When fully implemented, the Affordable Care Act will expand insurance coverage to the currently uninsured, and experiments in delivery and payment under the law's auspices could produce greater efficiencies in how care is delivered. Both factors may accelerate the development of one viable model to streamline care, integrated delivery systems--coordinated care networks that deliver all needed health services to a defined population. Through interviews and surveys, we examined ten California counties that participated in two federally and locally funded initiatives to redesign how care is delivered to predominantly poor and uninsured populations. We found substantial progress in assessing and managing access to specialists, monitoring and promoting quality, and offering disease management and care coordination training in a majority of counties. However, efforts to coordinate care, electronically disseminate patient information, and align financial incentives were less successful or more difficult to assess. We posit that integrated delivery systems could improve care efficiency and quality and make countywide safety-net systems a desirable source of care for newly insured patients under health reform.
Objective Elevated levels of pro-inflammatory cytokines are observed in severe COVID-19 infections and cytokine storm is associated with disease severity. Tocilizumab, an interleukin-6 receptor antagonist, is used to treat chimeric antigen receptor T cell-induced cytokine release syndrome and may attenuate the dysregulated immune response in COVID-19. We compared outcomes among tocilizumab-treated and untreated critically ill COVID-19 patients. Design, Setting, and Participants This was a retrospective observational study conducted at a tertiary referral center investigating all patients admitted to the intensive care unit for COVID-19 who had a disposition from the hospital because of death or hospital discharge between March 1, 2020 and May 18, 2020 (n = 96). The percentages of death and secondary infections were compared between patients treated with tocilizumab (n = 55) and those who were not (n = 41). Measurements and Main Results More tocilizumab-treated patients required mechanical ventilation (44/55, 80%) compared to non-treated patients (15/41, 37%; p < 0.001). Of 55 patients treated with tocilizumab, 32 (58%) were on mechanical ventilation at the time of administration and 12 (22%) progressed to mechanical ventilation after treatment. Thirty of 44 (68%) treated ventilated patients were intubated within one day of tocilizumab. Fewer deaths were observed among tocilizumab-treated patients, both in the overall population (15% vs. 37%; p = 0.02) and among the subgroup of patients requiring mechanical ventilation (14% vs. 60%; p = 0.001). Secondary infections were not different between the two groups (tocilizumab: 31%, non-tocilizumab: 17%; p = 0.16) and were predominantly related to invasive devices, such as urinary and central venous catheters. Conclusions Tocilizumab treatment was associated with fewer deaths compared to non-treatment despite predominantly being used in patients with more advanced respiratory disease.
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