Purpose Previous research suggests an association between depression and poorer clinical outcomes for heart failure patients. Administrative ICD-9 coding is used extensively in health services research to capture variables of interest for outcomes studies, such as mental health issues. However, there is limited evidence of the accuracy of administrative ICD-9 coding for identifying patient-level mental health issues. The purpose of this study was to determine the agreement between ICD-9 coding and ‘gold standard’ clinician documentation in a patient’s History & Physical, consult notes and/or discharge summary of a mental health issue, as part of a larger study examining predictors of readmission for hospitalized heart failure patients. Methods Study sample (n=504) was randomly chosen from the population of all unique patients (n=3770) hospitalized with a heart failure primary diagnosis from 2009-2012 at one of four Sharp HealthCare (a large community based health system) hospitals with complete electronic records. A mental health issue was defined as any ICD-9 code between 290-319 in any discharge diagnosis position from 1-30. Study sample patient records were manually reviewed to identify mental health issue documentation in the dictated History & Physical, discharge summary, and/or consult notes. Three reviewers copied text suggesting any mental health issue into a data spreadsheet and recorded where text was found. Documented text was reviewed by all three reviewers and consensus reached to indicate a mental health issue. Reviewers were blinded to administrative coding data. Agreement was calculated using the Kappa statistic for non-random agreement. Results Thirty four percent (n=1285) of the total HF population were coded for a mental health issue, and 33% of the study sample (n=164). Agreement between coding and chart review to identify mental health issue was 89%, with a 4% false positive and 10% false negative rate. Positive predictive value was 87% and negative predictive value was 85%. The Kappa statistic was .69: CI .61-.79, interpreted as substantial agreement. There was no significant difference in rates of mental health categories between manual chart review and ICD-9 coding for anxiety/depression, 31% vs. 29% (p=.59); dementia, 25% vs. 18% (p=.10); and alcohol/drug abuse, 14% vs. 18% (p=.39). Conclusion ICD-9 coding appears to be a reliable method for identifying mental health issues for patients hospitalized with heart failure. To our knowledge this is the first study to determine agreement between coding and clinician documentation of mental health issues/categories for hospitalized heart failure patients.

It has become a national priority to have an effective care delivery system for the 21st century. Improving the quality of care and ensuring that the care delivered in a patient-centered framework are goals for many organizations. Nursing practice will be at the core of these changes, working at the point of service as well as at the organizational level. In response to the need for nursing to realign our practices in accordance with the new healthcare mandate, the American Association of Colleges of Nursing has developed the clinical nurse leader (CNL) role. The CNL is a master’s-prepared RN educated to enhance the efficiency of care delivery and facilitate the coordination of care at the bedside through effective collaboration with all healthcare providers. Clinical nurse leader competencies align with key messages highlighted in the Institute of Medicine’s 2010 report on The Future of Nursing, including the need for a highly educated nursing workforce practicing at their full scope, and for RNs to become full partners with physicians and other health professionals in redesigning healthcare. The CNL role has been demonstrated to improve patient outcomes, but it has not been widely adopted throughout the country. This article describes how a progressive care unit (PCU) redesigned its care delivery system to implement the CNL role, using Kotter’s Eight Change Phases model as a guide.

Abstract Objective: To describe and evaluate Sharp’s Transitions program as a model of caring for the advanced heart failure (HF) population. Methods: Sharp HealthCare developed an innovative advanced chronic disease model of care that addresses patient, family, and caregiver needs throughout the progression of their illness. Advanced HF patients enrolled in Transitions between January 2008 and December 2010 were evaluated (n = 155). Patient demographic data, hospital and emergency department (ED) utilization, and total costs of care were obtained from electronic medical records to determine acute care utilization and total care costs for patients before and after enrollment. Results: Mean length of stay in Transitions was 165 days. 74% transferred into hospice care upon discharge. Within-group analysis showed a significant decrease in hospitalization rate after enrollment in Transitions, from 32% to 17%. There was also a significant decrease in ED visit rate after enrollment, from 57% to 31%. The average total cost of care decreased significantly during enrollment ($73,025 vs. $46,588). Conclusions: Aligned with the goals of comprehensive care management, Transitions provides an innovative model of health care delivery for the advanced chronic disease population that may be replicable across diverse chronic disease patient populations and health care organizations.

Background: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are chronic diseases that impart significant health and care costs to the patient and health system. Limited access to health services affects disease severity and functional status. Telemonitoring has shown promise in reducing acute care utilization for chronic disease patients, but the benefit for the underserved has not been determined. We evaluated acute care utilization outcomes following an acute event of a 90-day transitional care program integrating telemonitoring technology and home visits for underserved COPD and HF patients. Materials and Methods: Patients were enrolled into the program between October 2010 and August 2012. Primary outcomes included rates of emergency department (ED) visits and all-cause re-admission at 30, 90, and 180 days postdischarge. Program and functional status at enrollment and discharge and satisfaction with telemonitoring at discharge were measured. Telemonitoring included daily symptomatology recording and was removed at 90 days. A control cohort was identified through electronic health records and propensity-matched via 15 variables to achieve a sample size with balanced baseline characteristics. Results: Program patients showed 50% reduction in 30-day re-admission and 13–19% reduction in 180-day re-admission compared with control patients. There was no significant difference in ED utilization. Patients were satisfied with telemonitoring services, and functional status improved by program end. Conclusions: This feasibility study suggests telemonitoring in the context of a transitional care model following an acute event may reduce all-cause 30-day re-admissions by up to 50% and has the potential to reduce longterm acute care utilization and thus care costs. More rigorous and long-term investigation is warranted.

Objective: Suboptimal glycemic control (SGC) puts hospitalized patients with diabetes at risk for poor outcomes. The purpose of this study was to quantify factors with predictive capacity to identify patients at risk for SGC during hospitalization. Methods: 32 baseline and demographic variables were extracted from the electronic records of 23,100 patients with diabetes hospitalized between 2009 and 2012. The rate of blood glucose values between 70 and 180 mg/dL was calculated for each patient. A predictive model for SGC was developed using regression modeling, standardized coefficients, and classification tree analysis. Odds ratios (ORs) were calculated to isolate adjusted odds of SGC for top predictors. Results: The final predictive model included 13 variables (C statistic = 0.88). HbA1c (OR, 0.60 [95% confidence interval {CI}, 0.58-0.61]), admission blood glucose (OR, 0.91 [CI, 0.91-0.92]), and steroid use (OR, 0.06 [CI 0.04-0.08]) were the highest-ranking predictors of SGC. HbA1c and SGC had a strong linear relationship (R2= 0.99), with increasing odds for SGC as HbA1c increased. Admission blood glucose and SGC had a polynomial relationship (R2 = 0.95); increasing odds for SGC until 240 mg/dL; then odds started decreasing. Steroid use showed a steady threefold increase in odds for SGC across all rates of use. Conclusions: Poor preadmission diabetes control and inpatient steroid use strongly predict SGC. A range of thresholds for these predictors was empirically determined, providing a basis for targeted therapies on admission. Guidelines incorporating empirically derived thresholds should enhance the ability to achieve optimal glycemic control for hospitalized patients with diabetes.

Introduction It is unclear whether inpatient heart failure (HF) performance measures reduce post-discharge adverse events. This exploratory study examined the association between systematic adherence to a set of performance measures and outcomes. Measures included all four Joint Commission (JC) HF core measures and AHA recommended beta blockade prescription on discharge. Methods A retrospective review of a 3-hospital system was performed for all patients discharged with a primary diagnosis of HF in 2008-2009. Patients were included if they met eligibility criteria for one or more measures (n=1270). ‘Perfect care’ was defined as compliance with all eligible measures. Subsequent all-cause 30-day readmission and 1-year mortality was determined via electronic records and social security national database. Results ‘Perfect care’ significantly reduced 30-day readmissions (19.2% vs. 24.9%, p=.045; OR=.72, 95% CI 0.52-0.99). ‘Perfect care’ did not influence 1-year mortality. Conclusions Adherence to this set of composite performance measures positively influenced short-term patient outcomes. Benefit of adherence was found despite the longer LOS and higher severity of illness on index admission for patients receiving ‘perfect care’. The data support the clinical value of a systematic approach towards HF care on patient care quality. ‘Perfect care’ did not influence long term outcomes, which may be because inpatient processes do not extend to long term outpatient medical management.

We exposed nitrogen-implanted diamonds to beams of swift heavy ions (∼1 GeV, ∼4 MeV/u) and find that these irradiations lead directly to the formation of nitrogen vacancy (NV) centers, without thermal annealing. We compare the photoluminescence intensities of swift heavy ion activated NV- centers to those formed by irradiation with low-energy electrons and by thermal annealing. NV- yields from irradiations with swift heavy ions are 0.1 of yields from low energy electrons and 0.02 of yields from thermal annealing. We discuss possible mechanisms of NV center formation by swift heavy ions such as electronic excitations and thermal spikes. While forming NV centers with low efficiency, swift heavy ions could enable the formation of three dimensional NV- assemblies over relatively large distances of tens of micrometers. Further, our results show that NV center formation is a local probe of (partial) lattice damage relaxation induced by electronic excitations from swift heavy ions in diamond.

The recent completion of drilling at Vostok station in East Antarctica has allowed the extension of the ice record of atmospheric composition and climate to the past four glacial-interglacial cycles. The succession of changes through each climate cycle and termination was similar, and atmospheric and climate properties oscillated between stable bounds. Interglacial periods differed in temporal evolution and duration. Atmospheric concentrations of carbon dioxide and methane correlate well with Antarctic air-temperature throughout the record. Present-day atmospheric burdens of these two important greenhouse gases seem to have been unprecedented during the past 420,000 years.

The Belle II detector will provide a major step forward in precision heavy flavor physics, quarkonium and exotic states, searches for dark sectors, and many other areas. The sensitivity to a large number of key observables can be improved by about an order of magnitude compared to the current measurements, and up to two orders in very clean search measurements. This increase in statistical precision arises not only due to the increased luminosity, but also from improved detector efficiency and precision for many channels. Many of the most interesting observables tend to have very small theoretical uncertainties that will therefore not limit the physics reach. This book has presented many new ideas for measurements, both to elucidate the nature of current anomalies seen in flavor, and to search for new phenomena in a plethora of observables that will become accessible with the Belle II dataset. The simulation used for the studiesinthis book was state ofthe artat the time, though weare learning a lot more about the experiment during the commissioning period. The detector is in operation, and working spectacularly well.