1
|
McKnight MA, Sheber MK, Liebzeit DJ, Seaman AT, Husser EK, Buck HG, Reisinger HS, Lee S. Usability of the 4Ms Worksheet in the Emergency Department for Older Patients: A Qualitative Study. West J Emerg Med 2024; 25:230-236. [PMID: 38596924 PMCID: PMC11000547 DOI: 10.5811/westjem.18088] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/30/2023] [Accepted: 11/21/2023] [Indexed: 04/11/2024] Open
Abstract
Introduction Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework-what matters, medications, mentation, mobility-has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED). We aimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients' goals of care and 2) use of the worksheet was feasible in the ED. Methods We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January-June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories. Results A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively. Conclusion We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients' underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.
Collapse
Affiliation(s)
- Mackenzie A. McKnight
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | - Melissa K. Sheber
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
| | | | - Aaron T. Seaman
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Internal Medicine, Iowa City, Iowa
| | - Erica K. Husser
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania
| | | | - Heather S. Reisinger
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Internal Medicine, Iowa City, Iowa
| | - Sangil Lee
- University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Department of Internal Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Department of Emergency Medicine, Iowa City, Iowa
| |
Collapse
|
2
|
McKinley LL, Goedken CC, Balkenende EC, Hockett Sherlock SM, Knobloch MJ, Bartel R, Perencevich EN, Reisinger HS, Safdar N. Using a human-factors engineering approach to evaluate environmental cleaning in Veterans' Affairs acute and long-term care facilities: A qualitative analysis. Infect Control Hosp Epidemiol 2024; 45:351-359. [PMID: 37873620 DOI: 10.1017/ice.2023.226] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Environmental cleaning is important in the interruption of pathogen transmission. Although prevention initiatives have targeted environmental cleaning, practice variations exist and compliance is low. Evaluation of human factors influencing variations in cleaning practices can be valuable in developing interventions to standardized practices. We conducted a work-system analysis using a human-factors engineering (HFE) framework to identify barriers and facilitators to environmental cleaning practices in acute and long-term care settings within the Veterans' Affairs health system. METHODS We conducted a qualitative study with key stakeholders at 3 VA facilities. We analyzed transcripts for thematic content and mapped themes to the HFE framework. RESULTS Staffing consistency was felt to improve cleaning practices and teamwork. We found that many environmental management service (EMS) staff were veterans who were motivated to serve fellow veterans, especially to prevent infections. However, hiring veterans comes with regulatory hurdles that affect staffing. Sites reported some form of monitoring their cleaning process, but there was variation in method and frequency. The EMS workload was affected by whether rooms were occupied by patients or were semiprivate rooms; both were reportedly more difficult to clean. Room design and surface finishes were identified as important to cleaning efficiency. CONCLUSION HFE work analysis identified barriers and facilitators to environmental cleaning. These findings highlight intervention entry points that may facilitate standardized work practices. There is a need to develop task-specific procedures such as cleaning occupied beds and semiprivate rooms. Future research should evaluate interventions that address these determinants of environmental cleaning.
Collapse
Affiliation(s)
- Linda L McKinley
- William S. Middleton Memorial Veterans' Hospital, Madison, Wisconsin
| | - Cassie C Goedken
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
| | - Erin C Balkenende
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Stacey M Hockett Sherlock
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Mary Jo Knobloch
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Rosie Bartel
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Institute for Clinical and Translational Science, Iowa City, Iowa
| | - Nasia Safdar
- William S. Middleton Memorial Veterans' Hospital, Madison, Wisconsin
- University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
3
|
Fortney JC, Rajan S, Chen JA, Campbell SB, Nolan JP, Wong E, Sayre G, Petrova V, Simons CE, Reisinger HS, Schnurr PP. A mixed-methods evaluation of why an implementation trial failed to engage veterans with posttraumatic stress disorder in trauma-focused psychotherapy. J Trauma Stress 2023; 36:762-771. [PMID: 37370238 DOI: 10.1002/jts.22946] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 06/29/2023]
Abstract
An effectiveness trial found that telemedicine collaborative care for posttraumatic stress disorder (PTSD) significantly increased engagement in trauma-focused psychotherapy (TFP) and improved PTSD symptoms. However, in a subsequent implementation trial, very few veterans enrolled in collaborative care initiated TFP. We conducted a mixed-methods evaluation to determine why veterans did not initiate TFP in the implementation trial. After conducting chart reviews of 1,071 veterans with PTSD enrolled in collaborative care, patients were categorized into four mutually exclusive TFP groups: TFP not discussed; TFP discussed, declined; TFP discussed, did not decline; and TFP initiated. We conducted semistructured interviews with 43 unique patients and 58 unique providers (i.e., care managers and mental health specialists). Almost half (48.6%) of the veterans had no documentation of discussing TFP with their care manager; another 28.9% discussed it but declined. Most veterans (77.1%) had an encounter with a mental health specialist, 36.8% of whom never discussed TFP, and 35.7% of whom discussed it but declined. Providers reported that many veterans were not able, willing, or ready to engage in TFP and that non-trauma-focused therapies were better aligned with their treatment goals. Veterans gave numerous reasons for not initiating TFP, including having bad prior experiences with TFP and wanting to avoid thinking about past traumatic experiences. Commonly cited reasons for noninitiation were providers never discussing TFP with veterans and veterans declining TFP after discussing it with their provider. Interventions, such as shared decision-making tools, may be needed to engage providers and patients in informed discussions about TFP.
Collapse
Affiliation(s)
- John C Fortney
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Suparna Rajan
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Jessica A Chen
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Sarah B Campbell
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - John P Nolan
- Independent researcher, El Dorado, Arkansas, USA
| | - Edwin Wong
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - George Sayre
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
| | - Valentina Petrova
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Carol E Simons
- VA Health Services Research and Development, Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Heather S Reisinger
- VA Health Services Research and Development, Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Paula P Schnurr
- National Center for PTSD, VA Medical Center, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| |
Collapse
|
4
|
Sheber M, McKnight M, Liebzeit D, Seaman A, Husser EK, Buck H, Reisinger HS, Lee S. Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework. J Am Coll Emerg Physicians Open 2023; 4:e13012. [PMID: 37520079 PMCID: PMC10375261 DOI: 10.1002/emp2.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/01/2023] [Accepted: 07/07/2023] [Indexed: 08/01/2023] Open
Abstract
Background We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting. Methods A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework. Results A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry. Conclusions Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.
Collapse
Affiliation(s)
- Melissa Sheber
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Mackenzie McKnight
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | | | - Aaron Seaman
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Erica K. Husser
- Ross and Carol Nese College of NursingPennsylvania State University, University ParkPennsylvaniaUSA
| | - Harleah Buck
- University of Iowa College of NursingIowa CityIowaUSA
| | - Heather S. Reisinger
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Carver College of MedicineDepartment of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIowaUSA
| |
Collapse
|
5
|
Griffin BR, Vaughan-Sarrazin M, Perencevich E, Yamada M, Swee M, Sambharia M, Girotra S, Reisinger HS, Jalal D. Risk Factors for Death Among Veterans Following Acute Kidney Injury. Am J Med 2023; 136:449-457. [PMID: 36708794 PMCID: PMC10765959 DOI: 10.1016/j.amjmed.2023.01.006] [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: 08/09/2022] [Revised: 12/08/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Acute kidney injury is prevalent among hospitalized veterans, and associated with increased risk of death following discharge. However, risk factors for death following acute kidney injury have not been well defined. We developed a mortality prediction model using Veterans Health Administration data. METHODS This retrospective cohort study included inpatients from 2013 through 2018 with a creatinine increase of ≥0.3 mg/dL. We evaluated 45 variables for inclusion in our final model, with a primary outcome of 1-year mortality. Bootstrap sampling with replacement was used to identify variables selected in >60% of models using stepwise selection. Best sub-sets regression using Akaike information criteria was used to identify the best-fitting parsimonious model. RESULTS A total of 182,683 patients were included, and 38,940 (21.3%) died within 1 year of discharge. The 10-variable model to predict mortality included age, chronic lung disease, cancer within 5 years, unexplained weight loss, dementia, congestive heart failure, hematocrit, blood urea nitrogen, bilirubin, and albumin. Notably, acute kidney injury stage, chronic kidney disease, discharge creatinine, and proteinuria were not selected for inclusion. C-statistics in the primary validation cohorts were 0.77 for the final parsimonious model, compared with 0.52 for acute kidney injury stage alone. CONCLUSION We identified risk factors for long-term mortality following acute kidney injury. Our 10-variable model did not include traditional renal variables, suggesting that non-kidney factors contribute to the risk of death more than measures of kidney disease in this population, a finding that may have implications for post-acute kidney injury care.
Collapse
Affiliation(s)
- Benjamin R Griffin
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City.
| | - Mary Vaughan-Sarrazin
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Eli Perencevich
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Masaaki Yamada
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Melissa Swee
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Meenakshi Sambharia
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Saket Girotra
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Heather S Reisinger
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Diana Jalal
- Center for Access Delivery & Research and Evaluation (CADRE) Center, Iowa VA Health Care System, Iowa City; Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
| |
Collapse
|
6
|
McKinley L, Goedken CC, Balkenende E, Clore G, Hockett SS, Bartel R, Bradley S, Judd J, Lyons G, Rock C, Rubin M, Shaughnessy C, Reisinger HS, Perencevich E, Safdar N. Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study. Am J Infect Control 2023; 51:205-213. [PMID: 35644297 DOI: 10.1016/j.ajic.2022.05.014] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process. METHODS A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities. RESULTS Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis. CONCLUSION Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.
Collapse
Affiliation(s)
| | - C C Goedken
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA, Iowa City, IA
| | - E Balkenende
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA, Iowa City, IA; University of Iowa, Iowa City, IA
| | - G Clore
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA, Iowa City, IA; University of Iowa, Iowa City, IA
| | - Sherlock S Hockett
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA, Iowa City, IA; University of Iowa, Iowa City, IA
| | - R Bartel
- Patient-Centered Outcomes Research Institute (PCORI), Washington DC
| | - S Bradley
- Ann Arbor VA, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - J Judd
- Salt Lake City VA, Salt Lake City, UT; University of Utah, Salt Lake City, UT
| | - Goedken Lyons
- Ann Arbor VA, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - C Rock
- Johns Hopkins University, Baltimore, MD
| | - M Rubin
- Salt Lake City VA, Salt Lake City, UT; University of Utah, Salt Lake City, UT
| | | | - H S Reisinger
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA, Iowa City, IA; University of Iowa, Iowa City, IA
| | - E Perencevich
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA, Iowa City, IA; University of Iowa, Iowa City, IA
| | - N Safdar
- Madison VA, Madison, WI; University of Wisconsin - Madison, Madison, WI
| |
Collapse
|
7
|
Griffin BR, Wendt L, Vaughan-Sarrazin M, Hounkponou H, Reisinger HS, Goldstein SL, Jalal D, Misurac J. Nephrotoxin Exposure and Acute Kidney Injury in Adults. Clin J Am Soc Nephrol 2023; 18:163-172. [PMID: 36754005 PMCID: PMC10103278 DOI: 10.2215/cjn.0000000000000044] [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: 08/01/2022] [Accepted: 11/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Rates of nephrotoxic AKI are not well described in adults due to lack of a clear definition, debate over which drugs should be considered nephrotoxins, and illness-related confounding. Nephrotoxic Injury Negated by Just-in Time Action (NINJA), a program that reduces rates of nephrotoxic AKI in pediatric populations, may be able to address these concerns, but whether NINJA can be effectively applied to adults remains unclear. METHODS In this retrospective cohort study conducted at the University of Iowa Hospital, we included adult patients admitted to a general hospital floor for ≥48 hours during 2019. The NINJA algorithm screened charts for high nephrotoxin exposure and AKI. After propensity score matching, Cox proportional hazard modeling was used to evaluate the relationship between nephrotoxic exposure and all-stage AKI, stage 2-3 AKI, or death. Additional analyses evaluated the most frequent nephrotoxins used in this population. RESULTS Of 11,311 patients, 1527 (16%) had ≥1 day of high nephrotoxin exposure. Patients with nephrotoxic exposures subsequently developed AKI in 29% of cases, and 22% of all inpatient AKI events met nephrotoxic AKI criteria. Common nephrotoxins were vancomycin, iodinated contrast dye, piperacillin-tazobactam, acyclovir, and lisinopril. After propensity score matching, Cox proportional hazard models for high nephrotoxin exposure were significantly associated with all AKI (hazard ratio [HR] 1.43, 1.19-1.72, P<0.001), stage 2-3 AKI (HR 1.78, 1.18-2.67, P=0.006), and mortality (HR 2.12, 1.09-4.11, P=0.03). CONCLUSIONS Nephrotoxin exposure in adults is common and is significantly associated with AKI development, including stage 2-3 AKI.
Collapse
Affiliation(s)
- Benjamin R Griffin
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Linder Wendt
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Hermann Hounkponou
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Heather S Reisinger
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Diana Jalal
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Jason Misurac
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| |
Collapse
|
8
|
Carlisle EM, Shinkunas LA, Ruba E, Klipowicz CJ, Lieberman MT, Hoffman RM, Reisinger HS. A valued voice: A qualitative analysis of parental decision-making preferences in emergent paediatric surgery. Health Expect 2022; 26:531-541. [PMID: 36482826 PMCID: PMC9854285 DOI: 10.1111/hex.13686] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/21/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Shared decision-making, with an emphasis on patient autonomy, is often advised in healthcare decision-making. However, this may be difficult to implement in emergent settings. We have previously demonstrated that when considering emergent operations for their children, parents prefer surgeon guidance as opposed to shared decision-making. Here, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. METHODS Parents of paediatric patients who underwent surgery over the past 5 years at a University-based, tertiary children's hospital for cancer, an emergent operation while in the neonatal intensive care unit (NICU) or extracorporeal membrane oxygenation (ECMO) were invited to complete a 60-min semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Thematic content analysis was performed via deductive and inductive analysis. An iterative approach to thematic sampling/data analysis was used. RESULTS Thematic saturation was achieved after 12 interviews (4 cancer, 5 NICU and 3 ECMO). Five common themes were identified: (1) recommendations from surgeons are valuable; (2) 'lifesaving mode': parents felt there were no decisions to be made; (3) effective ways of obtaining information about treatment; (4) shared decision-making as a 'dialogue' or 'discussion' and (5) parents as a 'valued voice' to advocate for their children. CONCLUSIONS When engaging in decision-making regarding emergent surgical procedures for their children, parents value a surgeon's recommendation. Parents felt that discussion or dialogue with surgeons defined shared decision-making, and they believed that the opportunity to ask questions gave them a 'valued voice', even when they felt there were no decisions to be made. PATIENT OR PUBLIC CONTRIBUTION For this study, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. Parents thus provided all the data for the study.
Collapse
Affiliation(s)
- Erica M. Carlisle
- Department of Surgery, Division of Pediatric SurgeryUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA,College of Medicine, Program in Bioethics and HumanitiesUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Laura A. Shinkunas
- College of Medicine, Program in Bioethics and HumanitiesUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | - Emily Ruba
- College of MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
| | | | | | - Richard M. Hoffman
- Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | - Heather S. Reisinger
- College of Medicine, Program in Bioethics and HumanitiesUniversity of Iowa Carver College of MedicineIowa CityIowaUSA,Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA,Institute for Clinical and Translational ScienceUniversity of IowaIowa CityIowaUSA
| |
Collapse
|
9
|
Fortney JC, Rajan S, Reisinger HS, Moeckli J, Nolan JP, Wong ES, Rise P, Petrova VV, Sayre GG, Pyne JM, Grubaugh A, Simsek-Duran F, Grubbs KM, Morland LA, Felker B, Schnurr PP. Deploying a telemedicine collaborative care intervention for posttraumatic stress disorder in the U.S. Department of Veterans Affairs: A stepped wedge evaluation of an adaptive implementation strategy. Gen Hosp Psychiatry 2022; 77:109-117. [PMID: 35596963 DOI: 10.1016/j.genhosppsych.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/08/2022] [Accepted: 03/23/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To address barriers to trauma-focused psychotherapy for veterans with posttraumatic stress disorder (PTSD), we compared two implementation strategies to promote the deployment of telemedicine collaborative care. METHOD We conducted a Hybrid Type III Effectiveness Implementation trial at six VA medical centers and their 12 affiliated Community Based Outpatient Clinics. The trial used a stepped wedge design and an adaptive implementation strategy that started with standard implementation, followed by enhanced implementation for VA medical centers that did not achieve the performance benchmark. Implementation outcomes for the 544 veterans sampled from the larger population targeted by the intervention were assessed from chart review (care management enrollment and receipt of trauma-focused psychotherapy) and telephone survey (perceived access and PTSD symptoms) after each implementation phase. The primary outcome was enrollment in care management. RESULTS There was no significant difference between standard implementation and enhanced implementation on any of the implementation outcomes. 41.6% of sampled veterans had a care manager encounter, but only 6.0% engaged in trauma-focused psychotherapy. CONCLUSIONS While telemedicine collaborative care was shown to be effective at engaging veterans in trauma-focused psychotherapy in a randomized controlled trial, neither standard nor enhanced implementation strategies were sufficient to support successful deployment into routine care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02737098.
Collapse
Affiliation(s)
- John C Fortney
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America.
| | - Suparna Rajan
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Heather S Reisinger
- VA HSR&D Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, IA, United States of America; Department of Internal Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Jane Moeckli
- VA HSR&D Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, IA, United States of America
| | | | - Edwin S Wong
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Health and Systems and Population Health, University of Washington, Seattle, WA, United States of America
| | - Peter Rise
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Valentina V Petrova
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - George G Sayre
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Jeffrey M Pyne
- VA HSR&D Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States of America; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Anouk Grubaugh
- VA HSR&D Charleston Health Equity and Rural Outreach Innovation Center, Charleston, SC, United States of America; Department of Psychiatry, Medical University of South Carolina, Charleston, SC, United States of America
| | - Fatma Simsek-Duran
- Iowa City VA Health Care System, IA, United States of America; Department of Psychiatry, University of Iowa, Iowa City, IA, United States of America
| | - Kathleen M Grubbs
- VA San Diego Healthcare System, San Diego, CA, United States of America; Department of Psychiatry, University of California-San Diego, San Diego, CA, United States of America
| | - Leslie A Morland
- VA San Diego Healthcare System, San Diego, CA, United States of America; Department of Psychiatry, University of California-San Diego, San Diego, CA, United States of America
| | - Bradford Felker
- VA HSR&D Center for Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States of America
| | - Paula P Schnurr
- National Center for PTSD, VA Medical Center, White River Junction, VT, United States of America; Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| |
Collapse
|
10
|
O'Shea AM, Reisinger HS, Panos R, Goede M, Fortis S. Association of interactions between Tele-critical care and bedside with length of stay and mortality. J Telemed Telecare 2022:1357633X221107993. [PMID: 35770292 DOI: 10.1177/1357633x221107993] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization. METHODS We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes. RESULTS Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay. DISCUSSION Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.
Collapse
Affiliation(s)
- Amy Mj O'Shea
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, 12243University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, 12243University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Ralph Panos
- Pulmonary, Critical Care, and Sleep Division and Cincinnati Tele-CC, Cincinnati VAMC, Cincinnati, OH, USA
- Pulmonary, Critical Care, and Sleep Division, 12303University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matt Goede
- VA Tele-Critical. Care West, 20040Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Surgery, Division of Acute Care Surgery, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Spyridon Fortis
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- VA Tele-Critical. Care West, 20040Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, 12243University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
11
|
Cifra CL, Tigges CR, Miller SL, Curl N, Monson CD, Dukes KC, Reisinger HS, Pennathur PR, Sittig DF, Singh H. Reporting Outcomes of Pediatric Intensive Care Unit Patients to Referring Physicians via an Electronic Health Record-Based Feedback System. Appl Clin Inform 2022; 13:495-503. [PMID: 35545126 PMCID: PMC9095343 DOI: 10.1055/s-0042-1748147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Many critically ill children are initially evaluated in front-line settings by clinicians with variable pediatric training before they are transferred to a pediatric intensive care unit (PICU). Because clinicians learn from past performance, communicating outcomes of patients back to front-line clinicians who provide pediatric emergency care could be valuable; however, referring clinicians do not consistently receive this important feedback. OBJECTIVES Our aim was to determine the feasibility, usability, and clinical relevance of a semiautomated electronic health record (EHR)-supported system developed at a single institution to deliver timely and relevant PICU patient outcome feedback to referring emergency department (ED) physicians. METHODS Guided by the Health Information Technology Safety Framework, we iteratively designed, implemented, and evaluated a semiautomated electronic feedback system leveraging the EHR in one institution. After conducting interviews and focus groups with stakeholders to understand the PICU-ED health care work system, we designed the EHR-supported feedback system by translating stakeholder, organizational, and usability objectives into feedback process and report requirements. Over 6 months, we completed three cycles of implementation and evaluation, wherein we analyzed EHR access logs, reviewed feedback reports sent, performed usability testing, and conducted physician interviews to determine the system's feasibility, usability, and clinical relevance. RESULTS The EHR-supported feedback process is feasible with timely delivery and receipt of feedback reports. Usability testing revealed excellent Systems Usability Scale scores. According to physicians, the process was well-integrated into their clinical workflows and conferred minimal additional workload. Physicians also indicated that delivering and receiving consistent feedback was relevant to their clinical practice. CONCLUSION An EHR-supported system to deliver timely and relevant PICU patient outcome feedback to referring ED physicians was feasible, usable, and important to physicians. Future work is needed to evaluate impact on clinical practice and patient outcomes and to investigate applicability to other clinical settings involved in similar care transitions.
Collapse
Affiliation(s)
- Christina L Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Cody R Tigges
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Sarah L Miller
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Nathaniel Curl
- Emergency Medicine, UnityPoint Health-Trinity Medical Center, Rock Island, Illinois, United States
| | - Christopher D Monson
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Kimberly C Dukes
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, United States.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, United States.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States.,Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, United States
| | - Priyadarshini R Pennathur
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States.,Department of Industrial and Systems Engineering, College of Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Dean F Sittig
- School of Biomedical Informatics, Center for Healthcare Quality and Safety, University of Texas Health Science Center, Houston, Texas, United States
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, United States
| |
Collapse
|
12
|
Wong ES, Rajan S, Liu CF, Morland LA, Pyne JM, Simsek-Duran F, Reisinger HS, Moeckli J, Fortney JC. Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA. Implementation Research and Practice 2022; 3:26334895221116771. [PMID: 37091111 PMCID: PMC9924252 DOI: 10.1177/26334895221116771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Methods Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Results Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Conclusions Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.
Collapse
Affiliation(s)
- Edwin S. Wong
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Suparna Rajan
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
| | - Chuan-Fen Liu
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Leslie A. Morland
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California-San Diego, San Diego, CA
| | - Jeffrey M. Pyne
- Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Fatma Simsek-Duran
- Iowa City VA Health Care System, Iowa City, IA
- Department of Psychiatry, University of Iowa, Iowa City, IA
| | - Heather S. Reisinger
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
- Department of Internal Medicine, University of Iowa, Iowa
City, IA
| | - Jane Moeckli
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
| | - John C. Fortney
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| |
Collapse
|
13
|
Werzen A, Thom KA, Robinson GL, Li S, Rock C, Herwaldt LA, Diekema DJ, Reisinger HS, Perencevich EN. Comparing brief, covert, directly observed hand hygiene compliance monitoring to standard methods: A multicenter cohort study. Am J Infect Control 2019; 47:346-348. [PMID: 30314747 DOI: 10.1016/j.ajic.2018.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Abstract
Hand hygiene compliance is subject to the Hawthorne effect, which may be attenuated by covert observers and brief observation periods. This study demonstrated that hand hygiene compliance rates were between 8% and 29% greater when reported by infection prevention programs than when reported by covert observers over brief observation periods.
Collapse
|
14
|
Fortis S, O'Shea AMJ, Beck BF, Nair R, Goto M, Kaboli PJ, Perencevich EN, Reisinger HS, Sarrazin MV. An automated computerized critical illness severity scoring system derived from APACHE III: modified APACHE. J Crit Care 2018; 48:237-242. [PMID: 30243204 DOI: 10.1016/j.jcrc.2018.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the performance of an automated computerized ICU severity scoring derived from the APACHE III. MATERIALS AND METHODS Within a retrospective cohort of patients admitted to Veterans Health Administration ICUs between 2009 and 2015, we created an automated illness severity score(modified APACHE or mAPACHE), that we extracted from the electronic health records, using the same scoring as the APACHE III excluding the Glasgow Coma Scale, urine output, arterial blood gas components of APACHE III. We assessed the mAPACHE discrimination by using the area under the curve(AUC), and calibration by using the Hosmer-Lemeshow test and calculating the difference between observed and expected mortality across equal-sized risk deciles for death. RESULTS The ICU and 30-day mortality was 5.07% of 7.82%, respectively (n = 490,955 patients). The AUC of mAPACHE for ICU and 30-day mortality was 0.771 and 0.786, respectively. The Hosmer-Lemeshow test was significant for both ICU and 30-day mortality (p < .001). The absolute difference between observed and expected mortality did not exceed ±1.53% across equal-sized deciles of risk for death. The AUC for ICU mortality was >0.7 in all admission diagnosis categories except in endocrine, respiratory, and sepsis. The AUC for 30-day mortality was >0.7 in every category. CONCLUSION mAPACHE has adequate performance to predict mortality.
Collapse
Affiliation(s)
- Spyridon Fortis
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.
| | - Amy M J O'Shea
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Rajeshwari Nair
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary V Sarrazin
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
15
|
Fortis S, Sarrazin MV, Beck BF, Panos RJ, Reisinger HS. ICU Telemedicine Reduces Interhospital ICU Transfers in the Veterans Health Administration. Chest 2018; 154:69-76. [DOI: 10.1016/j.chest.2018.04.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/05/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022] Open
|
16
|
O’Shea AMJ, Vaughan Sarrazin M, Nassar B, Cram P, Johnson L, Bonello R, Panos RJ, Reisinger HS. Using electronic medical record notes to measure ICU telemedicine utilization. J Am Med Inform Assoc 2017; 24:969-974. [PMID: 28379510 PMCID: PMC7651918 DOI: 10.1093/jamia/ocx029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 11/17/2016] [Revised: 02/24/2017] [Accepted: 03/08/2017] [Indexed: 11/13/2022] Open
Abstract
Given the complexity of high-acuity health care, designing an effective clinical note template can be beneficial to both document patient care and clarify how telemedicine is used. We characterized documented interactions via a standardized note template between bedside intensive care unit (ICU) providers and teleintensivists in 2 Veterans Health Administration ICU telemedicine support centers. All ICUs linked to support centers and providing care from October 2012 through September 2014 were considered. Interactions were assessed based on initiation site, bedside initiator, contact type, and patient care change. Of 14 511 ICU admissions with teleintensivist access, teleintensivist interaction was documented in 21.6% (N = 3136). In particular, contacts were primarily initiated by bedside staff (74.4%), use increased over time, and of contacts resulting in changes in patient care, most were initiated by a bedside nurse (84.3%). Given this variation, future research necessitates inclusion of utilization in evaluation of Tele-ICU and patient outcomes.
Collapse
Affiliation(s)
- Amy MJ O’Shea
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary Vaughan Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Boulos Nassar
- Iowa City VA Health Care System
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine
| | - Peter Cram
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lynelle Johnson
- VA Integrated Healthcare Network 10, VA Healthcare System, Cincinnati, OH, USA
| | | | - Ralph J Panos
- Pulmonary, Critical Care, and Sleep Division and Cincinnati Tele-ICU, Cincinnati VAMC, Cincinnati, OH, USA
- Pulmonary, Critical Care, and Sleep Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Heather S Reisinger
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
17
|
Chang NCN, Reisinger HS, Jesson AR, Schweizer ML, Morgan DJ, Forrest GN, Perencevich EN. Feasibility of monitoring compliance to the My 5 Moments and Entry/Exit hand hygiene methods in US hospitals. Am J Infect Control 2016; 44:938-40. [PMID: 27061257 DOI: 10.1016/j.ajic.2016.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/02/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
We compared the ability to observe hand hygiene opportunities using the World Health Organization My 5 Moments method to the Entry/Exit method. Under covert direct observation, Entry/Exit method opportunities were observed at all times. My 5 Moments were observable in 32.3% of episodes, with a lower rate in wards versus intensive care units (28.0% vs 39.4%; P < .01). In US hospitals, the Entry/Exit method appears to be more feasible for directly observed hand hygiene compliance monitoring due to line-of-sight issues and other barriers.
Collapse
|
18
|
Nassar BS, Vaughan-Sarrazin MS, Jiang L, Reisinger HS, Bonello R, Cram P. Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system. JAMA Intern Med 2014; 174:1160-7. [PMID: 24819673 DOI: 10.1001/jamainternmed.2014.1503] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Intensive care unit (ICU) telemedicine (TM) programs have been promoted as improving access to intensive care specialists and ultimately improving patient outcomes, but data on effectiveness are limited and conflicting. OBJECTIVE To examine the impact of ICU TM on mortality rates and length of stay (LOS) in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS Observational pre-post study of patients treated in 8 "intervention" ICUs (7 hospitals within the US Department of Veterans Affairs health care system) during 2011-2012 that implemented TM monitoring during the post-TM period as well as patients treated in concurrent control ICUs that did not implement an ICU TM program. INTERVENTION Implementation of ICU TM monitoring. MAIN OUTCOMES AND MEASURES Unadjusted and risk-adjusted ICU, in-hospital, and 30-day mortality rates and ICU and hospital LOS for patients who did or did not receive treatment in ICUs equipped with TM monitoring. RESULTS Our study included 3355 patients treated in our intervention ICUs (1708 in the pre-TM period and 1647 in the post-TM period) and 3584 treated in the control ICUs during the same period. Patient demographics and comorbid illnesses were similar in the intervention and control ICUs during the pre-TM and post-TM periods; however, predicted ICU mortality rates were modestly lower for admissions to the intervention ICUs compared with control ICUs in both the pre-TM (3.0% vs 3.6%; P = .02) and post-TM (2.8% vs 3.5%; P < .001) periods. Implementation of ICU TM was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses. For example, unadjusted ICU mortality in the pre-TM vs post-TM periods were 2.9% vs 2.8% (P = .89) for the intervention ICUs and 4.0% vs 3.4% (P = .31) for the control ICUs. Unadjusted 30-day mortality during the pre-TM vs post-TM periods were 7.7% vs 7.8% (P = .91) for the intervention ICUs and 12.0% vs 10.2% (P = .08) for the control ICUs. Evaluation of interaction terms comparing the magnitude of mortality rate change during the pre-TM and post-TM periods in the intervention and control ICUs failed to demonstrate a significant reduction in mortality rates or LOS. CONCLUSIONS AND RELEVANCE We found no evidence that the implementation of ICU TM significantly reduced mortality rates or LOS.
Collapse
Affiliation(s)
- Boulos S Nassar
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa2Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Hospitals a
| | - Mary S Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa3Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Lan Jiang
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Heather S Reisinger
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa3Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City
| | - Robert Bonello
- Division of Pulmonary and Critical Care Medicine, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City5Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada6Division of General Internal Medicine, Mt Sinai/Un
| |
Collapse
|
19
|
Ward MA, Schweizer ML, Polgreen PM, Gupta K, Reisinger HS, Perencevich EN. Automated and electronically assisted hand hygiene monitoring systems: a systematic review. Am J Infect Control 2014; 42:472-8. [PMID: 24773785 DOI: 10.1016/j.ajic.2014.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/31/2013] [Accepted: 01/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hand hygiene is one of the most effective ways to prevent transmission of health care-associated infections. Electronic systems and tools are being developed to enhance hand hygiene compliance monitoring. Our systematic review assesses the existing evidence surrounding the adoption and accuracy of automated systems or electronically enhanced direct observations and also reviews the effectiveness of such systems in health care settings. METHODS We systematically reviewed PubMed for articles published between January 1, 2000, and March 31, 2013, containing the terms hand AND hygiene or hand AND disinfection or handwashing. Resulting articles were reviewed to determine if an electronic system was used. RESULTS We identified 42 articles for inclusion. Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks. Fewer than 20% of articles identified included calculations for efficiency or accuracy. CONCLUSIONS Limited data are currently available to recommend adoption of specific automatic or electronically assisted hand hygiene surveillance systems. Future studies should be undertaken that assess the accuracy, effectiveness, and cost-effectiveness of such systems. Given the restricted clinical and infection prevention budgets of most facilities, cost-effectiveness analysis of specific systems will be required before these systems are widely adopted.
Collapse
Affiliation(s)
- Melissa A Ward
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Marin L Schweizer
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Iowa City VA Health Care System, Iowa City, IA
| | - Philip M Polgreen
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Kalpana Gupta
- VA Boston Health Care System, West Roxbury, MA; Boston University School of Medicine, Jamaica Plain, MA
| | - Heather S Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Iowa City VA Health Care System, Iowa City, IA
| | - Eli N Perencevich
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Iowa City VA Health Care System, Iowa City, IA.
| |
Collapse
|
20
|
Katz DA, Paez MW, Reisinger HS, Gillette MT, Weg MWV, Titler MG, Nugent AS, Baker LJ, Holman JE, Ono SS. Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions. Addict Sci Clin Pract 2014; 9:1. [PMID: 24460974 PMCID: PMC3902188 DOI: 10.1186/1940-0640-9-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 01/17/2014] [Indexed: 11/13/2022] Open
Abstract
Background The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED. Methods We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts. Results The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED. Conclusions There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies. Trial registration ClinicalTrials.gov registration number NCT00756704
Collapse
Affiliation(s)
- David A Katz
- Department of Medicine, University of Iowa, Iowa City, IA, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Morgan DJ, Pineles L, Shardell M, Graham MM, Mohammadi S, Forrest GN, Reisinger HS, Schweizer ML, Perencevich EN. The effect of contact precautions on healthcare worker activity in acute care hospitals. Infect Control Hosp Epidemiol 2012; 34:69-73. [PMID: 23221195 DOI: 10.1086/668775] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Contact precautions are a cornerstone of infection prevention but have also been associated with less healthcare worker (HCW) contact and adverse events. We studied how contact precautions modified HCW behavior in 4 acute care facilities. DESIGN Prospective cohort study. PARTICIPANTS AND SETTING Four acute care facilities in the United States performing active surveillance for methicillin-resistant Staphylococcus aureus. METHODS Trained observers performed "secret shopper" monitoring of HCW activities during routine care, using a standardized collection tool and fixed 1-hour observation periods. RESULTS A total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions (2.78 vs 4.37 visits per hour; [Formula: see text]) as well as 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour; [Formula: see text]). Patients on contact precautions tended to have fewer visitors (23.6% fewer; [Formula: see text]). HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions; [Formula: see text]). CONCLUSION Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.
Collapse
Affiliation(s)
- Daniel J Morgan
- University of Maryland School of Medicine, Baltimore, Maryland, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Green KM, Doherty EE, Reisinger HS, Chilcoat HD, Ensminger M. Social integration in young adulthood and the subsequent onset of substance use and disorders among a community population of urban African Americans. Addiction 2010; 105:484-93. [PMID: 20402992 PMCID: PMC2858355 DOI: 10.1111/j.1360-0443.2009.02787.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS This paper examines the association between social integration in young adulthood and the later onset of substance use and disorders through mid-adulthood. Design Data come from a community cohort of African Americans followed longitudinally from age 6-42 years with four assessment periods. SETTING The cohort all lived in the Woodlawn neighborhood of Chicago in 1966, an urban disadvantaged setting. PARTICIPANTS All Woodlawn first graders in 1966 were asked to participate; 13 families declined (n = 1242). MEASUREMENT Substance use was measured via interview at age 42 and includes the onset of alcohol and drug use disorders and the onset of cocaine/heroin use between ages 32 and 42 years. Social integration measures were assessed via interview at age 32 and include social roles (employee, spouse, parent), participation in religious and social organizations and a measure of overall social integration. Control variables were measured in childhood and later in the life course. FINDINGS Multivariate regression analyses suggest that unemployment, being unmarried, infrequent religious service attendance and lower overall social integration in young adulthood predict later adult-onset drug use disorders, but not alcohol use disorders once confounders are taken into consideration. Unemployment and lower overall social integration predict onset of cocaine/heroin use later in adulthood. CONCLUSIONS Results show meaningful onset of drug use and substance use disorders during mid-adulthood and that social integration in young adulthood seems to play a role in later onset of drug use and drug disorders, but not alcohol disorders.
Collapse
Affiliation(s)
- Kerry M. Green
- Department of Public and Community Health, University of Maryland School of Public Health
| | - Elaine E. Doherty
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
| | | | - Howard D. Chilcoat
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health
| | - Margaret Ensminger
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health
| |
Collapse
|
23
|
Schwartz RP, Kelly SM, O'Grady KE, Peterson JA, Reisinger HS, Mitchell SG, Wilson ME, Agar MH, Brown BS. In-treatment vs. out-of-treatment opioid dependent adults: drug use and criminal history. Am J Drug Alcohol Abuse 2008; 34:17-28. [PMID: 18161640 DOI: 10.1080/00952990701653826] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This study compared the characteristics of opioid-addicted adults seeking (n = 169) and not seeking (n = 74) methadone treatment in Baltimore, Maryland. Participants entering treatment were recruited from six methadone treatment programs, while out-of-treatment participants were recruited from the streets using targeted sampling methods. Measures included the Addiction Severity Index, a Supplemental Questionnaire, and urine drug test. Data were analyzed using ANOVA, chi(2), and regression, holding key background variables constant. Despite the lack of differences between the samples in demographic characteristics, the out-of-treatment sample reported significantly more days of heroin, cocaine, and alcohol use and spent significantly more money on drugs and earned more illegal income at baseline.
Collapse
Affiliation(s)
- Robert P Schwartz
- Friends Research Institute, Inc., Social Research Center, Baltimore, Maryland 21201, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Trend theory is an effort to integrate histories of populations and distribution systems to explain the key epidemiological question: why do these people in this place at this time experience a rapid increase in heroin use? The theory grew out of work on heroin trends in the Baltimore metropolitan area, specifically on epidemics among urban African-Americans in the 1960s and among suburban white youth in the 1990s. This overview represents trend theory as an instance of agent-based adaptive models characteristic of complexity theory.
Collapse
Affiliation(s)
- M Agar
- Friends Social Research Center, Baltimore, Maryland 21217, USA.
| | | |
Collapse
|
25
|
Abstract
As part of a larger study on heroin trends in the city of Baltimore, the authors examined articles in the general circulation newspaper that serves the city and surrounding suburbs. Using computer archives, articles from 1992 to 1998 were searched for mentions of heroin. A method of analysis was developed that focused on the flow of articles through time with an emphasis on headlines and content summaries, with the goal of tracking the development of a new "topic framework," heroin use in the suburbs. The analysis shows how it is that certain stories work while others do not, and how eventually the topic framework is established so that the new trend is constituted as a community communicative resource. In the conclusion the model is generalized and four principles are hypothesized that account for why the topic framework finally took off.
Collapse
Affiliation(s)
- M H Agar
- Ethknoworks, Tacoma Park, Maryland 20913, USA.
| | | |
Collapse
|