001;136:765–772.
28. Jones KR, Fennie K. Factors influencing pressure ulcer healing in adults
over 50: an exploratory study. J A Med Dir Assoc. 2007;8(6):368–387.
REDUCING MEDICARE EXPENDITURES AND IMPROVING OUTCOMES
11. 42 OSTOMY WOUND MANAGEMENT SEPTEMBER 2010 www.o-wm.com
29. Donini LM, De Felice MR, Tagliaccica A, De Vernardini L, Cannella C.
Comorbidity, frailty, and evolution of pressure ulcers in geriatrics. Med
Sci Monit. 2005;11(7):CR326–CR336.
30. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treat-
ment of pressure ulcers: a systematic review. JAMA.
2008;300(22):2647–2662.
31. Minimum Data Set – Version 2.0. Centers for Medicare and Medicaid
Services. Available at:
www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20MD-
SAllForms.pdf. Accessed February 16, 2009.
32. Arnold-Long M. New and improved: 2007 pressure ulcer definitions;
avoid citations by understanding NPUAP’s new language for appropri-
ately staging wounds. Long Term Living. 2007. Available at: http://ltl-
magazine.com/me2/dirmod.asp?sid=9B6FFC446FF7486981EA3C0C3
CCE4943&nm=All+Issues&type=Publishing&mod=Publications%3A%3
AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=C8C
2965E78944AF5B2B786C62947E295. Accessed July 28, 2010.
33. NPUAP Statement on Reverse Staging on Pressure Ulcers. Available at:
www.npuap.org/archive/positn2.htm. Accessed July 28, 2010.
34. Pay-for-performance. Presented at the Symposium on Regulatory Is-
sues for Management (SORIM) in Long-Term Care. Reston, VA. Sep-
tember 22-–3, 2008;
35. Home Health Prospective Payment System Rate Update for Calendar
Year 2008. Fed Regis. 2008;73:65353.
FEATURE