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Kumar, Jay

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Kumar, Jay
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    Reversal of warfarin associated coagulopathy with 4-factor prothrombin complex concentrate in traumatic brain injury and intracranial hemorrhage
    (Elsevier BV, 2014) Yanamadala, Vijay; Walcott, Brian; Fecci, Peter; Rozman, Peter; Kumar, Jay; Nahed, Brian; Swearingen, Brooke
    Warfarin-associated intracranial hemorrhage is associated with a high mortality rate. Ongoing coagulopathy increases the likelihood of hematoma expansion and can result in catastrophic hemorrhage if surgery is performed without reversal. The current standard of care for emergency reversal of warfarin is with fresh frozen plasma (FFP). In April 2013, the USA Food and Drug Administration approved a new reversal agent, 4-factor prothrombin complex concentrate (PCC), which has the potential to more rapidly correct coagulopathy. We sought to to determine the feasibility and outcomes of using PCC for neurosurgical patients. A prospective, observational study of all patients undergoing coagulopathy reversal for intracranial hemorrhage from April 2013 to December 2013 at a single, tertiary care center was undertaken. Thirty three patients underwent emergent reversal of coagulopathy using either FFP or PCC at the discretion of the treating physicians. Intracranial hemorrhage included subdural hematoma, intraparenchymal hematoma, and subarachnoid hemorrhage. FFP was used in 28 patients and PCC was used in five patients. International normalized ratio at presentation was similar between groups (FFP 2.9, PCC 3.1, p = 0.89). The time to reversal was significantly shorter in the PCC group (FFP 256 minutes, PCC 65 minutes, p < 0.05). When operations were performed, the time delay to perform operations was also significantly shorter in the PCC group (FFP 307 minutes, PCC 159 minutes, p < 0.05). In this preliminary experience, PCC appears to provide a rapid reversal of coagulopathy. Normalization of coagulation parameters may prevent further intracranial hematoma expansion and facilitate rapid surgical evacuation, thereby improving neurological outcomes.
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    A Comparison of Tier 1 and Tier 3 Medical Homes Under Oklahoma Medicaid Program
    (2018-05-15) Kumar, Jay
    Introduction: The patient-centered medical home (PCMH) is a team-based model of care that seeks to improve quality of care and control costs. The Oklahoma Health Care Authority (OHCA) directs Oklahoma’s Medicaid program and contracts with 861 medical home practices across the state in one of three tiers of operational capacity: Tier 1 (Basic), Tier 2 (Advanced) and Tier 3 (Optimal). Only 13.5% (n=116) homes are at the optimal level; the majority (59%, n=508) at the basic level. In this study, we sought to determine the barriers that prevented Tier 1 homes from advancing to Tier 3 level and the incentives that would motivate providers to advance from Tier 1 to 3. Our hypotheses were that Tier 1 medical homes were in smaller practices with limited resources and the providers are not convinced that the expense of advancing from Tier 1 status to Tier 3 status was worth the added value. Methods: We analyzed OHCA records to compare the 508 Tier 1 (entry-level) with 116 Tier 3 (optimal) medical homes for demographic differences with regards to location: urban or rural, duration as medical home, percentage of contracts that were group contracts, number of providers per group contract, panel age range, panel size, and member-provider ratio. We surveyed all 508 Tier 1 homes with a mail–in survey, and with focused follow up visits to identify the barriers to, and incentives for, upgrading from Tier 1 to Tier 2 or 3. Results: We found that Tier 1 homes were more likely to be in rural areas, run by solo practitioners, serve exclusively adult panels, have smaller panel sizes, and have higher member- to-provider ratios in comparison with Tier 3 homes. Our survey had a 35% response rate. Results showed that the most difficult changes for Tier 1 homes to implement were providing 4 hours of after-hours care and a dedicated program for mental illness and substance abuse. The results also showed that the most compelling incentives for encouraging Tier 1 homes to upgrade their tier status were less “red tape” with prior authorizations, higher pay, and help with panel member follow-up. Discussion: Multiple interventions may help medical homes in Oklahoma advance from the basic to the optimal level such as sharing of resources among adjoining practices, expansion of OHCA online resources to help with pre-authorizations and patient follow up, and the generation and transmission of data on the benefits of medical homes.