Examining Knowledge Management and the Culture Change Movement in Long-Term Care: A Study of High-Medicaid-Census Nursing Homes

High-quality nursing home (NH) care has long been a challenge within the United States. For decades, policymakers at the state and federal levels have adopted and implemented regulations to target critical components of NH care outcomes. Simultaneously, our delivery system continues to change the role of NHs in patient care. For example, more acute patients are cared for in NHs, and the Center for Medicare and Medicaid Services (CMS) has implemented value payment programs targeting NH settings. As a part of these growing pressures from the broader healthcare delivery system, the culture-change movement has emerged among NHs over the past two decades, prompting NHs to embody more person-centered care as well as promote settings which resemble someone's home, as opposed to institutionalized healthcare settings. Researchers have linked culture change to high-quality outcomes and the ability to adapt and respond to the ever-changing pressures brought on by changes in our regulatory and delivery system. Making enduring culture change within organizations has long been a challenge and focus in NHs. Despite research suggesting that culture-change initiatives that promote greater resident-centered care are associated with several desirable patient outcomes, their adoption and implementation by NHs are resource intensive, and research has shown that NHs with high percentages of low-income residents are especially challenged to adopt these initiatives. This chapter takes a novel approach to examine factors that impact the adoption of culture-change initiatives by assessing knowledge management and the role of knowledge management activities in promoting the adoption of innovative care delivery models among under-resourced NHs throughout the United States. Using primary data from a survey of NH administrators, we conducted logistic regression models to assess the relationship between knowledge management and the adoption of a culture-change initiative as well as whether these relationships were moderated by leadership and staffing stability. Our study found that NHs were more likely to adopt a culture-change initiative when they had more robust knowledge management activities. Moreover, knowledge management activities were particularly effective at promoting adoption in NHs that struggle with leadership and nursing staff instability. Our findings support the notion that knowledge management activities can help NHs acquire and mobilize informational resources to support the adoption of care delivery innovations, thus highlighting opportunities to more effectively target efforts to stimulate the adoption and spread of these initiatives.

Umbilical Cord Milking Versus Delayed Cord Clamping in Infants 28 to 32 Weeks: A Randomized Trial

OBJECTIVES

To determine whether rate of severe intraventricular hemorrhage (IVH) or death among preterm infants receiving placental transfusion with UCM is noninferior to delayed cord clamping (DCC).

METHODS

Noninferiority randomized controlled trial comparing UCM versus DCC in preterm infants born 28 to 32 weeks recruited between June 2017 through September 2022 from 19 university and private medical centers in 4 countries. The primary outcome was Grade III/IV IVH or death evaluated at a 1% noninferiority margin.

RESULTS

Among 1019 infants (UCM n = 511 and DCC n = 508), all completed the trial from birth through initial hospitalization (mean gestational age 31 weeks, 44% female). For the primary outcome, 7 of 511 (1.4%) infants randomized to UCM developed severe IVH or died compared to 7 of 508 (1.4%) infants randomized to DCC (rate difference 0.01%, 95% confidence interval: (-1.4% to 1.4%), P = .99).

CONCLUSIONS

In this randomized controlled trial of UCM versus DCC among preterm infants born between 28 and 32 weeks' gestation, there was no difference in the rates of severe IVH or death. UCM may be a safe alternative to DCC in premature infants born at 28 to 32 weeks who require resuscitation.

Retrospective Evaluation of Mycoplasma genitalium Prevalence and Macrolide Resistance in a Study Cohort of Pregnant Women in Birmingham, AL, From 1997 to 2001

ABSTRACT

In a prospective study conducted in 2020 to 2021, macrolide resistance-associated mutations were found in 41% of pregnant persons in Birmingham, AL, with Mycoplasma genitalium detected. We retrospectively evaluated M. genitalium in 203 pregnant persons participating in a study conducted in 1997 to 2001 in Birmingham and adjacent areas and found a prevalence of 11% (95% confidence interval, 6.9%-15.7%), but no macrolide resistance-associated mutations.

Relationship Between Neighborhood Socioeconomic Disadvantage and Severe Maternal Morbidity and Maternal Mortality

Background

Rates of severe maternal morbidity and maternal mortality (SMM/MM) in the United States are rising. Disparities in SMM/MM persist by race, ethnicity and geography, and could partially be attributed to social determinants of health.

Purpose

Utilizing data from the largest, statewide referral hospital in Alabama, we investigated the relationship between residence in disadvantaged neighborhoods and SMM/MM.

Methods

Data on all pregnancies between 2010 and 2020 were included; SMM/MM cases were identified using CDC definitions. Area deprivation index (ADI) available at the census-block group was geographically linked to individual records and categorized using quintile cutoffs; higher ADI score indicated higher socioeconomic disadvantage. Generalized estimating equation models were used to adjust for spatial autocorrelation and ORs were computed to evaluate the relationship between ADI and SMM/MM, adjusted for covariates including age, race, insurance, residence in medically underserved areas/population (MUAP), and urban/rural residence.

Results

Overall, 32,909 live-birth deliveries were identified, with a prevalence of 9.8% deliveries with SMM/MM with blood transfusion and 5.3% without blood transfusion, respectively. Increased levels of ADI were associated with increased odds of SMM/MM. Compared to women in the lowest quintile, the adjusted OR for SMM/MM among women in highest quintile was 1.78 (95%CI, 1.22-2.59, P=.0027); increasing age, non-Hispanic Black, government insurance and residence in MUAP were also significantly associated with increased odds of SMM/MM.

Conclusion

Our results suggest that residence within disadvantaged neighborhoods may contribute to SMM/MM even after adjusting for patient-level factors. Measures such as ADI can help identify the most vulnerable populations and provide points to intervene.

Factors That Influence Posthospital Infant Feeding Practices Among Women Who Deliver at a Baby Friendly Hospital in Southern United States

Introduction: The Baby Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, little is known about posthospital infant feeding practices among women who deliver at baby friendly hospitals. Therefore we sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation. Methods: This was a prospective cohort study of women aged 14 and over, who delivered at the University of Alabama at Birmingham. The primary outcome was mode of infant feeding categorized as exclusive breastfeeding (EBF), combination breastfeeding and formula feeding (CF), and exclusive formula feeding (EFF) at the PPV. Secondary outcome was EBF discontinuation rate. Patients who initiated formula and/or who stopped breastfeeding were asked what influenced their decision. Results: At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2-38.8); 34.6% (28.0-41.9) were CF, and 33.8% (27.3-41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support. Conclusion: Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.

Value of HbA1c in Obese Women with Gestational Diabetes

OBJECTIVE

We sought to assess the association of hemoglobin A1c (HbA1c) with adverse perinatal outcomes in obese women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This was a secondary analysis of a multicenter randomized controlled trial assessing early (14-20 weeks) versus routine (24-28 weeks) screening for GDM in obese women. Women were included if they were diagnosed with GDM at either time during pregnancy and had a HbA1c result available. The primary exposure was HbA1c at 24 to 28 weeks. The primary outcome was a composite of macrosomia, primary cesarean, pregnancy-induced hypertension, shoulder dystocia, neonatal hypoglycemia, or hyperbilirubinemia. Receiver operating characteristics (ROC) curves were used to assess the association of HbA1c with the composite outcome. The Liu method was used to select an optimal HbA1c cutoff, and the incidence of the outcome compared.

RESULTS

Of 125 women with GDM, 93 (74%) had a HbA1c at 24 to 28 weeks and 103 (82.4%) had a HbA1c at 14 to 20 weeks. Baseline characteristics were balanced between groups above and below the cutoff. The area under the ROC curve for HbA1c and its association with the adverse perinatal composite outcome was 0.6 (95% confidence interval [CI]: 0.5-0.7). The frequency of the primary outcome was similar among women with low and high HbA1c at 24 to 28 weeks (adjusted relative risk, 1.12, 95% CI: 0.97-1.29). Compared with women with a decreasing HbA1c during pregnancy, women with a stable or increasing HbA1c did not have a significant increase in the primary adverse perinatal composite outcome. However, the frequency of preterm delivery was higher among women with stable or increasing HbA1c compared with those with a decreasing HbA1c (26.1 vs. 6.7%, p = 0.03).

CONCLUSION

A single HbA1c in women with GDM is not associated with a composite perinatal adverse outcome, but a HbA1c that increases or remains stable between 14 to 20 and 24 to 28 weeks is associated with an increase in preterm delivery.

KEY POINTS

· A single HbA1c in GDM is not associated with a composite perinatal adverse outcome.. · HbA1c that increases or remains stable may be associated with an increase in preterm delivery.. · HbA1c at 24 to 28 weeks was not significantly associated with the adverse perinatal composite outcome..

Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants

IMPORTANCE

Umbilical cord milking as an alternative to delayed umbilical cord clamping may provide equivalent benefits to preterm infants, but without delaying resuscitation.

OBJECTIVE

To determine whether the rates of death or severe intraventricular hemorrhage differ among preterm infants receiving placental transfusion with umbilical cord milking vs delayed umbilical cord clamping.

DESIGN, SETTING, AND PARTICIPANTS

Noninferiority randomized clinical trial of preterm infants (born at 23-31 weeks' gestation) from 9 university and private medical centers in 4 countries were recruited and enrolled between June 2017 and September 2018. Planned enrollment was 750 per group. However, a safety signal comprising an imbalance in the number of severe intraventricular hemorrhage events by study group was observed at the first interim analysis; enrollment was stopped based on recommendations from the data and safety monitoring board. The planned noninferiority analysis could not be conducted and a post hoc comparison was performed instead. Final date of follow-up was December 2018.

INTERVENTIONS

Participants were randomized to umbilical cord milking (n = 236) or delayed umbilical cord clamping (n = 238).

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of death or severe intraventricular hemorrhage to determine noninferiority of umbilical cord milking with a 1% noninferiority margin.

RESULTS

Among 540 infants randomized, 474 (88%) were enrolled and completed the trial (mean gestational age of 28 weeks; 46% female). Twelve percent (29/236) of the umbilical cord milking group died or developed severe intraventricular hemorrhage compared with 8% (20/238) of the delayed umbilical cord clamping group (risk difference, 4% [95% CI, -2% to 9%]; P = .16). Although there was no statistically significant difference in death, severe intraventricular hemorrhage was statistically significantly higher in the umbilical cord milking group than in the delayed umbilical cord clamping group (8% [20/236] vs 3% [8/238], respectively; risk difference, 5% [95% CI, 1% to 9%]; P = .02). The test for interaction between gestational age strata and treatment group was significant for severe intraventricular hemorrhage only (P = .003); among infants born at 23 to 27 weeks' gestation, severe intraventricular hemorrhage was statistically significantly higher with umbilical cord milking than with delayed umbilical cord clamping (22% [20/93] vs 6% [5/89], respectively; risk difference, 16% [95% CI, 6% to 26%]; P = .002).

CONCLUSIONS AND RELEVANCE

In this post hoc analysis of a prematurely terminated randomized clinical trial of umbilical cord milking vs delayed umbilical cord clamping among preterm infants born at less than 32 weeks' gestation, there was no statistically significant difference in the rate of a composite outcome of death or severe intraventricular hemorrhage, but there was a statistically significantly higher rate of severe intraventricular hemorrhage in the umbilical cord milking group. The early study termination and resulting post hoc nature of the analyses preclude definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03019367.

Radiation Oncologist Characteristics and their Association with Outcomes in Patients with Head and Neck Cancer

PURPOSE

Intensity modulated radiation therapy (IMRT) is widely used in the treatment of head and neck cancers (HNC). There is not enough evidence to suggest that some radiation oncologists (ROs) are associated with better outcomes in patients with HNC. We conducted a cross-sectional analysis to evaluate the effect of ROs' characteristics on outcomes in patients with HNC treated with IMRT.

METHODS AND MATERIALS

The study used the Surveillance Epidemiology and End Results-Medicare linked database to identify patient characteristics. Physician records were obtained from the American Medical Association. Logistic regression models with propensity scores were analyzed to look for an association between RO characteristics and patient outcomes.

RESULTS

RO characteristics showed that approximately 30% of ROS completed their training in or after the year 2000 (recently trained), and 17% were in top decile of treatment volume (high volume). Less than 3% of ROs work in academic settings. We found that ROs who were recently trained have higher odds (odds ratio [OR]: 1.10; 95% confidence interval [CI], 1.011-1.191) compared with those who were not. In addition, ROs who were treating high volumes of patients have higher odds (OR: 1.08; 95% CI, 1.010-1.165) compared with those treating low volumes of an event of adverse effect of IMRT or death among patients. ROs who work in academic settings have a protective effect (OR: 0.72; 95% CI, 0.569-0.925).

CONCLUSIONS

ROs who were recently trained and had a high treatment volume are associated with poorer outcomes among patients with HNC who receive IMRT treatment.

Feasibility of Complete Salpingectomy Compared With Standard Postpartum Tubal Ligation at Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

To evaluate the feasibility of salpingectomy compared with standard bilateral tubal ligation at the time of cesarean delivery in women with undesired fertility.

METHODS

We included women at 35 weeks of gestation or greater desiring permanent sterilization at the time of cesarean delivery. Patients were randomized after skin incision to bilateral salpingectomy or bilateral tubal ligation by a computer-generated scheme. If salpingectomy could not be completed on one or both sides, bilateral tubal ligation was attempted. Primary feasibility outcomes were total operative time and bilateral completion of the randomized procedure. Secondary outcomes included clinically estimated blood loss and surgical complications up to 6 weeks postpartum. We estimated that 80 patients (40 per group) would provide greater than 80% power to identify a 10-minute difference in the primary outcome (time) with a SD of 15 minutes and a two-sided α of 0.05. Analysis was by intent to treat.

RESULTS

Of 221 women screened from June 2015 to April 2017, 115 (52%) consented to the study; 80 were randomized-40 to salpingectomy and 40 to bilateral tubal ligation. Groups were similar at baseline. A total of 27 bilateral salpingectomies were successfully completed compared with 38 bilateral tubal ligations (68% compared with 95%, P=.002). Total operative time was on average 15 minutes longer for salpingectomies (75.4±29.1 compared with 60.0±23.3 minutes, P=.004). No adverse outcomes directly related to the sterilization procedure were noted in either group. Although estimated blood loss of only the sterilization procedure (surgeon estimate) was greater for the salpingectomy group (median 10 [interquartile range 5-25] compared with 5 [interquartile range 5-10] cc, P<.001), total estimated blood loss and safety outcomes were similar for both groups.

CONCLUSION

Adding 15 minutes to total operative times, salpingectomy can be successfully completed in approximately two thirds of women desiring permanent contraception with cesarean delivery.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT02374827.

Ultrasonographic Fetal Weight Estimation: Should Macrosomia-Specific Formulas Be Utilized?

OBJECTIVE

This study aims to derive an estimated fetal weight (EFW) formula in macrosomic fetuses, compare its accuracy to the 1986 Hadlock IV formula, and assess whether including maternal diabetes (MDM) improves estimation.

STUDY DESIGN

Retrospective review of nonanomalous live-born singletons with birth weight (BWT) ≥ 4 kg and biometry within 14 days of birth. Formula accuracy included: (1) mean error (ME = EFW - BWT), (2) absolute mean error (AME = absolute value of [1]), and (3) mean percent error (MPE, [1]/BWT × 100%). Using loge BWT as the dependent variable, multivariable linear regression produced a macrosomic-specific formula in a "training" dataset which was verified by "validation" data. Formulas specific for MDM were also developed.

RESULTS

Out of the 403 pregnancies, birth gestational age was 39.5 ± 1.4 weeks, and median BWT was 4,240 g. The macrosomic formula from the training data (n = 201) had associated ME = 54 ± 284 g, AME = 234 ± 167 g, and MPE = 1.6 ± 6.2%; evaluation in the validation dataset (n = 202) showed similar errors. The Hadlock formula had associated ME = -369 ± 422 g, AME = 451 ± 332 g, MPE = -8.3 ± 9.3% (all p < 0.0001). Diabetes-specific formula errors were similar to the macrosomic formula errors (all p = NS).

CONCLUSIONS

With BWT ≥ 4 kg, the macrosomic formula was significantly more accurate than Hadlock IV, which systematically underestimates fetal/BWT. Diabetes-specific formulas did not improve accuracy. A specific formula should be considered when macrosomia is suspected.

Abstract TP207: Baseline Characteristics And Functional Outcomes Of Pontine And Non-pontine Infarcts: On Behalf Of The Secondary Prevention Of Small Subcortical Strokes (SPS3) Investigators

BACKGROUND: Pontine stroke accounts for 7% of ischemic infarcts and 25% are due to cerebral small vessel disease (CVSD). Risk factors and functional outcomes distinguishing pontine from non-pontine small vessel infarcts are not well-defined.

METHODS: Data are from the Secondary Prevention of Small Subcortical Strokes (SPS3) trial. Patients have MRI-proven small vessel infarcts. The analysis compared baseline characteristics, clinical features and functional outcomes of participants with pontine and non-pontine infarcts.

RESULTS: Of 2871 participants, 634 (22%) had pontine infarcts. Pontine patients were more often male (69% vs 61%, p=0.0009), with history of hypertension (82% vs 73%, p<0.0001) and diabetes (45% vs 34%, p<0.0001). More Hispanics (38% vs 28%), Blacks (20% vs 15%), and fewer Whites (40% vs 54%, p<0.0001) had pontine infarcts. Pontine participants were more likely to have no white matter abnormalities (WMA) on MRI (13% vs 2%, p<0.0001). There was no difference in mean age (64 vs 63), presence of multiple infarcts (39% vs 40%), or rates of intra- (18% vs 16%) or extracranial (2% vs 3%) stenosis. Pontine infarcts had worse functional outcomes (mRS≤2 29% vs 23%, p<0.0001) and higher rates of MI on followup (1.1%/yr vs 0.5%, HR 2.2(1.3-3.7)). There was no significant difference for rates of stroke (2.5%/yr vs 2.6%) or all-cause mortality (2.2%/yr vs 1.6%) on followup. In a multivariable logistic regression model, significant differences persisted for gender (OR 1.4(1.1-1.8)), history of hypertension (1.6(1.2-2.1)) and diabetes (1.4(1.1-1.8)), white vs. black race (0.5(0.4-0.7)), and degree of WMA (moderate vs mild 0.6(0.5-0.9); severe vs mild 0.5(0.4-0.7)).

CONCLUSIONS: Participants with pontine infarcts had distinct baseline characteristics from those with non-pontine infarcts. These differences suggest that a stroke mechanism distinct from conventional CVSD may be responsible for a majority of pontine infarcts and may help to target future therapeutic strategies.

Abstract 2781: Prevalence and Characterization of Cerebral Microbleeds in Lacunar Stroke Patients: Observations from the Secondary Prevention Small Subcortical Strokes (SPS3) Trial

Background: The prevalence of cerebral microbleeds (CMBs) has been reported to be high in patients with cerebrovascular disease and particularly in those with cerebral small vessel disease; i.e. lacunar strokes. However, methodological limitations of previous studies imposed by small sample sizes and the absence of a clear classification of stroke subtypes hampers the conclusions regarding prevalence and characterization of CMBs in lacunar stroke patients.

Methods: SPS3 is a multi-center international randomized trial including a well-defined cohort of MRI proven lacunar stroke patients. We investigated patients within this population who had an axial T2*- GRE sequence available as part of their baseline clinical MRI. The Brain Observer MicroBleed Scale was used to rate the presence and topography of CMBs. CMB severity was graded as either absent, 1-2 CMBs or >2 CMBs. We compared baseline characteristics and vascular risk factors between patients with CMBs and those without and between the defined CMB severity grades.

Results: Of the 651 MRIs analyzed, 237 (36%) had CMBs. Patients with CMBs were more often male (73% vs 62%, p<0.01) and Hispanic (49% vs 39%, p=0.02), were more likely to have hypertension (95% vs 90%, p=0.01) and prior lacunar stroke (13% vs 7%, p=0.01), and had lower baseline mean Cognitive Abilities Screening Instrument (CASI) scores (80 vs 86, p<0.01). Male gender [OR 1.85 (95% CI, 1.26 to 2.70)], prior lacunar stroke [OR 2.19 (95% CI, 1.19 to 4.03)] and lower baseline CASI scores [OR 0.97 (95% CI, 0.95 to 0.98)] remained significant following multivariate analysis. A significant association was found between increasing CMB severity and decreasing CASI scores (p<0.01), an increased presence of multiple lacunar infarcts (p<0.0001) and moderate-severe white matter hyperintensities on MRI (p<0.0001).

Conclusions: Preliminary results of this large and well-defined cohort of lacunar stroke suggest a high prevalence of CMBs. A significant association was observed between CMBs and gender and a history of lacunar stroke. CMB severity was associated with multiple infarcts and severity of white matter disease on MRI, as well as lower cognitive function. Ongoing data from SPS3 will likely elucidate whether prognosis and response to therapy differ in patients with CMBs.

Gestational age at previous preterm birth does not affect cerclage efficacy

OBJECTIVE

The purpose of this study was to evaluate the effect of earliest previous spontaneous preterm birth (SPTB) gestational age on cervical length, pregnancy duration, and ultrasound-indicated cerclage efficacy in a subsequent gestation.

STUDY DESIGN

Planned secondary analysis of the National Institute of Child Health and Human Development-trial of cerclage for cervical length of <25 mm. Women with at least 1 previous SPTB between 17-33 weeks 6 days of gestation underwent serial vaginal ultrasound screening between 16 and 23 weeks 6 days of gestation; cervical length at qualifying randomization evaluation was used.

RESULTS

We observed a significant correlation (P = .0008) between previous SPTB gestational age and qualifying cervical length. In a linear regression model that was controlled for cervical length and cerclage, neither previous SPTB gestational age nor the interaction between cerclage and previous birth gestational age was significant predictor of subsequent birth gestational age.

CONCLUSION

Although there is an association between previous SPTB gestational age and cervical length in women with a mid-trimester cervical length of <25 mm, there does not appear to be a disproportionate benefit of cerclage in women with earlier previous SPTB.

Enhanced detection of viroid-RNA after selective divalent cation fractionation

Treatment of nucleic acid preparations from citrus exocortis viroid infected tissues with Ca2+, Co2+, Mn2+, and Zn2+ results in rapid precipitation of all large RNA molecules and selective precipitation of low-molecular-weight RNA species. Analysis of the viroid-RNA by polyacrylamide gel electrophoresis is greatly enhanced in the absence of any additional treatment with 2 M LiCl. The ratio of circular to linear molecules as well as the relative infectivity of Mn2+ -treated viroid preparations remain unaffected.

Neothiobinupharidine Sulfoxide, a New Alkaloid of Nupharluteum

A new alkaloid (C30H42N2O3S), isolated from Nupharluteum, is shown to be neothiobinupharidine sulfoxide. The mass spectra of neothiobinupharidine and the new alkaloid are discussed.