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Auerbach AD, Lee TM, Hubbard CC, Ranji SR, Raffel K, Valdes G, Boscardin J, Dalal AK, Harris A, Flynn E, Schnipper JL. Diagnostic Errors in Hospitalized Adults Who Died or Were Transferred to Intensive Care. JAMA Intern Med 2024; 184:164-173. [PMID: 38190122 PMCID: PMC10775080 DOI: 10.1001/jamainternmed.2023.7347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/07/2023] [Indexed: 01/09/2024]
Abstract
Importance Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. Objective To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died. Design, Setting, and Participants Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023. Main Outcomes and Measures Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors. Results Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors. Conclusions and Relevance In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
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Affiliation(s)
- Andrew D. Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Tiffany M. Lee
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Colin C. Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco
| | - Sumant R. Ranji
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Katie Raffel
- Department of Medicine, University of Colorado School of Medicine, Denver
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California San Francisco
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | | | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
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202
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Carroll AR, Hall M, Noelke C, Ressler RW, Brown CM, Spencer KS, Bell DS, Williams DJ, Fritz CQ. Association of neighborhood opportunity and pediatric hospitalization rates in the United States. J Hosp Med 2024; 19:120-125. [PMID: 38073069 PMCID: PMC10872227 DOI: 10.1002/jhm.13252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 02/03/2024]
Abstract
We examined associations between a validated, multidimensional measure of social determinants of health and population-based hospitalization rates among children <18 years across 18 states from the 2017 Healthcare Cost and Utilization Project State Inpatient Databases and the US Census. The exposure was ZIP code-level Child Opportunity Index (COI), a composite measure of neighborhood resources and conditions that matter for children's health. The cohort included 614,823 hospitalizations among a population of 29,244,065 children (21.02 hospitalizations per 1000). Adjusted hospitalization rates decreased significantly and in a stepwise fashion as COI increased (p < .001 for each), from 26.56 per 1000 (95% confidence interval [CI] 26.41-26.71) in very low COI areas to 14.76 per 1000 (95% CI 14.66-14.87) in very high COI areas (incidence rate ratio 1.8; 95% CI 1.78-1.81). Decreasing neighborhood opportunity was associated with increasing hospitalization rates among children in 18 US states. These data underscore the importance of social context and community-engaged solutions for health systems aiming to eliminate care inequities.
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Affiliation(s)
- Alison R. Carroll
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Clemens Noelke
- Heller School for Social Policy and Management, Brandeis University, Waltham, MS
| | - Robert W. Ressler
- Heller School for Social Policy and Management, Brandeis University, Waltham, MS
| | - Charlotte M. Brown
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - Katherine S. Spencer
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - Deanna S. Bell
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - Derek J. Williams
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - Cristin Q. Fritz
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
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203
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Gyftopoulos S, Simon E, Swartz JL, Smith SW, Martinez LS, Babb JS, Horwitz LI, Makarov DV. Efficacy and Impact of a Multimodal Intervention on CT Pulmonary Angiography Ordering Behavior in the Emergency Department. J Am Coll Radiol 2024; 21:309-318. [PMID: 37247831 DOI: 10.1016/j.jacr.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the efficacy of a multimodal intervention in reducing CT pulmonary angiography (CTPA) overutilization in the evaluation of suspected pulmonary embolism in the emergency department (ED). METHODS Previous mixed-methods analysis of barriers to guideline-concordant CTPA ordering results was used to develop a provider-focused behavioral intervention consisting of a clinical decision support tool and an audit and feedback system at a multisite, tertiary academic network. The primary outcome (guideline concordance) and secondary outcomes (yield and CTPA and D-dimer order rates) were compared using a pre- and postintervention design. ED encounters for adult patients from July 5, 2017, to January 3, 2019, were included. Fisher's exact tests and statistical process control charts were used to compare the pre- and postintervention groups for each outcome. RESULTS Of the 201,912 ED patient visits evaluated, 3,587 included CTPA. Guideline concordance increased significantly after the intervention, from 66.9% to 77.5% (P < .001). CTPA order rate and D-dimer order rate also increased significantly, from 17.1 to 18.4 per 1,000 patients (P = .035) and 30.6 to 37.3 per 1,000 patients (P < .001), respectively. Percent yield showed no significant change (12.3% pre- versus 10.8% postintervention; P = .173). Statistical process control analysis showed sustained special-cause variation in the postintervention period for guideline concordance and D-dimer order rates, temporary special-cause variation for CTPA order rates, and no special-cause variation for percent yield. CONCLUSION Our success in increasing guideline concordance demonstrates the efficacy of a mixed-methods, human-centered approach to behavior change. Given that neither of the secondary outcomes improved, our results may demonstrate potential limitations to the guidelines directing the ordering of CTPA studies and D-dimer ordering.
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Affiliation(s)
- Soterios Gyftopoulos
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, and Department of Orthopedic Surgery, NYU Grossman School of Medicine, New York, New York; Chief of Radiology, NYU-Brooklyn.
| | - Emma Simon
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, and Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York
| | - Jordan L Swartz
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York; and Chief, Division of Quality, Safety, and Practice Innovation, Institute for Innovations in Medical Education, NYU Langone Health, New York, New York
| | - Leticia Santos Martinez
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, and Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York
| | - James S Babb
- Department of Radiology, NYU Grossman School of Medicine, New York, New York
| | - Leora I Horwitz
- Department of Population Health, NYU Grossman School of Medicine, New York, New York; Center for Healthcare Innovation and Delivery Science, NYU Grossman School of Medicine, New York, New York; and Department of Medicine, NYU Grossman School of Medicine, New York, New York. https://twitter.com/Leorahorwitzmd
| | - Danil V Makarov
- Department of Population Health, NYU Grossman School of Medicine, New York, New York; Department of Urology, NYU Grossman School of Medicine, New York, New York; and Department of Urology, VA New York Harbor Healthcare System, New York, New York. https://twitter.com/Dannymak76
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204
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Auty SG, Daw JR, Admon LK, Gordon SH. Comparing approaches to identify live births using the Transformed Medicaid Statistical Information System. Health Serv Res 2024; 59:e14233. [PMID: 37771156 PMCID: PMC10771902 DOI: 10.1111/1475-6773.14233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE To evaluate the performance of different approaches for identifying live births using Transformed Medicaid Statistical Information System Analytic Files (TAF). DATA SOURCES The primary data source for this study were TAF inpatient (IP), other services (OT), and demographic and eligibility files. These data contain administrative claims for Medicaid enrollees in all 50 states and the District of Columbia from January 1, 2018 to December 31, 2018. STUDY DESIGN We compared five approaches for identifying live birth counts obtained from the TAF IP and OT data with the Centers for Disease Control and Prevention (CDC) Natality data-the gold standard for birth counts at the state level. DATA COLLECTION/EXTRACTION METHODS The five approaches used varying combinations of diagnosis and procedure, revenue, and place of service codes to identify live births. Approaches 1 and 2 follow guidance developed by the Centers for Medicare and Medicaid Services (CMS). Approaches 3 and 4 build on the approaches developed by CMS by including all inpatient hospital claims in the OT file and excluding codes related to delivery services for infants, respectively. Approach 5 applied Approach 4 to only the IP file. PRINCIPAL FINDINGS Approach 4, which included all inpatient hospital claims in the OT file and excluded codes related to infants to identify deliveries, achieved the best match of birth counts relative to CDC birth record data, identifying 1,656,794 live births-a national overcount of 3.6%. Approaches 1 and 3 resulted in larger overcounts of births (20.5% and 4.5%), while Approaches 2 and 5 resulted in undercounts of births (-3.4% and -6.8%). CONCLUSIONS Including claims from both the IP and OT files, and excluding codes unrelated to the delivery episode and those specific to services rendered to infants improves accuracy of live birth identification in the TAF data.
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Affiliation(s)
- Samantha G. Auty
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
| | - Jamie R. Daw
- Department of Health Policy and ManagementColumbia Mailman School of Public HealthNew York CityNew YorkUSA
| | - Lindsay K. Admon
- Department of Obstetrics and GynecologyUniversity of MichiganFlintMichiganUSA
| | - Sarah H. Gordon
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
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205
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Holler E, Du Y, Barboi C, Owora A. Prognostic models for predicting insomnia treatment outcomes: A systematic review. J Psychiatr Res 2024; 170:147-157. [PMID: 38141325 DOI: 10.1016/j.jpsychires.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/30/2023] [Accepted: 12/10/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE To identify and critically evaluate models predicting insomnia treatment response in adult populations. METHODS Pubmed, EMBASE, and PsychInfo databases were searched from January 2000 to January 2023 to identify studies reporting the development or validation of multivariable models predicting insomnia treatment outcomes in adults. Data were extracted according to CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) guidelines and study quality was assessed using the Prediction model study Risk Of Bias Assessment Tool (PROBAST). RESULTS Eleven studies describing 53 prediction models were included and appraised. Treatment response was most frequently assessed using wake after sleep onset (n = 10; 18.9%), insomnia severity index (n = 10; 18.9%), and sleep onset latency (n = 9, 17%). Dysfunctional Beliefs About Sleep (DBAS) score was the most common predictor in final models (n = 33). R2 values ranged from 0.06 to 0.80 for models predicting continuous response and area under the curve (AUC) ranged from 0.73 to 0.87 for classification models. Only two models were internally validated, and none were externally validated. All models were rated as having a high risk of bias according to PROBAST, which was largely driven by the analysis domain. CONCLUSION Prediction models may be a useful tool to assist clinicians in selecting the optimal treatment strategy for patients with insomnia. However, no externally validated models currently exist. These results highlight an important gap in the literature and underscore the need for the development and validation of modern, methodologically rigorous models.
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Affiliation(s)
- Emma Holler
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, IN, USA.
| | - Yu Du
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, IN, USA
| | - Cristina Barboi
- Indiana University School of Medicine, Dept of Anesthesiology and Critical Care Medicine, Indianapolis, IN, USA
| | - Arthur Owora
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, IN, USA
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Harlan EA, Venkatesh S, Morrison J, Cooke CR, Iwashyna TJ, Ford DW, Moscovice IS, Sjoding MW, Valley TS. Rural-Urban Differences in Mortality among Mechanically Ventilated Patients in Intensive and Intermediate Care. Ann Am Thorac Soc 2024. [PMID: 38294224 DOI: 10.1513/annalsats.202308-684oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/19/2024] [Indexed: 02/01/2024] Open
Abstract
RATIONALE Intermediate care (also termed "step-down" or "moderate care") has been proposed as a lower-cost alternative to care for patients who may not clearly benefit from intensive care unit (ICU) admission. Intermediate care units may be appealing to hospitals in financial crisis, including those in rural areas. Outcomes of patients receiving intermediate care are not widely described. OBJECTIVE To examine relationships between rurality, location of care, and mortality for mechanically ventilated patients. METHODS Medicare beneficiaries aged 65 and over who received invasive mechanical ventilation between 2010 to 2019 were included. Multivariable logistic regression was used to estimate the association between admission to rural or urban hospital and 30-day mortality with separate analyses for patients in general, intermediate, and intensive care. Models were adjusted for age, sex, area deprivation index, primary diagnosis, severity of illness, year, comorbidities, and hospital volume. RESULTS There were 2,752,492 hospitalizations for patients receiving mechanical ventilation from 2010 to 2019, and 193,745 patients (7.0%) were in rural hospitals. The proportion of patients in rural intermediate care increased from 4.1% in 2010 to 6.3% in 2019. Patient admissions to urban hospitals remained relatively stable. Patients in rural and urban ICUs had similar adjusted 30-day mortality, 46.7%, (adjusted absolute risk difference -0.1, 95% CI -0.7-0.6, p = 0.88). However, adjusted 30-day mortality for patients in rural intermediate care was significantly higher (37.0%) than for patients in urban intermediate care (31.3%) (adjusted absolute risk difference 5.6%, 95% CI 3.7%-7.6%, p < 0.001). CONCLUSIONS Hospitalization in rural intermediate care was associated with increased mortality. There is a need to better understand how intermediate care is used across hospitals and to carefully evaluate the types of patients admitted to intermediate care units.
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Affiliation(s)
- Emily A Harlan
- University of Michigan, 1259, Internal Medicine, Ann Arbor, Michigan, United States
- United States;
| | | | - Jean Morrison
- University of Michigan, 1259, Ann Arbor, Michigan, United States
| | - Colin R Cooke
- University of Michigan, Pulmonary and Critical Care Medicine, Ann Arbor, Michigan, United States
| | | | - Dee W Ford
- Medical University of South Carolina, Pulmonary and Critical Care Medicine, Charleston, South Carolina, United States
| | - Ira S Moscovice
- University of Minnesota System, 311816, Minneapolis, Minnesota, United States
| | - Michael W Sjoding
- University of Michigan, Internal Medicine Pulmonary Critical Care, Ann Arbor, Michigan, United States
| | - Thomas S Valley
- University of Michigan, Pulmonary and Critical Care Medicine, Ann Arbor, Michigan, United States
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207
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Jeffery AD, Fabbri D, Reeves RM, Matheny ME. Use of Noisy Labels as Weak Learners to Identify Incompletely Ascertainable Outcomes: A Feasibility Study with Opioid-Induced Respiratory Depression. medRxiv 2024:2024.01.29.24301963. [PMID: 38352435 PMCID: PMC10863026 DOI: 10.1101/2024.01.29.24301963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Objective Assigning outcome labels to large observational data sets in a timely and accurate manner, particularly when outcomes are rare or not directly ascertainable, remains a significant challenge within biomedical informatics. We examined whether noisy labels generated from subject matter experts' heuristics using heterogenous data types within a data programming paradigm could provide outcomes labels to a large, observational data set. We chose the clinical condition of opioid-induced respiratory depression for our use case because it is rare, has no administrative codes to easily identify the condition, and typically requires at least some unstructured text to ascertain its presence. Materials and Methods Using de-identified electronic health records of 52,861 post-operative encounters, we applied a data programming paradigm (implemented in the Snorkel software) for the development of a machine learning classifier for opioid-induced respiratory depression. Our approach included subject matter experts creating 14 labeling functions that served as noisy labels for developing a probabilistic Generative model. We used probabilistic labels from the Generative model as outcome labels for training a Discriminative model on the source data. We evaluated performance of the Discriminative model with a hold-out test set of 599 independently-reviewed patient records. Results The final Discriminative classification model achieved an accuracy of 0.977, an F1 score of 0.417, a sensitivity of 1.0, and an AUC of 0.988 in the hold-out test set with a prevalence of 0.83% (5/599). Discussion All of the confirmed Cases were identified by the classifier. For rare outcomes, this finding is encouraging because it reduces the number of manual reviews needed by excluding visits/patients with low probabilities. Conclusion Application of a data programming paradigm with expert-informed labeling functions might have utility for phenotyping clinical phenomena that are not easily ascertainable from highly-structured data.
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Affiliation(s)
- Alvin D Jeffery
- School of Nursing, Vanderbilt University, Department of Biomedical Informatics, Vanderbilt University Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, TN, USA
| | - Daniel Fabbri
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ruth M Reeves
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, TN, USA
| | - Michael E Matheny
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, TN, USA
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208
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Morgan DJ, Scherer L, Pineles L, Baghdadi J, Magder L, Thom K, Koch C, Wilkins N, LeGrand M, Stevens D, Walker R, Shirrell B, Harris AD, Korenstein D. Game-based learning to improve diagnostic accuracy: a pilot randomized-controlled trial. Diagnosis (Berl) 2024; 0:dx-2023-0133. [PMID: 38284830 DOI: 10.1515/dx-2023-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Perform a pilot study of online game-based learning (GBL) using natural frequencies and feedback to teach diagnostic reasoning. METHODS We conducted a multicenter randomized-controlled trial of computer-based training. We enrolled medical students, residents, practicing physicians and nurse practitioners. The intervention was a 45 min online GBL training vs. control education with a primary outcome of score on a scale of diagnostic accuracy (composed of 10 realistic case vignettes, requesting estimates of probability of disease after a test result, 0-100 points total). RESULTS Of 90 participants there were 30 students, 30 residents and 30 practicing clinicians. Of these 62 % (56/90) were female and 52 % (47/90) were white. Sixty were randomized to GBL intervention and 30 to control. The primary outcome of diagnostic accuracy immediately after training was better in GBL (mean accuracy score 59.4) vs. control (37.6), p=0.0005. The GBL group was then split evenly (30, 30) into no further intervention or weekly emails with case studies. Both GBL groups performed better than control at one-month and some continued effect at three-month follow up. Scores at one-month GBL (59.2) GBL plus emails (54.2) vs. control (33.9), p=0.024; three-months GBL (56.2), GBL plus emails (42.9) vs. control (35.1), p=0.076. Most participants would recommend GBL to colleagues (73 %), believed it was enjoyable (92 %) and believed it improves test interpretation (95 %). CONCLUSIONS In this pilot study, a single session with GBL nearly doubled score on a scale of diagnostic accuracy in medical trainees and practicing clinicians. The impact of GBL persisted after three months.
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- VA Maryland Healthcare System, Baltimore, MD, USA
| | - Laura Scherer
- Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Denver, CO, USA
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jon Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Larry Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kerri Thom
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christina Koch
- Division of General Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Deborah Stevens
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Renee Walker
- Visual Communication Design, Thomas Jefferson University, Philadelphia, PA, USA
| | - Beth Shirrell
- Visual Communication Design, Thomas Jefferson University, Philadelphia, PA, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah Korenstein
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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209
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Yuan IH, Greenhawt M, Abrams EM, Kim EH, Mustafa SS, Iglesia EGA. Food allergies on a college campus. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00069-3. [PMID: 38296046 DOI: 10.1016/j.anai.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/15/2024]
Abstract
There are limited data on food allergies among college students. In this article, we review the most current available studies. These self-reported surveys and qualitative interviews reported overall poor avoidance of known allergens and low rates of carrying self-injectable epinephrine among students with food allergy. College students may exhibit risk-taking food behaviors due to a number of factors, including age-appropriate risk-taking predilection, strong social influences, and lack of experience in self-advocacy. Having to disclose an otherwise invisible condition repeatedly in a new environment may also lead to "disclosure fatigue," creating an additional barrier to self-advocacy. Common themes in the narrative include hypervigilance, stigma management, and concern about others' misunderstanding of food allergy. Although there is a paucity of data in this area, it is likely that having greater support at the institution level, along with support from peers and faculty, may help improve awareness, self-injectable epinephrine carriage, and allergen avoidance. This review also discusses strategies for preparedness at school, including specific steps to maximize safety.
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Affiliation(s)
- Irene H Yuan
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, Aurora, Colorado
| | - Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Edwin H Kim
- Division of Pediatric Allergy and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - S Shahzad Mustafa
- Division of Allergy, Immunology, and Rheumatology, Rochester Regional Health, Rochester, New York; Division of Allergy, Immunology, and Rheumatology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Edward G A Iglesia
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Nack T, Vallejo JG, Dunn J, Flores AR, McNeil JC. Invasive Group A Streptococcus in Infants Less Than 1-year of Age From 2012 to 2022: A Single-Center Experience. J Pediatric Infect Dis Soc 2024; 13:110-113. [PMID: 37978871 PMCID: PMC10824259 DOI: 10.1093/jpids/piad105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023]
Abstract
The incidence of invasive Group A Streptococcus (iGAS) has varied throughout the COVID-19 pandemic. We reviewed iGAS infections in infants ≤1 year from 2012 to 2022. Twenty-five percent of cases occurred in the last quarter of 2022. Pneumonia (21.8%) was the most common presentation. Twenty-one patients (65.6%) were successfully transitioned to oral antibiotics.
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Affiliation(s)
- Taylor Nack
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - Jesus G Vallejo
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - James Dunn
- Department of Pathology, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - Anthony R Flores
- Division of Infectious Diseases, Department of Pediatrics, McGovern Medical School at UTHealth Houston and Children’s Memorial Hermann Hospital, Houston, Texas, USA
| | - J Chase McNeil
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
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Duan KI, Donovan LM, Spece LJ, Wong ES, Feemster LC, Bryant AD, Plumley R, Crothers K, Au DH. Inhaler Formulary Change in COPD and the Association with Exacerbations, Health Care Utilization, and Costs. Chronic Obstr Pulm Dis 2024; 11:37-46. [PMID: 37931593 PMCID: PMC10913920 DOI: 10.15326/jcopdf.2023.0425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/08/2023]
Abstract
Rationale Prescription formularies specify which medications are available to patients. Formularies change frequently, potentially forcing patients to switch medications for nonclinical indications (nonmedical switching). Nonmedical switching is known to impact disease control and adherence. The consequences of nonmedical switching have not been rigorously studied in COPD. Methods We conducted a cohort study of Veterans with COPD on inhaler therapy in January 2016 when formoterol was removed from the Department of Veterans Affairs (VA) national formulary. A 2-point difference-in-differences analysis using multivariable negative binomial and generalized linear models was performed to estimate the association of the formulary change with patient outcomes in the 6 months before and after the change. Our primary outcome was the number of COPD exacerbations in 6 months, with secondary outcomes of total health care encounters and encounter-related costs in 6 months. Results We identified 10,606 Veterans who met our inclusion criteria, of which 409 (3.9%) experienced nonmedical switching off formoterol. We did not identify a change in COPD exacerbations (-0.04 exacerbations; 95% confidence interval [CI] -0.12, 0.03) associated with the formulary change. In secondary outcome analysis, we did not observe a change in the number of health care encounters (-0.12 visits; 95% CI -1.00, 0.77) or encounter-related costs ($369; 95% CI -$1141, $1878). Conclusions Among COPD patients on single inhaler therapy, nonmedical inhaler switches due to formulary discontinuation of formoterol were not associated with changes in COPD exacerbations, encounters, or encounter-related costs. Additional research is needed to confirm our findings in more severe disease and other settings.
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Affiliation(s)
- Kevin I Duan
- Division of Respiratory Medicine, University of British Columbia, Vancouver, Canada
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
| | - Lucas M Donovan
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
| | - Laura J Spece
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
| | - Edwin S Wong
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, United States
| | - Laura C Feemster
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
| | | | - Robert Plumley
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
| | - Kristina Crothers
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
| | - David H Au
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, United States
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, United States
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212
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Raj P, Cho Y, Jiang Y, Gong Y. Challenges in Selecting Patient-Reported Outcome Measures for Use in a Patient-Facing Technology. Stud Health Technol Inform 2024; 310:1432-1433. [PMID: 38269682 DOI: 10.3233/shti231230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Patient-reported outcome measures (PROMs) have been increasingly integrated into patient-facing technologies to engage and empower patients in cancer self-management at home. However, researchers and developers face several challenges in selecting the best-suited PROMs for patient-facing technologies, due to the complex nature of the disease, the multitude of PROMs with high psychometric quality, and the lack of clear standards for PROM utilization. In this paper, we have discussed these challenges, illustrated by breast cancer instruments.
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Affiliation(s)
- Priyank Raj
- The University of Texas Health Science Center at Houston, Houston, Texas, US
| | - Youmin Cho
- The University of Texas Health Science Center at Houston, Houston, Texas, US
| | - Yun Jiang
- University of Michigan, Ann Arbor, Michigan, US
| | - Yang Gong
- The University of Texas Health Science Center at Houston, Houston, Texas, US
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213
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Ding M, Cho Y, Jiang Y, Gong Y. A Quantitative Analysis of Patient-Facing Technologies for Patient Self-Reporting. Stud Health Technol Inform 2024; 310:504-508. [PMID: 38269860 DOI: 10.3233/shti231016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Dramatic improvements in patient-facing technologies have demonstrated the potential to transform healthcare delivery for a 360-degree holistic view of care. A key question regarding how such technologies affect patient self-reporting still needs to be answered. This study presents the technologies and their associated key variables via quantitative analysis. Associations were found between single-platform and web-based applications (apps), Android apps and physician view, mental health disease, and user feedback. The results are intended to inform future design, development, and evaluation of patient-facing technologies. More systematic, theory-driven, framework-based design and evaluation are necessary to fully characterize the effectiveness and maintenance of patient-facing technologies toward a sustainable strategy.
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Affiliation(s)
- Mengchen Ding
- The University of Texas Health Science Center at Houston
| | - Youmin Cho
- The University of Texas Health Science Center at Houston
| | | | - Yang Gong
- The University of Texas Health Science Center at Houston
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214
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Phong K, Ding M, Cho Y, Jiang Y, Gong Y. Exploring a Mechanism Toward Automated Feedback for Cancer Patient Self-Reporting. Stud Health Technol Inform 2024; 310:539-543. [PMID: 38269867 DOI: 10.3233/shti231023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
"Infobuttons" spearheaded electronic health records (EHR) based decision support by offering automated knowledge resources to physicians. However, how such a mechanism could be leveraged to provide optimal resources to patients remains unanswered. Informatics approaches are expected to utilize more relevant information beyond EHR, such as patient-reported outcomes, to support clinical decisions. This pilot study is intended to explore how patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE) in EHR can be incorporated and how to recommend tailored content to cancer patients via automated feedback.
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Affiliation(s)
- Kevin Phong
- The University of Texas Health Science Center at Houston, USA
| | - Mengchen Ding
- The University of Texas Health Science Center at Houston, USA
| | - Youmin Cho
- The University of Texas Health Science Center at Houston, USA
| | | | - Yang Gong
- The University of Texas Health Science Center at Houston, USA
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215
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Kim K, Liu G, Dick AW, Choi SW, Agbese E, Corr TE, Hsuan C, Wright MS, Park S, Velott D, Leslie DL. Timing of treatment for opioid use disorder among birthing people. J Subst Use Addict Treat 2024; 161:209289. [PMID: 38272119 DOI: 10.1016/j.josat.2024.209289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND The number of pregnant women with opioid use disorder (OUD) has increased over time. Although effective treatment options exist, little is known about the extent to which women receive treatment during pregnancy and at what stage of pregnancy care is initiated. METHODS Using a national private health insurance claims database, we identified women aged 13-49 who gave birth in 2006-2019 and had an OUD or nonfatal opioid overdose (NFOO) diagnosis during the year prior to or at delivery. We then identified women who received their first OUD treatment prior to or during pregnancy. In this cross-sectional study, we investigated how rates and timing of the initial OUD treatment changed over time. Furthermore, we examined factors associated with early initiation of OUD treatment among birthing people. RESULTS Of the 7057 deliveries from 6747 women with OUD or NFOO, 63.3 % received any OUD treatment. Rates of OUD treatment increased from 42.9 % in 2006 to 69 % in 2019. Of those treated, in 2006, 54.5 % received their first treatment prior to conception and 24.2 % initiated care during the 1st trimester. In 2019, 68.9 % received their first treatment prior to conception, and 15.1 % initiated care during the 1st trimester. The percentage of women who were first treated in the 2nd trimester or later decreased from 21.2 % in 2006 to 16.1 % in 2019. Factors associated with early treatment initiation include being 25 years or older (age 25-34: aOR, 1.51, 95 % CI, 1.28-1.78; age 35-49: aOR, 1.82, 95 % CI, 1.39-2.37), living in urban areas (aOR, 1.28; 95 % CI, 1.05-1.56), having pre-existing behavioral health comorbidities such as anxiety disorders (aOR, 1.8; 95 % CI, 1.40-2.32), mood disorders (aOR, 1.63; 95 % CI, 1.02-2.61), and substance use disorder other than OUD (aOR, 2.56; 95 % CI, 2.03-3.32). CONCLUSION Overall, rates of OUD treatment increased over time, and more women initiated OUD treatment prior to conception. Despite these improvements, over one-third of pregnant women with OUD/NFOO either received no treatment or did not initiate care until the 3rd trimester in 2019. Future research should examine barriers to OUD treatment initiation among pregnant women.
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Affiliation(s)
- Kyungha Kim
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
| | - Guodong Liu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | | | - Sung W Choi
- School of Public Affairs, The Pennsylvania State University, Harrisburg, PA, USA
| | - Edeanya Agbese
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Tammy E Corr
- Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Charleen Hsuan
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA, USA
| | - Megan S Wright
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA; Penn State Law, University Park, PA, USA; Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
| | - Sujeong Park
- School of Public Affairs, The Pennsylvania State University, Harrisburg, PA, USA
| | - Diana Velott
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Douglas L Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Al Hussein Al Awamlh B, Wallis CJD, Penson DF, Huang LC, Zhao Z, Conwill R, Talwar R, Morgans AK, Goodman M, Hamilton AS, Wu XC, Paddock LE, Stroup A, O’Neil BB, Koyama T, Hoffman KE, Barocas DA. Functional Outcomes After Localized Prostate Cancer Treatment. JAMA 2024; 331:302-317. [PMID: 38261043 PMCID: PMC10807259 DOI: 10.1001/jama.2023.26491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/04/2023] [Indexed: 01/24/2024]
Abstract
Importance Adverse outcomes associated with treatments for localized prostate cancer remain unclear. Objective To compare rates of adverse functional outcomes between specific treatments for localized prostate cancer. Design, Setting, and Participants An observational cohort study using data from 5 US Surveillance, Epidemiology, and End Results Program registries. Participants were treated for localized prostate cancer between 2011 and 2012. At baseline, 1877 had favorable-prognosis prostate cancer (defined as cT1-cT2bN0M0, prostate-specific antigen level <20 ng/mL, and grade group 1-2) and 568 had unfavorable-prognosis prostate cancer (defined as cT2cN0M0, prostate-specific antigen level of 20-50 ng/mL, or grade group 3-5). Follow-up data were collected by questionnaire through February 1, 2022. Exposures Radical prostatectomy (n = 1043), external beam radiotherapy (n = 359), brachytherapy (n = 96), or active surveillance (n = 379) for favorable-prognosis disease and radical prostatectomy (n = 362) or external beam radiotherapy with androgen deprivation therapy (n = 206) for unfavorable-prognosis disease. Main Outcomes and Measures Outcomes were patient-reported sexual, urinary, bowel, and hormone function measured using the 26-item Expanded Prostate Cancer Index Composite (range, 0-100; 100 = best). Associations of specific therapies with each outcome were estimated and compared at 10 years after treatment, adjusting for corresponding baseline scores, and patient and tumor characteristics. Minimum clinically important differences were 10 to 12 for sexual function, 6 to 9 for urinary incontinence, 5 to 7 for urinary irritation, and 4 to 6 for bowel and hormone function. Results A total of 2445 patients with localized prostate cancer (median age, 64 years; 14% Black, 8% Hispanic) were included and followed up for a median of 9.5 years. Among 1877 patients with favorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -12.1 [95% CI, -16.2 to -8.0]), but not worse sexual function (adjusted mean difference, -7.2 [95% CI, -12.3 to -2.0]), compared with active surveillance. Among 568 patients with unfavorable prognosis, radical prostatectomy was associated with worse urinary incontinence (adjusted mean difference, -26.6 [95% CI, -35.0 to -18.2]), but not worse sexual function (adjusted mean difference, -1.4 [95% CI, -11.1 to 8.3), compared with external beam radiotherapy with androgen deprivation therapy. Among patients with unfavorable prognosis, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel (adjusted mean difference, -4.9 [95% CI, -9.2 to -0.7]) and hormone (adjusted mean difference, -4.9 [95% CI, -9.5 to -0.3]) function compared with radical prostatectomy. Conclusions and Relevance Among patients treated for localized prostate cancer, radical prostatectomy was associated with worse urinary incontinence but not worse sexual function at 10-year follow-up compared with radiotherapy or surveillance among people with more favorable prognosis and compared with radiotherapy for those with unfavorable prognosis. Among men with unfavorable-prognosis disease, external beam radiotherapy with androgen deprivation therapy was associated with worse bowel and hormone function at 10-year follow-up compared with radical prostatectomy.
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Affiliation(s)
| | - Christopher J. D. Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David F. Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Affairs Tennessee Valley Geriatric Research Education and Clinical Center, Nashville
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ralph Conwill
- Office of Patient and Community Education, Patient Advocacy Program, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ruchika Talwar
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alicia K. Morgans
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael Goodman
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Ann S. Hamilton
- Department of Population and Public Health Sciences, Keck School of Medicine at the University of Southern California, Los Angeles
| | - Xiao-Cheng Wu
- Department of Epidemiology, Louisiana State University New Orleans School of Public Health, New Orleans
| | - Lisa E. Paddock
- Cancer Epidemiology Services, New Jersey Department of Health, Rutgers Cancer Institute of New Jersey, New Brunswick
- Rutgers School of Public Health, New Brunswick, New Jersey
| | - Antoinette Stroup
- Cancer Epidemiology Services, New Jersey Department of Health, Rutgers Cancer Institute of New Jersey, New Brunswick
- Rutgers School of Public Health, New Brunswick, New Jersey
| | - Brock B. O’Neil
- Department of Urology, University of Utah Health, Salt Lake City
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen E. Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Center, Houston
| | - Daniel A. Barocas
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
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217
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Thornburg B, Kennedy-Hendricks A, Rosen JD, Eisenberg MD. Anxiety and Depression Symptoms After the Dobbs Abortion Decision. JAMA 2024; 331:294-301. [PMID: 38261045 PMCID: PMC10807253 DOI: 10.1001/jama.2023.25599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/20/2023] [Indexed: 01/24/2024]
Abstract
Importance In 2022, the US Supreme Court abolished the federal right to abortion in the Dobbs v Jackson Women's Health Organization decision. In 13 states, abortions were immediately banned via previously passed legislation, known as trigger laws. Objective To estimate changes in anxiety and depression symptoms following the Dobbs decision among people residing in states with trigger laws compared with those without them. Design, Setting, and Participants Using the nationally representative repeated cross-sectional Household Pulse Survey (December 2021-January 2023), difference-in-differences models were estimated to examine the change in symptoms of depression and anxiety after Dobbs (either the June 24, 2022, Dobbs decision, or its May 2, 2022, leaked draft benchmarked to the baseline period, prior to May 2, 2022) by comparing the 13 trigger states with the 37 nontrigger states. Models were estimated for the full population (N = 718 753), and separately for 153 108 females and 102 581 males aged 18 through 45 years. Exposure Residing in states with trigger laws following the Dobbs decision or its leaked draft. Main Outcomes and Measures Anxiety and depression symptoms were measured via the Patient Health Questionnaire-4 ([PHQ-4]; range, 0-12; scores of more than 5 indicate elevated depression or anxiety symptoms; minimal important difference unknown). Results The survey response rate was 6.04% overall, and 87% of respondents completed the PHQ-4. The population-weighted mean age was 48 years (SD, 17 years), and 51% were female. In trigger states, the mean PHQ-4 scores in the baseline period and after the Dobbs decision were 3.51 (95% CI, 3.44 to 3.59) and 3.81 (95% CI, 3.75 to 3.87), respectively, and in nontrigger states were 3.31 (95% CI, 3.27 to 3.34) and 3.49 (95% CI, 3.45 to 3.53), respectively. There was a significantly greater increase in the mean PHQ-4 score by 0.11 (95% CI, 0.06 to 0.16; P < .001) in trigger states vs nontrigger states. From baseline to after the draft was leaked, the change in PHQ-4 was not significantly different for those in trigger states vs nontrigger states (difference-in-differences estimate, 0.09; 95% CI, -0.03 to 0.21; P = .15). From baseline to after the Dobbs opinion, there was a significantly greater increase in mean PHQ-4 scores for those in trigger states vs nontrigger states among females aged 18 through 45 years (difference-in-differences estimate, 0.23; 95% CI, 0.08 to 0.37; P = .002). Among males aged 18 through 45 years, the difference-in-differences estimate was not statistically significant (0.14; 95% CI, -0.08 to 0.36; P = .23). Differences in estimates for males and females aged 18 through 45 were statistically significant (P = .02). Conclusions and Relevance In this study of US survey data from December 2021 to January 2023, residence in states with abortion trigger laws compared with residence in states without such laws was associated with a small but significantly greater increase in anxiety and depression symptoms after the Dobbs decision.
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Affiliation(s)
- Benjamin Thornburg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Center for Mental Health and Addiction Policy, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Joanne D. Rosen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Center for Law and the Public’s Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Matthew D. Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Center for Mental Health and Addiction Policy, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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218
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Kneifati-Hayek JZ, Geist E, Applebaum JR, Dal Col AK, Salmasian H, Schechter CB, Elhadad N, Weintraub J, Adelman JS. Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient? BMJ Qual Saf 2024; 33:132-135. [PMID: 38071526 PMCID: PMC10872565 DOI: 10.1136/bmjqs-2023-016162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/24/2023] [Indexed: 12/22/2023]
Abstract
Studying near-miss errors is essential to preventing errors from reaching patients. When an error is committed, it may be intercepted (near-miss) or it will reach the patient; estimates of the proportion that reach the patient vary widely. To better understand this relationship, we conducted a retrospective cohort study using two objective measures to identify wrong-patient imaging order errors involving radiation, estimating the proportion of errors that are intercepted and those that reach the patient. This study was conducted at a large integrated healthcare system using data from 1 January to 31 December 2019. The study used two outcome measures of wrong-patient orders: (1) wrong-patient orders that led to misadministration of radiation reported to the New York Patient Occurrence Reporting and Tracking System (NYPORTS) (misadministration events); and (2) wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder (RAR) measure, a measure identifying orders placed for a patient, retracted and rapidly reordered by the same clinician on a different patient (near-miss events). All imaging orders that involved radiation were extracted retrospectively from the healthcare system data warehouse. Among 293 039 total eligible orders, 151 were wrong-patient orders (3 misadministration events, 148 near-miss events), for an overall rate of 51.5 per 100 000 imaging orders involving radiation placed on the wrong patient. Of all wrong-patient imaging order errors, 2% reached the patient, translating to 50 near-miss events for every 1 error that reached the patient. This proportion provides a more accurate and reliable estimate and reinforces the utility of systematic measure of near-miss errors as an outcome for preventative interventions.
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Affiliation(s)
| | - Elias Geist
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jo R Applebaum
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Alexis K Dal Col
- Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Hojjat Salmasian
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Noémie Elhadad
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Joshua Weintraub
- Department of Radiology, Columbia University, New York, New York, USA
| | - Jason S Adelman
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, New York, USA
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219
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Newman-Toker DE, Nassery N, Schaffer AC, Yu-Moe CW, Clemens GD, Wang Z, Zhu Y, Saber Tehrani AS, Fanai M, Hassoon A, Siegal D. Burden of serious harms from diagnostic error in the USA. BMJ Qual Saf 2024; 33:109-120. [PMID: 37460118 PMCID: PMC10792094 DOI: 10.1136/bmjqs-2021-014130] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 06/24/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Diagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. We previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. OBJECTIVE We sought to estimate the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. METHODS Cross-sectional analysis of US-based nationally representative observational data. We estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). Annual new cancers were taken from US-based registries (2014). Years were selected for coding consistency with prior literature. Disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories) were multiplied by literature-based rates to derive diagnostic errors and serious harms. We calculated uncertainty estimates using Monte Carlo simulations. Validity checks included sensitivity analyses and comparison with prior published estimates. RESULTS Annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers. Per 'Big Three' dangerous disease case, weighted mean error and serious harm rates were 11.1% and 4.4%, respectively. Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), we estimated total serious harms annually in the USA to be 795 000 (plausible range 598 000-1 023 000). Sensitivity analyses using more conservative assumptions estimated 549 000 serious harms. Results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. The 15 dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%. CONCLUSION An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
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Affiliation(s)
- David E Newman-Toker
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Najlla Nassery
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Adam C Schaffer
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Patient Safety, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
| | - Chihwen Winnie Yu-Moe
- Department of Patient Safety, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
| | - Gwendolyn D Clemens
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zheyu Wang
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yuxin Zhu
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ali S Saber Tehrani
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Mehdi Fanai
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ahmed Hassoon
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dana Siegal
- Candello, The Risk Management Foundation of the Harvard Medical Institutions Inc, Boston, Massachusetts, USA
- Department of Risk Management & Analytics, Coverys, Boston, Massachusetts, USA
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220
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Mangal S, Berger L, Bruzzese JM, de la Cruz A, Lor M, Naqvi IA, Solis de Ovando E, Spiegel-Gotsch N, Stonbraker S, Arcia A. Seeing things the same way: perspectives and lessons learned from research-design collaborations. J Am Med Inform Assoc 2024; 31:542-547. [PMID: 37437899 PMCID: PMC10797272 DOI: 10.1093/jamia/ocad124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 05/15/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023] Open
Abstract
Information visualizations are increasingly being developed by informatics researchers to communicate health information to lay audiences. For high-quality results, it is advisable to collaborate with creative professionals such as graphic designers, illustrators, or user interface/user experience designers. However, such collaborations are often a novel experience for both parties, each of which may be unfamiliar with the needs and processes of the other. We have coalesced our experiences from both the research and design perspectives to offer practical guidance in hopes of promoting the success of future collaborations. We offer suggestions for determining design needs, communicating with design professionals, and carrying out the design process. We assert that successful collaborations are predicated on careful and intentional planning at the outset of a project, a thorough understanding of each party's scope expertise, clear communication, and ample time for the design process to unfold.
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Affiliation(s)
- Sabrina Mangal
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, Washington, USA
| | | | | | | | - Maichou Lor
- University of Wisconsin-Madison School of Nursing, Madison, Wisconsin, USA
| | - Imama A Naqvi
- Department of Neurology, Division of Stroke and Cerebrovascular Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Eugenio Solis de Ovando
- Seidenberg School of Computer Science and Information Systems, Pace University, New York, New York, USA
| | | | | | - Adriana Arcia
- Hahn School of Nursing and Health Science, University of San Diego, San Diego, California, USA
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Olaya F, Brin M, Caraballo PB, Halpern M, Jia H, Ramírez SO, Padilla JJ, Stonbraker S, Schnall R. A randomized controlled trial of the dissemination of an mHealth intervention for improving health outcomes: the WiseApp for Spanish-speakers living with HIV study protocol. BMC Public Health 2024; 24:201. [PMID: 38233908 PMCID: PMC10792787 DOI: 10.1186/s12889-023-17538-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/19/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND While there is no cure for HIV, adherence to antiretroviral therapy can extend the lifespan and improve the quality of life of people with HIV. Despite the global reduction of HIV infection rates in recent years, New York City and La Romana, Dominican Republic, continue to report high infection rates among Latino populations. Many people with HIV remain virally unsuppressed in these geographic hotspots, suggesting a need for additional interventions to overcome medication adherence barriers. Tailored and culturally appropriate mobile health (mHealth) technology can be an engaging way to improve adherence. The primary objective of this trial is to test the effectiveness of an mHealth tool to improve HIV medication adherence among Spanish-speaking people living in New York City and the Dominican Republic. METHODS The WiseApp study is a two-arm randomized controlled trial among 248 people with HIV across the New York and Dominican Republic sites over the course of 12 months. Participants are randomly assigned to either receive a CleverCap pill bottle that is linked to the WiseApp (intervention) or standard of care (control). All participants complete surveys at baseline, 3-month, 6-month, and 12-month follow-up visits and the study team obtains HIV-1 viral load and CD4 count results through blood draw at each study timepoint. DISCUSSION The use of mHealth technologies to improve medication adherence among people with HIV has been implemented in recent years. Although some studies have found improvement in adherence to antiretroviral therapy in the short term, there is limited information about how these interventions improve adherence among Spanish-speaking populations. Disproportionate rates of HIV infection among Latinos in New York City suggest an existing inequitable approach in reaching and treating this population. Due to a lack of mHealth studies with Latino populations, and apps tailored to Spanish-speakers, the WiseApp study will not only demonstrate the effectiveness of this particular mHealth app but will also contribute to the mHealth research community as a whole. TRIAL REGISTRATION This trial was registered with Clinicaltrials.gov (NCT05398185) on 5/31/2022.
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Affiliation(s)
- Felix Olaya
- School of Nursing, Columbia University, 560 W 168th St, New York, NY, 10032, USA
| | - Maeve Brin
- School of Nursing, Columbia University, 560 W 168th St, New York, NY, 10032, USA
| | | | - Mina Halpern
- Clínica de Familia La Romana, La Romana, Dominican Republic
| | - Haomiao Jia
- School of Nursing, Columbia University, 560 W 168th St, New York, NY, 10032, USA
| | - Sergio Ozoria Ramírez
- NYU Steinhardt School of Culture, Education, and Human Development, New York, NY, 10003, USA
| | | | - Samantha Stonbraker
- University of Colorado College of Nursing, Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Rebecca Schnall
- School of Nursing, Columbia University, 560 W 168th St, New York, NY, 10032, USA.
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222
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Wyte-Lake T, Cohen DJ, Williams S, Casey D, Chan M, Frank B, Levander XA, Stein D, White KK, Bailey SR. Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study. J Gen Intern Med 2024:10.1007/s11606-023-08586-6. [PMID: 38228990 DOI: 10.1007/s11606-023-08586-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed. OBJECTIVE To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care. DESIGN Comparative case study, using video- and telephone-based semi-structured interviews. PARTICIPANTS Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system. APPROACH Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process. KEY RESULTS Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference. CONCLUSIONS Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.
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Affiliation(s)
- Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Shannon Williams
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Casey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Matt Chan
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brian Frank
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ximena A Levander
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Dan Stein
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Katie Kirkman White
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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223
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Stewart JW, Hou H, Hawkins RB, Pagani FD, Sterling MR, Likosky DS, Thompson MP. Hospital Variation in Skilled Nursing Facility Use After Coronary Artery Bypass Graft Surgery. J Am Heart Assoc 2024; 13:e029833. [PMID: 38193303 PMCID: PMC10926789 DOI: 10.1161/jaha.123.029833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 10/25/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Over 20% of patients are discharged to a skilled nursing facility (SNF) after coronary artery bypass graft surgery, but little is known about specific drivers for postdischarge SNF use. The purpose of this study was to evaluate hospital variation in SNF use and its association with postoperative outcomes after coronary artery bypass graft. METHODS AND RESULTS A retrospective study design utilizing Medicare Provider Analysis and Review files was used to evaluate SNF use among 70 509 beneficiaries undergoing coronary artery bypass graft, with or without valve procedures, between 2016 and 2018. A total of 17 328 (24.6%) were discharged to a SNF, ranging from 0% to 88% across 871 hospitals. Multilevel logistic regression models identified significant patient-level predictors of discharge to SNF including increasing age, comorbidities, female sex, Black race, dual eligibility, and postoperative complications. After adjusting for patient and hospital factors, 15.6% of the variation in hospital SNF use was attributed to the discharging hospital. Compared with the lower quartile of hospital SNF use, hospitals in the top quartile of SNF use had lower risk-adjusted 1-year mortality (12.5% versus 8.6%, P<0.001) and readmission (59.9% versus 49.8%, P<0.001) rates for patients discharged to a SNF. CONCLUSIONS There is high variability in SNF use among hospitals that is only partially explained by patient characteristics. Hospitals with higher SNF utilization had lower risk-adjusted 1-year mortality and readmission rates for patients discharged to a SNF. More work is needed to better understand underlying provider and hospital-level factors contributing to SNF use variability.
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Affiliation(s)
- James W. Stewart
- Department of SurgeryYale School of MedicineNew HavenCTUSA
- Department of SurgeryMichigan MedicineAnn ArborMIUSA
| | - Hechuan Hou
- Department of Cardiac SurgeryMichigan MedicineAnn ArborMIUSA
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224
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Ramanathan S, Evans CT, Hershow RC, Calip GS, Rowan S, Hubbard C, Suda KJ. Guideline concordance and antibiotic-associated adverse events between Veterans administration and non-Veterans administration dental settings: a retrospective cohort study. Front Pharmacol 2024; 15:1249531. [PMID: 38292941 PMCID: PMC10824966 DOI: 10.3389/fphar.2024.1249531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Background: Antibiotics prescribed as infection prophylaxis prior to dental procedures have the potential for serious adverse drug events (ADEs). However, the extent to which guideline concordance and different dental settings are associated with ADEs from antibiotic prophylaxis is unknown. Aim: The purpose was to assess guideline concordance and antibiotic-associated ADEs and whether it differs by VA and non-VA settings. Methods: Retrospective cohort study of antibiotic prophylaxis prescribed to adults with cardiac conditions or prosthetic joints from 2015 to 2017. Multivariable logistic regression models were fit to assess the impact of ADEs, guideline concordance and dental setting. An interaction term of concordance and dental setting evaluated whether the relationship between ADEs and concordance differed by setting. Results: From 2015 to 2017, 61,124 patients with antibiotic prophylaxis were identified with 62 (0.1%) having an ADE. Of those with guideline concordance, 18 (0.09%) had an ADE while 44 (0.1%) of those with a discordant antibiotic had an ADE (unadjusted OR: 0.84, 95% CI: 0.49-1.45). Adjusted analyses showed that guideline concordance was not associated with ADEs (OR: 0.78, 95% CI: 0.25-2.46), and this relationship did not differ by dental setting (Wald χ^2 p-value for interaction = 0.601). Conclusion: Antibiotic-associated ADEs did not differ by setting or guideline concordance.
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Affiliation(s)
- Swetha Ramanathan
- School of Public Heath, University of Illinois at Chicago, Chicago, IL, United States
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, United States
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University of Feinberg School of Medicine, Chicago, IL, United States
| | - Ronald C. Hershow
- School of Public Heath, University of Illinois at Chicago, Chicago, IL, United States
| | - Gregory S. Calip
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
| | - Susan Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, IL, United States
| | - Colin Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, United States
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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225
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Prasath V, Quinn PL, Arjani S, Li S, Oliver JB, Mahmoud O, Jaloudi M, Hajifathalian K, Chokshi RJ. Locally Advanced Gastric Cancer Management: A Cost-Effectiveness Analysis. Am Surg 2024:31348241227180. [PMID: 38225880 DOI: 10.1177/00031348241227180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Across the nation, patients with locally advanced gastric cancer (LAGC) are managed with modalities including upfront surgery (US) and perioperative chemotherapy (PCT). Preoperative therapies have demonstrated survival benefits over US and thus long-term outcomes are expected to vary between the options. However, as these 2 modalities continue to be regularly employed, we sought to perform a decision analysis comparing the costs and quality-of-life associated with the treatment of patients with LAGC to identify the most cost-effective option. We designed a decision tree model to investigate the survival and costs associated with the most commonly utilized management modalities for LAGC in the United States: US and PCT. The tree described costs and treatment strategies over a 6-month time horizon. Costs were derived from 2022 Medicare reimbursement rates using the third-party payer perspective for physicians and hospitals. Effectiveness was represented using quality-adjusted life-years (QALYs). One-way, two-way, and probabilistic sensitivity analyses were utilized to test the robustness of our findings. PCT was the most cost-effective treatment modality for patients with LAGC over US with a cost of $40,792.16 yielding 3.11 QALYs. US has a cost of $55,575.57 while yielding 3.15 QALYs; the incremental cost-effectiveness ratio (ICER) was $369,585.25. One-way and two-way sensitivity analyses favored PCT in all variations of variables across their standard deviations. Across 100,000 Monte Carlo simulations, 100% of trials favored PCT. In our model simulating patients with LAGC, the most cost-effective treatment strategy was PCT. While US demonstrated improved QALYs over PCT, the associated cost was too great to justify its use.
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Affiliation(s)
- Vishnu Prasath
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Patrick L Quinn
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Simran Arjani
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sharon Li
- Division of Hematology/Oncology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Joseph B Oliver
- Department of Surgery, East Orange Veterans Affairs Medical Center, East Orange, NJ, USA
| | - Omar Mahmoud
- Department of Radiation Oncology, Baptist MD Anderson, Jacksonville, FL, USA
| | - Mohammed Jaloudi
- Division of Hematology/Oncology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
- Division of Medical Oncology, Scripps MD Anderson Cancer Center, La Jolla, CA, USA
| | - Kaveh Hajifathalian
- Division of Gastroenterology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
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226
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Bridges JM, Li J, Mannion ML, Clowse MEB, Schmajuk G, Singh JA. Contraception Care Patterns for Adult Females With Juvenile Idiopathic Arthritis on Teratogens in the Rheumatology Informatics System for Effectiveness (RISE) Registry. J Rheumatol 2024:jrheum.2023-1057. [PMID: 38224995 DOI: 10.3899/jrheum.2023-1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
As patients with juvenile idiopathic arthritis (JIA) age into adulthood, they often require antirheumatic medication.1 Antirheumatic medications used in JIA have significant reproductive considerations in unplanned pregnancies, including teratogenicity and fetal loss.2.
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Affiliation(s)
- John M Bridges
- J.M. Bridges, MD, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jing Li
- J. Li, MPH, Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Melissa L Mannion
- M.L. Mannion, MD, University of Alabama at Birmingham, Birmingham, Alabama
| | - Megan E B Clowse
- M.E.B. Clowse, MD, MPH, Duke University, Division of Rheumatology and Immunology, Durham, North Carolina
| | - Gabriela Schmajuk
- G. Schmajuk, MD, MS, Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, California, P.R. Lee Institute for Health Policy Research, Department of Medicine, University of California San Francisco, San Francisco, California, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Jasvinder A Singh
- J.A. Singh, MD, MPH, Medicine Service, VA Medical Center, Birmingham, Alabama,Department of Medicine at the School of Medicine, University of Alabama at Birmingham (UAB), and Department of Epidemiology at the UAB School of Public Health, Birmingham, Alabama, USA
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Dossabhoy SS, Fisher AT, Chang TI, Owens DK, Arya S, Stern JR, Lee JT. Preoperative proteinuria is independently associated with mortality after fenestrated endovascular aneurysm repair. J Vasc Surg 2024:S0741-5214(24)00073-9. [PMID: 38219966 DOI: 10.1016/j.jvs.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 01/16/2024]
Abstract
OBJECTIVE Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR. METHODS A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling. RESULTS Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05). CONCLUSIONS In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR.
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Affiliation(s)
- Shernaz S Dossabhoy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Andrea T Fisher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Douglas K Owens
- Department of Health Policy, Stanford University School of Medicine, Stanford, CA
| | - Shipra Arya
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA; Baszucki Vascular Surgery Biobank, Stanford University School of Medicine, Stanford, CA.
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Balbin CA, Kawamoto K. The SIMPLE Architectural Pattern for Integrating Patient-Facing Apps into Clinical Workflows: Desiderata and Application for Lung Cancer Screening. AMIA Annu Symp Proc 2024; 2023:844-853. [PMID: 38222334 PMCID: PMC10785839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
In December 2022, regulations from the U.S. Office of the National Coordinator for Health IT came into effect that require electronic health record (EHR) systems to accept the connection of any patient-facing digital health app using the SMART on FHIR standard. However, little has been reported with regard to architectural patterns that can be reused to take advantage of this industry development and integrate patient-facing apps into clinical workflows. To address this need, we propose SIMPLE, short for Standards-based Implementation Maximizing Portability Leveraging the EHR. The SIMPLE architectural pattern was designed to meet several key desiderata: do not require patients to install new software; do not retain patient data outside of the EHR; leverage EHRs' existing personal health record (PHR) capabilities to optimize user experience; and maximize portability. Using this pattern, an application for lung cancer screening known as MyLungHealth has been designed and is undergoing iterative user-centered enhancement.
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Affiliation(s)
- Christian A Balbin
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
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Moy AJ, Cato KD, Kim EY, Withall J, Rossetti SC. A Computational Framework to Evaluate Emergency Department Clinician Task Switching in the Electronic Health Record Using Event Logs. AMIA Annu Symp Proc 2024; 2023:1183-1192. [PMID: 38222361 PMCID: PMC10785917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Workflow fragmentation, defined as task switching, may be one proxy to quantify electronic health record (EHR) documentation burden in the emergency department (ED). Few measures have been operationalized to evaluate task switching at scale. Theoretically grounded in the time-based resource-sharing model (TBRSM) which conceives task switching as proportional to the cognitive load experienced, we describe the functional relationship between cognitive load and the time and effort constructs previously applied for measuring documentation burden. We present a computational framework, COMBINE, to evaluate multilevel task switching in the ED using EHR event logs. Based on this framework, we conducted a descriptive analysis on task switching among 63 full-time ED physicians from one ED site using EHR event logs extracted between April-June 2021 (n=2,068,605 events) which were matched to scheduled shifts (n=952). On average, we found a high volume of event-level (185.8±75.3/hr) and within-(6.6±1.7/chart) and between-patient chart (27.5±23.6/hr) switching per shift worked.
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Affiliation(s)
- Amanda J Moy
- Columbia University (CU) Department of Biomedical Informatics, NY, NY
| | - Kenrick D Cato
- CU Irving Medical Center Department of Emergency Medicine, NY, NY, USA
- CU School of Nursing, NY, NY, USA
- Children's Hospital of Philadelphia Department of Biomedical and Health Informatics, Philadelphia, PA, USA
| | - Eugene Y Kim
- CU Irving Medical Center Department of Emergency Medicine, NY, NY, USA
| | | | - Sarah C Rossetti
- Columbia University (CU) Department of Biomedical Informatics, NY, NY
- CU School of Nursing, NY, NY, USA
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Mastrianni A, Hamlin L, Alberto EC, Sullivan TM, Ranganna A, Marsic I, Burd RS, Sarcevic A. Analysis of Task Attributes Associated with Crisis Checklist Compliance in Pediatric Trauma Resuscitation. AMIA Annu Symp Proc 2024; 2023:504-513. [PMID: 38222377 PMCID: PMC10785895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Although checklists can improve overall team performance during medical crises, non-compliant checklist use poses risks to patient safety. We examined how task attributes affected checklist compliance by studying the use of a digital checklist during trauma resuscitation. We first determined task attributes and checklist compliance behaviors for 3,131 resuscitation tasks. Using statistical analyses and qualitative video review, we then identified barriers to accurately tracking task status, finding that certain task attributes were associated with non-compliant checklist behaviors. For example, tasks with multiple steps were more likely to be incorrectly recorded as completed when the task was not performed to completion. We discuss challenges in capturing and tracking the status of tasks with attributes that contribute to non-compliant checklist use. We also contribute a framework for understanding how tasks with certain attributes can be designed on checklists to improve compliance.
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Affiliation(s)
- Angela Mastrianni
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Leah Hamlin
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Emily C Alberto
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Travis M Sullivan
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Adesh Ranganna
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, USA
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Hospital, Washington, DC, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
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231
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Withall J, Tran M, Schroeder B, Lee R, Moy A, Bokhari SMA, Cato K, Rossetti S. Identifying Reuse and Redundancies in Respiratory Flowsheet Documentation: Implications for Clinician Documentation Burden. AMIA Annu Symp Proc 2024; 2023:1297-1303. [PMID: 38222343 PMCID: PMC10785890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Documentation burden is experienced by clinical end-users of the electronic health record. Flowsheet measure reuse and clinical concept redundancy are two contributors to documentation burden. In this paper, we described nursing flowsheet documentation hierarchy and frequency of use for one month from two hospitals in our health system. We examined respiratory care management documentation in greater detail. We found 59 instances of reuse of respiratory care flowsheet measure fields over two or more templates and groups, and 5 instances of clinical concept redundancy. Flowsheet measure fields for physical assessment observations and measurements were the most frequently documented and most reused, whereas respiratory intervention documentation was less frequently reused. Further research should investigate the relationship between flowsheet measure reuse and redundancy and EHR information overload and documentation burden.
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Affiliation(s)
| | - Mai Tran
- Columbia University, Department of Biomedical Informatics, New York, NY
| | - Bobby Schroeder
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY
| | - Rachel Lee
- Columbia University, School of Nursing, New York, NY
| | - Amanda Moy
- Columbia University, Department of Biomedical Informatics, New York, NY
| | | | - Kenrick Cato
- Columbia University, School of Nursing, New York, NY
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sarah Rossetti
- Columbia University, School of Nursing, New York, NY
- Columbia University, Department of Biomedical Informatics, New York, NY
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232
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Zhang Z, Joy K, Bhadani AS, Joshi TD, Adelgais K, Ozkaynak M. Information Seeking and Sensemaking in Emergency Medical Service through Simulation Video Review. AMIA Annu Symp Proc 2024; 2023:804-813. [PMID: 38222399 PMCID: PMC10785834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Emergency medical services (EMS) providers often face significant challenges in their work, including collecting, integrating, and making sense of a variety of information. Despite their criticality, EMS work is one of the very few medical domains with limited technical support. To design and implement effective decision support, it is essential to examine and gain a holistic understanding of the fine-grained process of sensemaking in the field. To that end, we reviewed 25 video recordings of EMS simulations to understand the nuances of EMS sensemaking work, including 1) the types of information and situation that are collected and made sense of in the field; 2) the work practices and temporal patterns of EMS sensemaking work; and 3) the challenges in EMS sensemaking and decision-making process. Based on the results, we discuss implications for technology opportunities to support rapid information acquisition and sensemaking in time-critical, high-risk medical settings such as EMS.
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233
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Thanarajasingam G, Kluetz P, Bhatnagar V, Brown A, Cathcart-Rake E, Diamond M, Faust L, Fiero MH, Huntington S, Jeffery MM, Jones L, Noble B, Paludo J, Powers B, Ross JS, Ritchie JD, Ruddy K, Schellhorn S, Tarver M, Dueck AC, Gross C. Integrating 4 methods to evaluate physical function in patients with cancer (In4M): protocol for a prospective cohort study. BMJ Open 2024; 14:e074030. [PMID: 38199641 PMCID: PMC10806877 DOI: 10.1136/bmjopen-2023-074030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/03/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Accurate, patient-centred evaluation of physical function in patients with cancer can provide important information on the functional impacts experienced by patients both from the disease and its treatment. Increasingly, digital health technology is facilitating and providing new ways to measure symptoms and function. There is a need to characterise the longitudinal measurement characteristics of physical function assessments, including clinician-reported outcome, patient-reported ported outcome (PRO), performance outcome tests and wearable data, to inform regulatory and clinical decision-making in cancer clinical trials and oncology practice. METHODS AND ANALYSIS In this prospective study, we are enrolling 200 English-speaking and/or Spanish-speaking patients with breast cancer or lymphoma seen at Mayo Clinic or Yale University who will receive intravenous cytotoxic chemotherapy. Physical function assessments will be obtained longitudinally using multiple assessment modalities. Participants will be followed for 9 months using a patient-centred health data aggregating platform that consolidates study questionnaires, electronic health record data, and activity and sleep data from a wearable sensor. Data analysis will focus on understanding variability, sensitivity and meaningful changes across the included physical function assessments and evaluating their relationship to key clinical outcomes. Additionally, the feasibility of multimodal physical function data collection in real-world patients with breast cancer or lymphoma will be assessed, as will patient impressions of the usability and acceptability of the wearable sensor, data aggregation platform and PROs. ETHICS AND DISSEMINATION This study has received approval from IRBs at Mayo Clinic, Yale University and the US Food and Drug Administration. Results will be made available to participants, funders, the research community and the public. TRIAL REGISTRATION NUMBER NCT05214144; Pre-results.
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Affiliation(s)
| | - Paul Kluetz
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Abbie Brown
- Health Education and Content Services, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew Diamond
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Louis Faust
- Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Scott Huntington
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale's Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Molly Moore Jeffery
- Division of Health Care Delivery Research and Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lee Jones
- Patient Advocate, Arlington, Virginia, USA
| | - Brie Noble
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Brad Powers
- CancerHacker Lab, Boston, Massachusetts, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jessica D Ritchie
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathryn Ruddy
- Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah Schellhorn
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale's Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michelle Tarver
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Amylou C Dueck
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
| | - Cary Gross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale's Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA
- Yale-New Haven Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
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234
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French MA, Hayes H, Johnson JK, Young DL, Roemmich RT, Raghavan P. The effect of post-acute rehabilitation setting on 90-day mobility after stroke: A difference-in-difference analysis. medRxiv 2024:2024.01.08.24301026. [PMID: 38260437 PMCID: PMC10802638 DOI: 10.1101/2024.01.08.24301026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background After discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge. Methods In this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health. Results We included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services (β=-3.5 (1.4), p=0.01 and β=-8.2 (1.3), p=<0.001, respectively). Conclusions These findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.
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Affiliation(s)
- Margaret A. French
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heather Hayes
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
| | - Joshua K. Johnson
- Department of Physical Medicine & Rehabilitation, Cleveland Clinic, Cleveland, OH
| | - Daniel L. Young
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV
| | - Ryan T. Roemmich
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, MD
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
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235
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Nash KA, Weerahandi H, Yu H, Venkatesh AK, Holaday LW, Herrin J, Lin Z, Horwitz LI, Ross JS, Bernheim SM. Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance. JAMA 2024; 331:111-123. [PMID: 38193960 PMCID: PMC10777266 DOI: 10.1001/jama.2023.24874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/13/2023] [Indexed: 01/10/2024]
Abstract
Importance Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes. Objectives To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value). Design, Setting, and Participants Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019. Main Outcomes and Measures We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method). Exposures Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost). Results Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity. Conclusion and Relevance A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.
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Affiliation(s)
- Katherine A. Nash
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Himali Weerahandi
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
| | - Huihui Yu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Louisa W. Holaday
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeph Herrin
- Flying Buttress Associates, Charlottesville, Virginia
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Leora I. Horwitz
- Center for Healthcare Innovation and Delivery Science, NYU Langone Health, New York, New York
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Division of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Deputy Editor, JAMA
| | - Susannah M. Bernheim
- Division of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
- Now with Centers for Medicaid and Medicare Services, Baltimore, Maryland
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236
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Robertson SE, Steingrimsson JA, Joyce NR, Stuart EA, Dahabreh IJ. Estimating Subgroup Effects in Generalizability and Transportability Analyses. Am J Epidemiol 2024; 193:149-158. [PMID: 35225329 DOI: 10.1093/aje/kwac036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Methods for extending-generalizing or transporting-inferences from a randomized trial to a target population involve conditioning on a large set of covariates that is sufficient for rendering the randomized and nonrandomized groups exchangeable. Yet, decision makers are often interested in examining treatment effects in subgroups of the target population defined in terms of only a few discrete covariates. Here, we propose methods for estimating subgroup-specific potential outcome means and average treatment effects in generalizability and transportability analyses, using outcome model--based (g-formula), weighting, and augmented weighting estimators. We consider estimating subgroup-specific average treatment effects in the target population and its nonrandomized subset, and we provide methods that are appropriate both for nested and non-nested trial designs. As an illustration, we apply the methods to data from the Coronary Artery Surgery Study (North America, 1975-1996) to compare the effect of surgery plus medical therapy versus medical therapy alone for chronic coronary artery disease in subgroups defined by history of myocardial infarction.
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237
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McLarnan SM, Bramer LM, Dixon HM, Scott RP, Calero L, Holmes D, Gibson EA, Cavalier HM, Rohlman D, Miller RL, Kincl L, Waters KM, Anderson KA, Herbstman JB. Predicting personal PAH exposure using high dimensional questionnaire and wristband data. J Expo Sci Environ Epidemiol 2024:10.1038/s41370-023-00617-y. [PMID: 38177333 DOI: 10.1038/s41370-023-00617-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Polycyclic aromatic hydrocarbons (PAHs) are a class of pervasive environmental pollutants with a variety of known health effects. While significant work has been completed to estimate personal exposure to PAHs, less has been done to identify sources of these exposures. Comprehensive characterization of reported sources of personal PAH exposure is a critical step to more easily identify individuals at risk of high levels of exposure and for developing targeted interventions based on source of exposure. OBJECTIVE In this study, we leverage data from a New York (NY)-based birth cohort to identify personal characteristics or behaviors associated with personal PAH exposure and develop models for the prediction of PAH exposure. METHODS We quantified 61 PAHs measured using silicone wristband samplers in association with 75 questionnaire variables from 177 pregnant individuals. We evaluated univariate associations between each compound and questionnaire variable, conducted regression tree analysis for each PAH compound and completed a principal component analysis of for each participant's entire PAH exposure profile to determine the predictors of PAH levels. RESULTS Regression tree analyses of individual compounds and exposure mixture identified income, time spent outdoors, maternal age, country of birth, transportation type, and season as the variables most frequently predictive of exposure.
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Affiliation(s)
- Sarah M McLarnan
- Department of Environmental Health Sciences, Columbia University, Columbia Center for Children's Environmental Health, Mailman School of Public Health, New York City, NY, USA.
| | - Lisa M Bramer
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
| | - Holly M Dixon
- Environmental and Molecular Toxicology, Food Safety and Environmental Stewardship Program, Oregon State University, Corvallis, OR, USA
| | - Richard P Scott
- Environmental and Molecular Toxicology, Food Safety and Environmental Stewardship Program, Oregon State University, Corvallis, OR, USA
| | - Lehyla Calero
- Department of Environmental Health Sciences, Columbia University, Columbia Center for Children's Environmental Health, Mailman School of Public Health, New York City, NY, USA
| | - Darrell Holmes
- Department of Environmental Health Sciences, Columbia University, Columbia Center for Children's Environmental Health, Mailman School of Public Health, New York City, NY, USA
| | - Elizabeth A Gibson
- Department of Environmental Health Sciences, Columbia University, Columbia Center for Children's Environmental Health, Mailman School of Public Health, New York City, NY, USA
| | - Haleigh M Cavalier
- Department of Environmental Health Sciences, Columbia University, Columbia Center for Children's Environmental Health, Mailman School of Public Health, New York City, NY, USA
| | - Diana Rohlman
- Oregon State University, College of Public Health and Human Sciences, Corvallis, OR, USA
| | - Rachel L Miller
- Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Laurel Kincl
- Oregon State University, College of Public Health and Human Sciences, Corvallis, OR, USA
| | - Katrina M Waters
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA, USA
- Environmental and Molecular Toxicology, Food Safety and Environmental Stewardship Program, Oregon State University, Corvallis, OR, USA
| | - Kim A Anderson
- Environmental and Molecular Toxicology, Food Safety and Environmental Stewardship Program, Oregon State University, Corvallis, OR, USA
| | - Julie B Herbstman
- Department of Environmental Health Sciences, Columbia University, Columbia Center for Children's Environmental Health, Mailman School of Public Health, New York City, NY, USA
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238
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Young RA. Re: Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW. J Am Board Fam Med 2024; 36:1087-1088. [PMID: 38012010 PMCID: PMC10833475 DOI: 10.3122/jabfm.2023.230230r0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Affiliation(s)
- Richard A Young
- Co-Associate Program Director and Director of Research, John Peter Smith Family Medicine Residency Program, Fort Worth, TX
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239
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Mitchell JT, Covington NV, Morrow E, de Riesthal M, Duff MC. Memory and Traumatic Brain Injury: Assessment and Management Practices of Speech-Language Pathologists. Am J Speech Lang Pathol 2024; 33:279-306. [PMID: 38032245 PMCID: PMC10950318 DOI: 10.1044/2023_ajslp-23-00231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE Memory impairments are among the most commonly reported deficits and among the most frequent rehabilitation targets for individuals with traumatic brain injury (TBI). Memory and learning are also critical for rehabilitation success and broader long-term outcomes. Speech-language pathologists (SLPs) play a central role in memory management for individuals with TBI across the continuum of care. Yet, little is known about the current practice patterns of SLPs for post-TBI memory disorders. This study aims to examine the clinical management of memory disorders in adults with TBI by SLPs and identify opportunities to improve post-TBI memory outcomes. METHOD SLPs from across the continuum of care were recruited to complete an online survey. The survey assessed key practice areas specific to memory and memory disorders post-TBI, including education and training, knowledge and confidence, and assessment and treatment patterns. RESULTS Surveys from 155 SLPs were analyzed. Results revealed that TBI-specific training remains low in the field. Respondents varied in their practice patterns in assessing and treating memory disorders. Most SLPs do not appear to have access to appropriate standardized assessments to measure unique forms of memory. Respondents also reported a range of barriers and opportunities to advance memory outcomes following TBI and provided suggestions of areas in which they would like to see more basic and clinical research. CONCLUSIONS These findings establish a baseline of the current practices for clinical management of memory impairment in adults with TBI by SLPs. Improved opportunities for clinician training, the development of a single tool to assess multiple forms of memory, better access to existing memory assessments, and implementation of evidence-based interventions promise to lead to improved memory outcomes for individuals with TBI.
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Affiliation(s)
- Jade T. Mitchell
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Natalie V. Covington
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Speech-Language-Hearing Sciences, University of Minnesota, Minneapolis
- Courage Kenny Research, Courage Kenny Rehabilitation Institute, Allina Health, Minneapolis, MN
| | - Emily Morrow
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN
| | - Michael de Riesthal
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa C. Duff
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN
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240
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Michelson KA, Bachur RG, Rangel SJ, Finkelstein JA, Monuteaux MC, Goyal MK. Disparities in Diagnostic Timeliness and Outcomes of Pediatric Appendicitis. JAMA Netw Open 2024; 7:e2353667. [PMID: 38270955 PMCID: PMC10811560 DOI: 10.1001/jamanetworkopen.2023.53667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/06/2023] [Indexed: 01/26/2024] Open
Abstract
This cohort study compares rates of delayed diagnosis and complications of appendicitis by race and ethnicity and Child Opportunity Index among children in 8 states.
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Affiliation(s)
- Kenneth A. Michelson
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Richard G. Bachur
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Shawn J. Rangel
- Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts
| | - Jonathan A. Finkelstein
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Monika K. Goyal
- Division of Emergency Medicine, Department of Pediatrics, Children’s National Hospital, George Washington University, Washington, DC
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241
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Ashburn NP, McCord JK, Snavely AC, Christenson RH, Apple FS, Nowak RM, Peacock WF, deFilippi CR, Mahler SA. Navigating the Observation Zone: Do Risk Scores Help Stratify Patients With Indeterminate High-Sensitivity Cardiac Troponins? Circulation 2024; 149:70-72. [PMID: 38153992 PMCID: PMC10756639 DOI: 10.1161/circulationaha.123.065030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Robert H. Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Fred S. Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, MI, USA
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Richard M. Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, MI, USA
| | - William F. Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Devine JW, Tadrous M, Hernandez I, Callaway Kim K, Rothenberger SD, Mukhopadhyay N, Gellad WF, Suda KJ. A Retrospective Cohort Study of the 2018 Angiotensin Receptor Blocker Recalls and Subsequent Drug Shortages in Patients With Hypertension. J Am Heart Assoc 2024; 13:e032266. [PMID: 38156554 PMCID: PMC10863811 DOI: 10.1161/jaha.123.032266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/21/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Valsartan was recalled by the US Food and Drug Administration in July 2018 for carcinogenic impurities, resulting in a drug shortage and management challenges for valsartan users. The influence of the valsartan recall on clinical outcomes is unknown. We compared the risk of adverse events between hypertensive patients using valsartan and a propensity score-matched group using nonrecalled angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. METHODS AND RESULTS We used Optum's deidentified Clinformatics Datamart (July 2017-January 2019). Hypertensive patients who received valsartan or nonrecalled angiotensin receptor blockers/angiotensin-converting enzyme inhibitors for 1 year before and on the recall date were compared. Primary outcomes were measured in the 6 months following the recall and included: (1) a composite measure of all-cause hospitalization, all-cause emergency department visit, and all-cause urgent care visit, and (2) a composite cardiac event measure of hospitalizations for acute myocardial infarction and hospitalizations/emergency department visits/urgent care visits for stroke/transient ischemic attack, heart failure, or hypertension. We compared the risk of outcomes between treatment groups using Cox proportional hazard models. Of the hypertensive patients, 76 934 received valsartan, and 509 472 received a nonrecalled angiotensin receptor blocker/angiotensin-converting enzyme inhibitor. Valsartan use at the time of recall was associated with a higher risk of all-cause hospitalization, emergency department use, or urgent care use (hazard ratio [HR], 1.02 [95% CI, 1.00-1.04]) and the composite of cardiac events (HR, 1.22 [95% CI, 1.15-1.29]) within 6 months after the recall. CONCLUSIONS The valsartan recall and shortage affected hypertensive patients. Local- and national-level systems need to be enhanced to protect patients from drug shortages by providing safe and reliable medication alternatives.
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Affiliation(s)
| | - Mina Tadrous
- Leslie Dan Faculty of PharmacyUniversity of TorontoOntarioCanada
- Institute for Health System Solutions and Virtual CareWomen’s College HospitalTorontoOntarioCanada
| | - Inmaculada Hernandez
- University of California San DiegoSchool of Pharmacy and Pharmaceutical SciencesLa JollaCAUSA
| | - Katherine Callaway Kim
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Department of Health Policy and ManagementUniversity of Pittsburgh School of Public HealthPittsburghPAUSA
| | - Scott D. Rothenberger
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Nandita Mukhopadhyay
- University of Pittsburgh School of Dental MedicineDepartment of Oral and Craniofacial Sciences, Center for Craniofacial and Dental GeneticsPittsburghPAUSA
| | - Walid F. Gellad
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghPAUSA
| | - Katie J. Suda
- Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghPAUSA
- Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghPAUSA
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Maganty A, Kaufman SR, Oerline MK, Faraj K, Caram ME, Shahinian VB, Hollenbeck BK. Association Between Urologist Merit-Based Incentive Payment System Performance and Quality of Prostate Cancer Care. Urol Pract 2024; 11:207-214. [PMID: 37748132 PMCID: PMC10842494 DOI: 10.1097/upj.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION We performed a study to evaluate the association between urologist performance in the Merit-Based Incentive Payment System (MIPS), and quality and spending for prostate cancer care. METHODS Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019 were assigned to their primary urologist. Associated MIPS scores were identified and categorized based on thresholds for payment adjustment as low (worst), moderate, and high (best). Multivariable mixed effects models were used to measure the association between MIPS performance and adherence to quality measures and price standardized spending for prostate cancer. RESULTS Adherence to quality measures did not vary across MIPS performance groups for pretreatment counselling by both a urologist and radiation oncologist (low-76%, [95% CI 73%-80%], moderate-77% [95% CI 74%-79%], and high-75% [95% CI 74%-76%]) and avoiding treatment in men with a high risk of noncancer mortality within 10 years of diagnosis (low-40% [95% CI 35%-45%], moderate-39% [95% CI 36%-43%], high-38% [95% CI 36%-39%]). Men on active surveillance managed by high performers more likely received a confirmatory test (44% [95% CI 43%-46%]) compared to those managed by moderate (38% [95% CI 33%-42%]) performers, but not low performers (36% [95% CI 29%-44%]). There was no difference in adjusted spending across MIPS performance groups. CONCLUSIONS Better performance in MIPS is associated with a higher rate of confirmatory testing in men initiating active surveillance for prostate cancer. However, performance was not associated with other dimensions of quality nor spending.
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Affiliation(s)
- Avinash Maganty
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Samuel R. Kaufman
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Mary K. Oerline
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Kassem Faraj
- University of Michigan, Department of Urology, Division of Health Services Research
| | - Megan E.V. Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Vahakn B. Shahinian
- University of Michigan, Department of Urology, Division of Health Services Research
- Division of Nephrology, Department of Internal Medicine, University of Michigan
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Jolliff A, Coller RJ, Kearney H, Warner G, Feinstein JA, Chui MA, O'Brien S, Willey M, Katz B, Bach TD, Werner NE. An mHealth Design to Promote Medication Safety in Children with Medical Complexity. Appl Clin Inform 2024; 15:45-54. [PMID: 37989249 PMCID: PMC10794091 DOI: 10.1055/a-2214-8000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks. OBJECTIVES The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home. METHODS Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured. RESULTS A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented. CONCLUSION This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.
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Affiliation(s)
- Anna Jolliff
- Department of Health and Wellness Design, Indiana University at Bloomington, Bloomington, Indiana, United States
| | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Hannah Kearney
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Gemma Warner
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - James A. Feinstein
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michelle A. Chui
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Steve O'Brien
- Noble Applications, Madison, Wisconsin, United States
| | - Misty Willey
- Noble Applications, Madison, Wisconsin, United States
| | - Barbara Katz
- Family Voices of Wisconsin, Madison, Wisconsin, United States
| | - Theodore D. Bach
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, United States
| | - Nicole E. Werner
- Department of Health and Wellness Design, Indiana University at Bloomington, Bloomington, Indiana, United States
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245
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Handley SC, Salazar EG, Kunz SN, Lorch SA, Edwards EM. Transfer Patterns Among Infants Born at 28 to 34 Weeks' Gestation. Pediatrics 2024; 153:e2023063118. [PMID: 38268423 PMCID: PMC10827647 DOI: 10.1542/peds.2023-063118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Although postnatal transfer patterns among high-risk (eg, extremely preterm or surgical) infants have been described, transfer patterns among lower-risk populations are unknown. The objective was to examine transfer frequency, indication, timing, and trajectory among very and moderate preterm infants. METHODS Observational study of the US Vermont Oxford Network all NICU admissions database from 2016 to 2021 of inborn infants 280/7 to 346/7 weeks. Infants' first transfer was assessed by gestational age, age at transfer, reason for transfer, and transfer trajectory. RESULTS Across 467 hospitals, 294 229 infants were eligible, of whom 12 552 (4.3%) had an initial disposition of transfer. The proportion of infants transferred decreased with increasing gestational age (9.6% [n = 1415] at 28 weeks vs 2.4% [n = 2646] at 34 weeks) as did the median age at time of transfer (47 days [interquartile range 30-73] at 28 weeks vs 8 days [interquartile range 3-16] at 34 weeks). The median post menstrual age at transfer was 34 or 35 weeks across all gestational ages. The most common reason for transfer was growth or discharge planning (45.0%) followed by medical and diagnostic services (30.2%), though this varied by gestation. In this cohort, 42.7% of transfers were to a higher-level unit, 10.2% to a same-level unit, and 46.7% to a lower-level unit, with indication reflecting access to specific services. CONCLUSIONS Over 4% of very and moderate preterm infants are transferred. In this population, the median age of transfer is later and does not reflect immediate care needs after birth, but rather the provision of risk-appropriate care.
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Affiliation(s)
- Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Sarah N. Kunz
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Larner College of Medicine, The University of Vermont, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington, Vermont
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246
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Franklin PD, Drane D. Assessment of learning health system science competency in the equity and justice domain. Learn Health Syst 2024; 8:e10381. [PMID: 38249846 PMCID: PMC10797565 DOI: 10.1002/lrh2.10381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/29/2023] [Accepted: 07/01/2023] [Indexed: 01/23/2024] Open
Abstract
Seven knowledge domains were originally defined for the learning health system (LHS) scientist. To assess proficiency in each of these domains, we developed and published an assessment tool for use by emerging LHS scientists and training programs. (LHS, October 2022). In mid-2022, the AHRQ adopted an eighth LHS knowledge domain, Equity and Justice. The addition of this eighth domain emphasizes the importance and centrality of equity in the LHS and improvement science. To extend our prior LHS competency assessment, we developed a proficiency assessment for the new equity and justice domain. Content experts and trainees iteratively defined, reviewed, and edited the assessment criteria. The items were developed by trainees and experts at one LHS training center with experience conducting research focused on healthcare inequities among marginalized populations. The proficiency assessment criteria for the Equity domain apply the same four levels of mastery: "no exposure," "foundational awareness," "emerging," and "proficient" as were used for original competencies. LHS training programs can use these proficiency criteria to monitor skills among emerging scientists across the eight domains, with particular attention to equity and justice.
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Affiliation(s)
- Patricia D. Franklin
- Department of Medical Social Sciences, Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Denise Drane
- Program Evaluation Core & Searle Center for Advancing Learning and TeachingNorthwestern UniversityChicagoIllinoisUSA
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Zamalin D, Hamlin I, Shults J, Katherine Henry M, Campbell KA, Anderst JD, Bachim AN, Berger RP, Frasier LD, Harper NS, Letson MM, Melville JD, Lindberg DM, Wood JN. Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation. Acad Pediatr 2024; 24:78-86. [PMID: 37178908 PMCID: PMC10638459 DOI: 10.1016/j.acap.2023.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). METHODS Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. CONCLUSIONS Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.
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Affiliation(s)
- Danielle Zamalin
- Department of Pediatrics (D Zamalin), Kravis Children's Hospital, Icahn School of Medicine, Mount Sinai Hospital, New York, NY.
| | - Irene Hamlin
- Perelman School of Medicine (I Hamlin), University of Pennsylvania, Philadelphia, Pa.
| | - Justine Shults
- Department of Biostatistics, Epidemiology (J Shults), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - M Katherine Henry
- Division of General Pediatrics, Clinical Futures, and PolicyLab (M Katherine Henry), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - Kristine A Campbell
- Department of Pediatrics (KA Campbell), University of Utah, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, Utah.
| | - James D Anderst
- Children's Mercy Kansas City (JD Anderst), University of Missouri Kansas City School of Medicine.
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics (AN Bachim), Baylor College of Medicine, Texas Children's Hospital, Houston, Tex.
| | - Rachel P Berger
- Department of Pediatrics (RP Berger), UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pa.
| | - Lori D Frasier
- Department of Pediatrics (LD Frasier), Penn State Children's Hospital, Penn State Hershey College of Medicine, Hershey, Pa; Penn State Hershey Medical Center (LD Frasier), Center for the Protection of Children, Hershey, Pa.
| | - Nancy S Harper
- University of Minnesota School of Medicine (NS Harper), Center for Safe and Healthy Children, Minneapolis, Minn.
| | - Megan M Letson
- Nationwide Children's Hospital (MM Letson), The Ohio State University College of Medicine, Columbus, Ohio.
| | - John D Melville
- Division of Child Abuse Pediatrics (JD Melville), Medical University of South Carolina, Charleston, SC.
| | - Daniel M Lindberg
- Department of Emergency Medicine (DM Lindberg), The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, Aurora, Colo.
| | - Joanne N Wood
- Division of General Pediatrics and PolicyLab (JN Wood), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
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Apple A, Mulugeta-Gordon L, Zafman K, Leitner K. An unusual cause of small bowel obstruction: Case report of spontaneous uteroenteric fistula. Int J Gynaecol Obstet 2024; 164:349-351. [PMID: 37723887 DOI: 10.1002/ijgo.15122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 09/20/2023]
Abstract
SynopsisUteroenteric fistulae in the setting of degenerating leiomyomas may present with small bowel obstruction and require multidisciplinary surgical management to perform fertility‐sparing myomectomy.
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Affiliation(s)
- Annie Apple
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lakeisha Mulugeta-Gordon
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly Zafman
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kirstin Leitner
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Khouja T, Shah NH, Suda KJ, Polk DE. Trajectories of opioid prescribing by general dentists, specialists, and oral and maxillofacial surgeons in the United States, 2015-2019. J Am Dent Assoc 2024; 155:7-16.e7. [PMID: 37988047 PMCID: PMC10870999 DOI: 10.1016/j.adaj.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite decreases in opioid prescribing from 2016 through 2019, some dentists (general, specialists, oral and maxillofacial surgeons) in the United States continue to prescribe opioids at high rates. The authors' objective was to define dentists' trajectories of opioid prescribing. METHODS The authors identified actively prescribing dentists from the IQVIA Longitudinal Prescription data set, from 2015 through 2019. Group-based trajectory modeling identified opioid prescribing trajectories on the basis of dentists' annual prescribing rates for the overall sample (model 1) and for high prescribers (model 2). The authors used χ2 or Mann-Whitney U tests to characterize the model 2 trajectory groups. RESULTS In model 1 (n = 199,145 prescribers), group-based trajectory modeling identified 8 trajectories that were grouped into 5 categories. A total of 14.8% were nonprescribers who composed less than 1% of all prescriptions, low prescribers (3 groups; 46.0%) prescribed at low rates (2015: 5.5%-16.9%; 2019: 1.5%-11.9%), decliners (7.3%) decreased prescribing rapidly (2015: 29.4%; 2019: 5.1%), moderately high prescribers (2 groups; 28.5%) prescribed moderately (2015: 28.7% and 39.2%; 2019: 18.1% and 28.8%), and consistently high prescribers (3.4%) prescribed at high rates (2015: 54.6%; 2019: 44.7%). In model 2, from consistently high prescribers (n = 6,845), 4 trajectories were identified. Of these 4 groups, 1 group (7.5%) declined prescribing rapidly. The groups did not differ meaningfully; however, the rapid decliners included fewer oral and maxillofacial surgeons (13.0% vs 18.4%), saw more Medicaid patients (2.5% vs 1.0%), and had higher opioid prescribing rates in 2015 (95.5% vs 91.6%) (P < .001 for all). CONCLUSIONS The authors identified variations in dentists' opioid prescribing rates. Although 60% of dentists decreased prescribing rates by 30% through 83%, 3.4% of dentists consistently prescribed at high rates. PRACTICAL IMPLICATIONS Some dentists continue to prescribe opioids at high levels, indicating that additional information is needed to better inform policy and clinical decision making.
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Sick-Samuels AC, Koontz DW, Xie A, Kelly D, Woods-Hill CZ, Aneja A, Xiao S, Colantuoni EA, Marsteller J, Milstone AM. A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative. Pediatr Crit Care Med 2024; 25:e20-e30. [PMID: 37812030 PMCID: PMC10756695 DOI: 10.1097/pcc.0000000000003379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. DESIGN Cross-sectional survey conducted May 2021-January 2022. SETTING Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. SUBJECTS Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). CONCLUSIONS Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.
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Affiliation(s)
- Anna C Sick-Samuels
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
| | - Danielle W Koontz
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Kelly
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Anushree Aneja
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shaoming Xiao
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jill Marsteller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
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