Assessing an innovative method to promote learning from patient narratives: Findings from a field experiment in ambulatory care

OBJECTIVE

To assess whether an online interactive report designed to facilitate interpretation of patients' narrative feedback produces change in ambulatory staff learning, behavior at the individual staff and practice level, and patient experience survey scores.

DATA SOURCES AND SETTING

We studied 22 ambulatory practice sites within an academic medical center using three primary data sources: 333 staff surveys; 20 in-depth interviews with practice leaders and staff; and 9551 modified CG-CAHPS patient experience surveys augmented by open-ended narrative elicitation questions.

STUDY DESIGN

We conducted a cluster quasi-experimental study, comparing 12 intervention and 10 control sites. At control sites, narratives were delivered free-form to site administrators via email; at intervention sites, narratives were delivered online with interactive tools for interpretation, accompanied by user training. We assessed control-versus-intervention site differences in learning, behavior, and patient experience scores.

DATA COLLECTION

Staff surveys and interviews were completed at intervention and control sites, 9 months after intervention launch. Patient surveys were collected beginning 4 months pre-launch through 9 months post-launch. We used control-versus-intervention and difference-in-difference analyses for survey data and thematic analysis for interview data.

PRINCIPAL FINDINGS

Interviews suggested that the interface facilitated narrative interpretation and use for improvement. Staff survey analyses indicated enhanced learning from narratives at intervention sites (29% over control sites' mean of 3.19 out of 5 across eight domains, p < 0.001) and greater behavior change at staff and practice levels (31% and 21% over control sites' means of 3.35 and 3.39, p < 0.001, respectively). Patient experience scores for interactions with office staff and wait time information increased significantly at intervention sites, compared to control sites (3.7% and 8.2%, respectively); however, provider listening scores declined 3.3%.

CONCLUSIONS

Patient narratives presented through structured feedback reporting methods can catalyze positive changes in staff learning, promote behavior change, and increase patient experience scores in domains of non-clinical interaction.

Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion

Importance

The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known.

Objective

To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations.

Design, Setting, and Participants

Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys.

Exposure

Time-varying state-level adoption of Medicaid expansion.

Main Outcomes and Measures

Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits.

Results

The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion.

Conclusion and Relevance

Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Learning from patients: The impact of using patients' narratives on patient experience scores

BACKGROUND

Enthusiasm has grown about using patients' narratives-stories about care experiences in patients' own words-to advance organizations' learning about the care that they deliver and how to improve it, but studies confirming association have not been published.

PURPOSE

We assessed whether primary care clinics that frequently share patients' narratives with their staff have higher patient experience survey scores.

APPROACH

We conducted a 1-year study of 5,545 adult patients and 276 staff affiliated with nine clinics in one health system. We used multilevel models to analyze survey data from patients about their experiences and from staff about exposure to useful narratives. We examined staff confidence in own knowledge as a moderator because confidence can influence use of new information sources.

RESULTS

Frequency of sharing useful narratives with staff was associated with patient experience scores for all measures, conditional on staff confidence in own knowledge ( p < .01). For operational measures (e.g., care coordination), increased sharing correlated with subsequently higher performance for more confident staff and lower performance or no difference for less confident staff, depending on measure. For relational measures (e.g., patient-provider communication), increased sharing correlated with higher scores for less confident staff and lower scores for more confident staff.

CONCLUSION

Sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge.

PRACTICE IMPLICATIONS

Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organizations need to address how narrative feedback interacts with their staff's confidence to realize higher experience scores across domains.

Drug resistant tuberculosis among elderly: Challenges

The article deals with challenges faced by the geriatric populations while on MDR treatment. Risk factors like tobacco use, low socio-economic status, previous disease, longer delays in seeking treatment and reduced mobility are some of the challenges while initiating MDR treatment. Other issues like drug-related adverse events and increased co-morbidity pose a major challenge while treating patients. Susceptibility among the geriatric age group includes various anatomical and physiological changes including nutritional deficiencies and co morbidities.

Changes in Unemployment Among Health Care Workers Following the COVID-19 Pandemic

This study examines changes in unemployment among US health care workers from January 2015 to April 2022, before and after the onset of the COVID-19 pandemic.

Objective Assessment of Covid-19 Severity Affecting the Vocal and Respiratory System Using a Wearable, Autonomous Sound Collar

Introduction

Since the outbreak began in January 2020, Covid-19 has affected more than 161 million people worldwide and resulted in about 3.3 million deaths. Despite efforts to detect human infection with the virus as early as possible, the confirmatory test still requires the analysis of sputum or blood with estimated results available within approximately 30 minutes; this may potentially be followed by clinical referral if the patient shows signs of aggravated pneumonia. This work aims to implement a soft collar as a sound device dedicated to the objective evaluation of the pathophysiological state resulting from dysphonia of laryngeal origin or respiratory failure of inflammatory origin, in particular caused by Covid-19.

Methods

In this study, we exploit the vibrations of waves generated by the vocal and respiratory system of 30 people. A biocompatible acoustic sensor embedded in a soft collar around the neck collects these waves. The collar is also equipped with thermal sensors and a cross-data analysis module in both the temporal and frequency domains (STFT). The optimal coupling conditions and the electrical and dimensional characteristics of the sensors were defined based on a mathematical approach using a matrix formalism.

Results

The characteristics of the signals in the time domain combined with the quantities obtained from the STFT offer multidimensional information and a decision support tool for determining a pathophysiological state representative of the symptoms explored. The device, tested on 30 people, was able to differentiate patients with mild symptoms from those who had developed acute signs of respiratory failure on a severity scale of 1 to 10.

Conclusion

With the health constraints imposed by the effects of Covid-19, the heavy organization to be implemented resulting from the flow of diagnostics, tests and clinical management, it was urgent to develop innovative and safe biomedical technologies. This passive listening technique will contribute to the non-invasive assessment and dynamic observation of lesions. Moreover, it merits further examination to provide support for medical operators to improve clinical management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12195-021-00712-w.

The Role of Public Health Expenditures in COVID-19 control: Evidence from Local Governments in England

For over 150 years the local health departments of England have been critical in controlling 19^th and 20^th century infectious epidemics. However, recent administrative changes have hollowed out their flexibility to serve communities. We use administrative data on past budgetary allocations per capita to public health departments at upper tier local areas (UTLAs) of England to examine whether public health funding levels were correlated with more rapid control of the first wave of the COVID-19 pandemic between March and July of 2020. The dependent variable was the number of days between a UTLA's 10th case of COVID-19 and the day when new cases per 100,000 peaked and began to decline. Our models controlled for regional socio-economic factors. We found no correlation between local public health expenditure and the speed of control of COVID-19. However, overall public expenditure allocated to improve local areas helped reduce time to reach peak. Contrary to expectation, more dense areas such as London experienced shorter duration. Higher income areas had more rapid success in accelerating the time of the first peak in the first wave of their local COVID-19 incidence. We contribute to understanding the impact of how public expenditure and socio-economic factors affect an epidemic.

Identifying Cohabiting Couples in Administrative Data: Evidence from Medicare Address Data

Marital status is recognized as an important social determinant of health, income, and social support, but is rarely available in administrative data. We assessed the feasibility of using exact address data and zip code history to identify cohabiting couples using the 2018 Medicare Vital Status file and ZIP codes in the 2011-2014 Master Beneficiary Summary Files. Medicare beneficiaries meeting our algorithm displayed characteristics consistent with assortative mating and resembled known married couples in the Health and Retirement Study linked to Medicare claims. Address information represents a promising strategy for identifying cohabiting couples in administrative data including healthcare claims and other data types.

Lifetime Measurements of Excited States in ^{172}Pt and the Variation of Quadrupole Transition Strength with Angular Momentum

Lifetimes of the first excited 2^{+} and 4^{+} states in the extremely neutron-deficient nuclide ^{172}Pt have been measured for the first time using the recoil-distance Doppler shift and recoil-decay tagging techniques. An unusually low value of the ratio B(E2:4_{1}^{+}→2_{1}^{+})/B(E2:2_{1}^{+}→0_{gs}^{+})=0.55(19) was found, similar to a handful of other such anomalous cases observed in the entire Segré chart. The observation adds to a cluster of a few extremely neutron-deficient nuclides of the heavy transition metals with neutron numbers N≈90-94 featuring the effect. No theoretical model calculations reported to date have been able to explain the anomalously low B(E2:4_{1}^{+}→2_{1}^{+})/B(E2:2_{1}^{+}→0_{gs}^{+}) ratios observed in these cases. Such low values cannot, e.g., be explained within the framework of the geometrical collective model or by algebraic approaches within the interacting boson model framework. It is proposed that the group of B(E2:4_{1}^{+}→2_{1}^{+})/B(E2:2_{1}^{+}→0_{gs}^{+}) ratios in the extremely neutron-deficient even-even W, Os, and Pt nuclei around neutron numbers N≈90-94 reveal a quantum phase transition from a seniority-conserving structure to a collective regime as a function of neutron number. Although a system governed by seniority symmetry is the only theoretical framework for which such an effect may naturally occur, the phenomenon is highly unexpected for these nuclei that are not situated near closed shells.

Co-regulation of intragenic microRNA miR-153 and its host gene Ia-2 β: identification of miR-153 target genes with functions related to IA-2β in pancreas and brain

AIMS/HYPOTHESIS

We analysed the genomic organisation of miR-153, a microRNA embedded in genes that encode two of the major type 1 diabetes autoantigens, islet-associated protein (IA)-2 and IA-2β. We also identified miR-153 target genes that correlated with IA-2β localisation and function.

METHODS

A bioinformatics approach was used to identify miR-153's genomic organisation. To analyse the co-regulation of miR-153 and IA-2β, quantitative PCR analysis of miR-153 and Ia-2β (also known as Ptprn2) was performed after a glucose stimulation assay in MIN6B cells and isolated murine pancreatic islets, and also in wild-type Ia-2 (also known as Ptprn), Ia-2β single knockout and Ia-2/Ia-2β double knockout mouse brain and pancreatic islets. Bioinformatics identification of miR-153 target genes and validation via luciferase reporter assays, western blotting and quantitative PCR were also carried out.

RESULTS

Two copies of miR-153, miR-153-1 and miR-153-2, are localised in intron 19 of Ia-2 and Ia-2β, respectively. In rodents, only miR-153-2 is conserved. We demonstrated that expression of miR-153-2 and Ia-2β in rodents is partially co-regulated as demonstrated by a strong reduction of miR-153 expression levels in Ia-2β knockout and Ia-2/Ia-2β double knockout mice. miR-153 levels were unaffected in Ia-2 knockout mice. In addition, glucose stimulation, which increases Ia-2 and Ia-2β expression, also significantly increased expression of miR-153. Several predicted targets of miR-153 were reduced after glucose stimulation in vitro, correlating with the increase in miR-153 levels.

CONCLUSIONS/INTERPRETATION

This study suggests the involvement of miR-153, IA-2β and miR-153 target genes in a regulatory network, which is potentially relevant to insulin and neurotransmitter release.

Are procedures performed by dental auxiliaries safe and of comparable quality? A systematic review

The objective of the current study was to systematically evaluate the existing evidence in relation to the safety, quality, productivity or cost-benefit, and patient satisfaction of the procedures performed by the different groups of dental providers. Due to the diversity of the procedures performed and the outcomes measured, it was not possible to create pooled estimates in a meaningful manner. Therefore, summary results of individual studies are presented and critically evaluated.

Post exposure management of animal bite cases attending a primary health center of Delhi

Rabies is an ancient disease of mankind. Every year 4 million people are exposed worldwide after animal bite and around 60000 fell victim to the rabies of which more than 95% of cases are bitten by the dogs. Rabies is a disease associated with many myths. The present study was conducted to find out the clinical profile of the animal bite cases including the common practices, precautions adopted by them after animal bite and lastly the extent and completion of post exposure treatment. Total 147 cases of animal bites attended the OPD during the study. In present study, 123 (83.7%) cases were bitten by dogs, followed by monkey (8.2%) and cat (8.2%). Majority (54.4%) suffered class II bites followed by class I (31.3%) and class III bite (14.3%). Of the total 147 cases, 116 cases (78.9%) completed post exposure prophylaxis which was observed higher among male and in younger age group.

Assessment of knowledge about malaria among patients reported with fever: a hospital-based study

BACKGROUND & OBJECTIVES

Knowledge about malaria, attitude and health seeking behaviour of fever patients attending Medicine Out Patient Department at Safdarjang Hospital, New Delhi were studied from June to August 2003.

METHODS

Cross-sectional survey comprising 200 fever cases was done with prestructured and pretested questionnaire. Data on sociodemographic profile, history of fever, health seeking behaviour, etc were recorded.

RESULTS

About 83% of fever cases did not approach the doctor even after three days of onset of fever symptom, 25.5% tried self medication and 20.5% approached chemists for treatment. Knowledge about causes and prevention of malaria was found to be inadequate in the study subjects.

INTERPRETATION & CONCLUSION

Knowledge about malaria is poor even in persons residing in urban localities and proper health education is required for successful control of malaria. Information, education and communication activities are indicated to create awareness among the community.

Comprehensive interdisciplinary care: making a difference in pregnancy outcomes for Hispanic women

Hispanic women constitute one of the fastest growing and most diverse groups in the United States, representing many countries of origin and cultural practices. The purpose of this evaluation study, using an ex post facto design, was to examine well-being during pregnancy and pregnancy outcomes for a cohort of 113 Hispanic women receiving perinatal care at the clinic of a community hospital in an old industrial city in the Northeast. The received adequacy of prenatal care for the study sample women was very high. The low-birthweight rate was lower than for the study hospital, the study city, the state, and the entire United States. The results of this study demonstrate the favorable effects of a comprehensive, interdisciplinary, and culturally sensitive model of prenatal care on these women's well-being and birth outcomes. Findings also support the need for an outreach program targeted at hard-to-reach women in the inadequate, received-care group and women with later initiation of care.

The adrenocorticotropin response to interleukin-1 beta instilled into the rat median eminence depends on the local release of catecholamines

Interleukin-1 beta (IL-1 beta) is a potent ACTH secretagogue which activates the release of hypothalamic CRF but is unable to cross the blood brain barrier. Recently, it was reported that IL-1 beta, instilled directly into the hypothalamic median eminence (ME), rapidly induced ACTH secretion. Thus, due to the lack of a blood brain barrier the ME appears to be a site whereby iv IL-1 beta can access the brain to stimulate CRF and, consequently, ACTH secretion. To evaluate the role of central catecholamines in this process, 250 g male rats were lesioned with 6-hydroxy-dopamine instilled into the lateral ventricle. Ten days later, rats received recombinant h-IL-1 beta (10 or 30 ng) into the ME and blood was sampled via indwelling jugular cannulae. The ACTH response to IL-1 beta, 30 ng, was reduced by approximately 50% in the lesioned rats (P = 0.05), and it was abolished in those receiving IL-1 beta, 10 ng (P less than 0.05). Moreover, in rats given iv IL-1 beta (1 microgram), 6-hydroxy-dopamine significantly reduced the ACTH response by more than 50% (P less than 0.001). To determine the effect of acute epinephrine depletion, 2,3 dichloro-alpha-methylbenzylamine (DCMB, 60 mg/kg BW) and SKF64139 (SKF) (100 mg/kg BW), inhibitors of the enzyme which converts norepinephrine to epinephrine, were administered ip 4 h before intra-ME IL-1 beta (30 ng). DCMB reduced the ACTH response by 80% and SKF reduced it to its own baseline. LY 10853, which acutely depletes both norepinephrine and epinephrine, also reduced the ACTH response by 80%. Because of the reported capacities of DCMB and SKF to block alpha 2 adrenoreceptors in vitro, yohimbine, an alpha 2 receptor antagonist, was studied. Intra-ME yohimbine failed to inhibit the ACTH response to intra-ME IL-1 beta. In contrast, a significant (P less than 0.01) dose-dependent reduction in the ACTH response to intra-ME IL-1 beta (30 ng) was observed in rats pretreated with either a nonselective alpha or beta adrenoreceptor antagonist (phentolamine, 2-40 micrograms or propranolol, 2-20 micrograms, respectively, into the ME). In contrast, intra-ME phentolamine, 20 micrograms, failed to reduce the ACTH response to iv CRF, 1 microgram/kg BW. Thus, the secretion of ACTH stimulated by the action of IL-1 beta at the ME depends, in part, on the local secretion of norepinephrine and epinephrine interacting with both alpha and beta adrenergic receptors.

[Should drainage be performed in perforated appendicitis?]

During a follow-up study we examined 85 patients (34 children) with perforated appendicitis. The operating procedure is shortly sketched. The very favourable early and late results of our patients confirm the findings of other authors [2, 4, 5] that an intraperitoneal drainage is unnecessary in patients with perforated appendicitis. We take a thick Penrose drain for any abscess within a capsule.

Breaking a cycle of hospitalization through the psychiatric house call

The authors discuss a case in which family therapy administered in a home setting helped to break a cycle of psychiatric hospitalization that had continued for ten years. Their patient had adopted a persistent behavioral pattern involving protective magic rituals and consultations with spirits as a defense against other problems in her family relationships. With regular visits from the therapists and cooperation from each member of the family, the patient's symptoms were ameliorated and the family situation greatly improved after eight months. The authors believe that because they worked with the entire family as a system, were able to recognize sociocultural factors that had not been dealt with in the patient's hospitalizations, and were able to stimulate communication among family members in a home setting, they were able to see more immediate results and thus were able to break the costly cycle of repeated hospitalizations.