Development and validation of a rule-based algorithm to identify periodontal diagnosis using structured electronic health record data

AIM

To develop and validate an automated electronic health record (EHR)-based algorithm to suggest a periodontal diagnosis based on the 2017 World Workshop on the Classification of Periodontal Diseases and Conditions.

MATERIALS AND METHODS

Using material published from the 2017 World Workshop, a tool was iteratively developed to suggest a periodontal diagnosis based on clinical data within the EHR. Pertinent clinical data included clinical attachment level (CAL), gingival margin to cemento-enamel junction distance, probing depth, furcation involvement (if present) and mobility. Chart reviews were conducted to confirm the algorithm's ability to accurately extract clinical data from the EHR, and then to test its ability to suggest an accurate diagnosis. Subsequently, refinements were made to address limitations of the data and specific clinical situations. Each refinement was evaluated through chart reviews by expert periodontists at the study sites.

RESULTS

Three-hundred and twenty-three charts were manually reviewed, and a periodontal diagnosis (healthy, gingivitis or periodontitis including stage and grade) was made by expert periodontists for each case. After developing the initial version of the algorithm using the unmodified 2017 World Workshop criteria, accuracy was 71.8% for stage alone and 64.7% for stage and grade. Subsequently, 16 modifications to the algorithm were proposed and 14 were accepted. This refined version of the algorithm had 79.6% accuracy for stage alone and 68.8% for stage and grade together.

CONCLUSIONS

Our findings suggest that a rule-based algorithm for suggesting a periodontal diagnosis using EHR data can be implemented with moderate accuracy in support of chairside clinical diagnostic decision making, especially for inexperienced clinicians. Grey-zone cases still exist, where clinical judgement will be required. Future applications of similar algorithms with improved performance will depend upon the quality (completeness/accuracy) of EHR data.

Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings

BACKGROUND

Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT.

METHODS

EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT.

RESULTS

Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT.

CONCLUSIONS

In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters.

TRIAL REGISTRATION AND IRB

Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Cancer care coordination in rural Hawaii: a focus group study

BACKGROUND

Rural populations consistently experience a disproportionate burden of cancer, including higher incidence and mortality rates, compared to the urban populations. Factors that are thought to contribute to these disparities include limited or lack of access to care and challenges with care coordination (CC). In Hawaii, many patients residing in rural areas experience unique challenges with CC as they require inter-island travel for their cancer treatment. In this focus group study, we explored the specific challenges and positive experiences that impact the CC in rural Hawaii cancer patients.

METHODS

We conducted two semi-structured focus group interviews with cancer patients receiving active treatment for any type of cancer (n = 8). The participants were recruited from the rural areas of Hawaii, specifically the Hawaii county and Kauai. Rural was defined using the Rural-Urban Commuting Area Codes (RUCA; rural ≥ 4). The focus group discussions were facilitated using open-ended questions to explore patients' experiences with CC.

RESULTS

Content analysis revealed that 47% of the discussions were related to CC-related challenges, including access to care (27.3%), insurance (9.1%), inter-island travel (6.1%), and medical literacy (4.5%). Other major themes from the discussions focused on facilitators of CC (30.3%), including the use of electronic patient portal (12.1%), team-based approach (9.1%), family caregiver support (4.5%), and local clinic staff (4.5%).

CONCLUSION

Our findings indicate that there are notable challenges in rural patients' experiences regarding their cancer care coordination. Specific factors such as the lack of oncologist and oncology services, fragmented system, and the lack of local general medical providers contribute to problems with access to care. However, there are also positive factors found through the help of facilitators of CC, notability the use of electronic patient portal, team-based approach, family caregiver support, and local clinic staff. These findings highlight potential targets of interventions to improve cancer care delivery for rural patients.

TRIAL REGISTRATION

Not required.

Changing patterns of routine laboratory testing over time at children's hospitals

BACKGROUND

Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time.

OBJECTIVES

To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database.

MAIN OUTCOMES AND MEASURES

We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index.

RESULTS

Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.

Sociotechnical feasibility of natural language processing-driven tools in clinical trial eligibility prescreening for Alzheimer's disease and related dementias

BACKGROUND

Alzheimer's disease and related dementias (ADRD) affect over 55 million globally. Current clinical trials suffer from low recruitment rates, a challenge potentially addressable via natural language processing (NLP) technologies for researchers to effectively identify eligible clinical trial participants.

OBJECTIVE

This study investigates the sociotechnical feasibility of NLP-driven tools for ADRD research prescreening and analyzes the tools' cognitive complexity's effect on usability to identify cognitive support strategies.

METHODS

A randomized experiment was conducted with 60 clinical research staff using three prescreening tools (Criteria2Query, Informatics for Integrating Biology and the Bedside [i2b2], and Leaf). Cognitive task analysis was employed to analyze the usability of each tool using the Health Information Technology Usability Evaluation Scale. Data analysis involved calculating descriptive statistics, interrater agreement via intraclass correlation coefficient, cognitive complexity, and Generalized Estimating Equations models.

RESULTS

Leaf scored highest for usability followed by Criteria2Query and i2b2. Cognitive complexity was found to be affected by age, computer literacy, and number of criteria, but was not significantly associated with usability.

DISCUSSION

Adopting NLP for ADRD prescreening demands careful task delegation, comprehensive training, precise translation of eligibility criteria, and increased research accessibility. The study highlights the relevance of these factors in enhancing NLP-driven tools' usability and efficacy in clinical research prescreening.

CONCLUSION

User-modifiable NLP-driven prescreening tools were favorably received, with system type, evaluation sequence, and user's computer literacy influencing usability more than cognitive complexity. The study emphasizes NLP's potential in improving recruitment for clinical trials, endorsing a mixed-methods approach for future system evaluation and enhancements.

Demographics and clinical characteristics of patients of prescribing psychologists, psychiatrists, and primary care physicians

To describe the characteristics of patients receiving psychotropic medication from prescribing psychologists, psychiatrists, and primary care physicians. This descriptive study was conducted using private insurance claims of patients from New Mexico and Louisiana receiving psychotropic medications (anticonvulsants, antidepressants, antipsychotics, hypotensive agents, anxiolytics/sedatives/hypnotics, and stimulants) from 2004 to 2021 (N = 307,478). Patient characteristics were captured during the 6 months prior to their first psychotropic medication using administrative information, diagnosis and procedure codes, and medication data. Logistic regression models estimated the associations of patient characteristics with prescriber type. Additional logistic regression models estimated the association of prescriber type with medication classes prescribed. Patients were most likely to see specialists (psychologists or psychiatrists) if they had bipolar disorder (average marginal effect and 95% CI 0.214 [0.196, 0.231]), schizophrenia/psychotic disorders (0.118 [0.097, 0.138]), or had 1-4 visits of psychotherapy (0.267 [0.258, 0.026]). Specialist patients were most likely to see a prescribing psychologist if they had 1-4 visits of psychotherapy (0.196 [0.183, 0.210]) or had insomnia (0.309 [0.203, 0.415]). Prescribing psychologists were more likely to prescribe antidepressants (0.028 [0.011, 0.045]) and less likely to prescribe antipsychotics (-0.016 [-0.020, -0.012]) than psychiatrists. Primary care physicians were less likely to prescribe all psychotropic medications except antidepressants (0.011 [0.002, 0.019]) and anxiolytics (0.074 [0.067, 0.080]). Prescribing psychologists treat patients who are more similar to those of psychiatrists than patients of primary care physicians; they are less likely to prescribe antipsychotics and more likely to prescribe antidepressants. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits

BACKGROUND

Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year.

METHODS

This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region.

RESULTS

Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020.

CONCLUSIONS

Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.

Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach

BACKGROUND

The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE.

OBJECTIVE

Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens.

METHODS

We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift.

RESULTS

From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys).

INTERPRETATION

Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

Antibiotics Not Associated with Shorter Duration or Reduced Severity of Acute Lower Respiratory Tract Infection

BACKGROUND

Antibiotic use remains common for the treatment of lower respiratory tract infections. The objective of this study was to evaluate the impact of antibiotic use on the duration and severity of acute lower respiratory tract infection (LRTI).

PARTICIPANTS

Adult patients presenting to US primary or urgent care sites with a chief complaint of cough and symptoms consistent with LRTI.

MAIN MEASURES

Collected data included demographics, comorbidities, symptoms, and 48 viral and bacterial respiratory pathogens by PCR. Severity of signs/symptoms was reported for up to 28 days using diaries and text messages. Interpolation was used where data were missing.

KEY RESULTS

Of 718 patients with baseline data, 29% had an antibiotic prescribed at baseline. The most common antibiotics were amoxicillin-clavulanate, azithromycin, doxycycline, and amoxicillin in 85% of patients. Provision of an antibiotic had no effect on the duration or overall severity of cough, including in patients with viral, bacterial, and mixed infections. Receipt of an antibiotic did reduce the likelihood of a follow-up visit (14.1% vs 8.2%, aOR 0.47, 95% CI 0.26-0.84), perhaps by removing the motivation of getting an antibiotic at a follow-up visit. However, they were also more likely to receive a systemic corticosteroid (31.9% vs 4.5%, p < 0.001) and were also more likely to receive an albuterol inhaler (22.7% vs 7.6%, p < 0.001). Patients believed that receiving an antibiotic would reduce the duration of their illness by nearly 4 days.

CONCLUSIONS

In this large prospective study in the US primary and urgent care setting, antibiotics had no measurable impact on the severity or duration of cough due to acute LRTI. Patients had unrealistic expectations regarding the duration of LRTI and the effect of antibiotics which should be the target of antibiotic stewardship efforts.

Characterizing nursing time with patients using computer vision

BACKGROUND

Compared to other providers, nurses spend more time with patients, but the exact quantity and nature of those interactions remain largely unknown. The purpose of this study was to characterize the interactions of nurses at the bedside using continuous surveillance over a year long period.

METHODS

Nurses' time and activity at the bedside were characterized using a device that integrates the use of obfuscated computer vision in combination with a Bluetooth beacon on the nurses' identification badge to track nurses' activities at the bedside. The surveillance device (AUGi) was installed over 37 patient beds in two medical/surgical units in a major urban hospital. Forty-nine nurse users were tracked using the beacon. Data were collected 4/15/19-3/15/20. Statistics were performed to describe nurses' time and activity at the bedside.

RESULTS

A total of n = 408,588 interactions were analyzed over 670 shifts, with >1.5 times more interactions during day shifts (n = 247,273) compared to night shifts (n = 161,315); the mean interaction time was 3.34 s longer during nights than days (p < 0.0001). Each nurse had an average of 7.86 (standard deviation [SD] = 10.13) interactions per bed each shift and a mean total interaction time per bed of 9.39 min (SD = 14.16). On average, nurses covered 7.43 beds (SD = 4.03) per shift (day: mean = 7.80 beds/nurse/shift, SD = 3.87; night: mean = 7.07/nurse/shift, SD = 4.17). The mean time per hourly rounding (HR) was 69.5 s (SD = 98.07) and 50.1 s (SD = 56.58) for bedside shift report.

DISCUSSION

As far as we are aware, this is the first study to provide continuous surveillance of nurse activities at the bedside over a year long period, 24 h/day, 7 days/week. We detected that nurses spend less than 1 min giving report at the bedside, and this is only completed 20.7% of the time. Additionally, hourly rounding was completed only 52.9% of the time and nurses spent only 9 min total with each patient per shift. Further study is needed to detect whether there is an optimal timing or duration of interactions to improve patient outcomes.

CLINICAL RELEVANCE

Nursing time with the patient has been shown to improve patient outcomes but precise information about how much time nurses spend with patients has been heretofore unknown. By understanding minute-by-minute activities at the bedside over a full year, we provide a full picture of nursing activity; this can be used in the future to determine how these activities affect patient outcomes.

Who gets screened and who tests positive? Drug screening among justice-involved youth in a midwestern urban county

BACKGROUND

Given high rates of substance use among justice-involved youth, justice systems have attempted to monitor use through drug screening (DS) procedures. However, there is discretion in deciding who is screened for substance use, as not every youth who encounters the system is screened. The aim of the current study was to examine factors associated with selection for and results of oral DS among justice-involved youth assigned to probation to better inform potential DS policy. Electronic court records from 4,668 youth with first-incident records assigned to probation in a midwestern urban county's juvenile justice system between 2011 and 2016 were included in the analytical sample. Race/ethnicity, gender, age, number of charges and charge type for the current incident were included as independent variables.

RESULTS

Multivariable hierarchical logistic regression analyses indicated that males were more likely to be assigned to DS (aOR = 0.40, 95%CI [0.34, 0.46]), and more likely to test positive for use (aOR = 0.43, 95% CI [0.34, 0.54]) than females. As age increased, youth were less likely to be assigned to DS (aOR = 0.91, 95% CI [0.87, 0.94]), with non-significant differences in DS results. Greater number of charges were associated with a higher likelihood of being assigned to DS (aOR = 1.55, 95% CI [1.43, 1.68]). Youth with violent offenses were more likely to be assigned to DS than those with other offense types (property offenses, drug offenses, statutory offenses, disorderly conduct, and all other offenses), but less likely to test positive for use.

CONCLUSIONS

Many factors were associated with differences in DS, but these factors were not always associated with differential DS results. Demographic or charge-based decisions may not be appropriate for DS assignment.

Evaluating and improving the usability of a mHealth platform to assess postoperative dental pain

Objectives

The use of interactive mobile health (mHealth) applications to monitor patient-reported postoperative pain outcomes is an emerging area in dentistry that requires further exploration. This study aimed to evaluate and improve the usability of an existing mHealth application.

Materials and methods

The usability of the application was assessed iteratively using a 3-phase approach, including a rapid cognitive walkthrough (Phase I), lab-based usability testing (Phase II), and in situ pilot testing (Phase III). The study team conducted Phase I, while providers and patients participated in Phase II and III.

Results

The rapid cognitive walkthrough identified 23 potential issues that could negatively impact user experience, with the majority classified as system issues. The lab-based usability testing yielded 141 usability issues.; 43% encountered by patients and 57% by dentists. Usability problems encountered during pilot testing included undelivered messages due to mobile phone carrier and service-related issues, errors in patients' phone number data entry, and problems in provider training.

Discussion

Through collaborative and iterative work with the vendor, usability issues were addressed before launching a trial to assess its efficacy.

Conclusion

The usability of the mHealth application for postoperative dental pain was remarkably improved by the iterative analysis and interdisciplinary collaboration.

Changes in telemedicine use and ambulatory visit volumes at a multispecialty cardiovascular center during the COVID-19 pandemic

Early in the COVID-19 pandemic, cardiology clinics rapidly implemented telemedicine to maintain access to care. Little is known about subsequent trends in telemedicine use and visit volumes across cardiology subspecialties. We conducted a retrospective cohort study including all patients with ambulatory visits at a multispecialty cardiovascular center in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). Telemedicine use increased from 3.5% of visits (1200/33,976) during the pre-COVID period to 63.0% (21,251/33,706) during the COVID period. Visit volumes were below pre-COVID levels from March to May 2020 but exceeded pre-COVID levels after June 2020, including when local COVID-19 cases peaked. Telemedicine use was above 75% of visits in all cardiology subspecialties in April 2020 and stabilized at rates ranging from over 95% in electrophysiology to under 25% in heart transplant and vascular medicine. From June 2020 to February 2021, subspecialties delivering a greater percentage of visits through telemedicine experienced larger increases in new patient visits (r = 0.81, p = 0.029). Telemedicine can be used to deliver a significant proportion of outpatient cardiovascular care though utilization varies across subspecialties. Higher rates of telemedicine adoption may increase access to care in cardiology clinics.

State-Level Firearm Laws and Firearm Homicide in US Cities: Heterogenous Associations by City Characteristics

Despite well-studied associations of state firearm laws with lower state- and county-level firearm homicide, there is a shortage of studies investigating differences in the effects of distinct state firearm law categories on various cities within the same state using identical methods. We examined associations of 5 categories of state firearm laws-pertaining to buyers, dealers, domestic violence, gun type/trafficking, and possession-with city-level firearm homicide, and then tested differential associations by city characteristics. City-level panel data on firearm homicide cases of 78 major cities from 2010 to 2020 was assessed from the Centers for Disease Control and Prevention's National Vital Statistics System. We modeled log-transformed firearm homicide rates as a function of firearm law scores, city, state, and year fixed effects, along with time-varying city-level confounders. We considered effect measure modification by poverty, unemployment, vacant housing, and income inequality. A one z-score increase in state gun type/trafficking, possession, and dealer law scores was associated with 25% (95% confidence interval [CI]:-0.37,-0.1), 19% (95% CI:-0.29,-0.07), and 17% (95% CI:-0.28, -0.4) lower firearm homicide rates, respectively. Protective associations were less pronounced in cities with high unemployment and high housing vacancy, but more pronounced in cities with high income inequality. In large US cities, state-level gun type/trafficking, possession, and dealer laws were associated with lower firearm homicide rates, but buyers and domestic violence laws were not. State firearm laws may have differential effects on firearm homicides based on city characteristics, and city-wide policies to enhance socioeconomic drivers may add benefits of firearm laws.

Medicare meets the cloud: the development of a secure platform for the storage and analysis of claims data

Introduction

Cloud-based solutions are a modern-day necessity for data intense computing. This case report describes in detail the development and implementation of Amazon Web Services (AWS) at Emory-a secure, reliable, and scalable platform to store and analyze identifiable research data from the Centers for Medicare and Medicaid Services (CMS).

Materials and Methods

Interdisciplinary teams from CMS, MBL Technologies, and Emory University collaborated to ensure compliance with CMS policy that consolidates laws, regulations, and other drivers of information security and privacy.

Results

A dedicated team of individuals ensured successful transition from a physical storage server to a cloud-based environment. This included implementing access controls, vulnerability scanning, and audit logs that are reviewed regularly with a remediation plan. User adaptation required specific training to overcome the challenges of cloud computing.

Conclusion

Challenges created opportunities for lessons learned through the creation of an end-product accepted by CMS and shared across disciplines university-wide.

Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry

BACKGROUND

In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings.

METHODS

We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use.

RESULTS

We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment.

CONCLUSION

In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial

Rationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.

Clinicians' interpretation of thresholds in hospital antibiograms for gram-negative rod infections: A survey and contingent valuation study of hospitalists

Clinical guidelines suggest that hospital antibiograms are a key component when deciding empiric therapy, but little is known about how often clinicians use antibiograms and how they influence clinicians' empiric therapy decisions. We surveyed hospitalists at seven healthcare systems in the United States on their reported practices related to antibiograms and their hypothetical prescribing for four clinical scenarios associated with gram-negative rod pathogens. Each was given a randomly assigned antibiogram susceptibility percentage, and we used contingent valuation analysis to assess whether the antibiogram susceptibility percentage was associated with prescribing practices. Of the 193 survey responders, only 52 (26.9%) respondents reported using antibiograms more than monthly. Across all four clinical scenarios, there was no evidence that antibiogram susceptibility levels influenced antibiotic prescribing practices. With limited utilization and no evidence that they influenced practice, antibiograms may have a limited role in hospitalist care delivery for common gram-negative rod infections.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19

BACKGROUND

Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge.

METHODS

Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization.

RESULTS

Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization.

CONCLUSIONS

HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Clarifying the causal contrast: An empirical example applying the prevalent new user study design

PURPOSE

The prevalent new user design extends the active comparator new user design to include patients switching to a treatment of interest from a comparator. We examined the impact of adding "switchers" to incident new users on the estimated hazard ratio (HR) of hospitalized heart failure.

METHODS

Using MarketScan claims data (2000-2014), we estimated HRs of hospitalized heart failure between patients initiating GLP-1 receptor agonists (GLP-1 RA) and sulfonylureas (SU). We considered three estimands: (1) the effect of incident new use; (2) the effect of switching; and (3) the effect of incident new use or switching, combining the two population. We used time-conditional propensity scores (TCPS) and time-stratified standardized morbidity ratio (SMR) weighting to adjust for confounding.

RESULTS

We identified 76 179 GLP-1 RA new users, of which 12% were direct switchers (within 30 days) from SU. Among incident new users, GLP-1 RA was protective against heart failure (adjHRSMR = 0.74 [0.69, 0.80]). Among switchers, GLP-1 RA was not protective (adjHRSMR = 0.99 [0.83, 1.18]). Results in the combined population were largely driven by the incident new users, with GLP-1 RA having a protective effect (adjHRSMR = 0.77 [0.72, 0.83]). Results using TCPS were consistent with those estimated using SMR weighting.

CONCLUSIONS

When analyses were conducted only among incident new users, GLP-1 RA had a protective effect. However, among switchers from SU to GLP-1 RA, the effect estimates substantially shifted toward the null. Combining patients with varying treatment histories can result in poor confounding control and camouflage important heterogeneity.

Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care

BACKGROUND

Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances.

METHODS

We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations.

RESULTS

We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%.

CONCLUSIONS

The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.

Effects of the valsartan recall on heart failure patients: A nationwide analysis

BACKGROUND

Valsartan is commonly used for cardiac conditions. In 2018, the Food and Drug Administration recalled generic valsartan due to the detection of impurities. Our objective was to determine if heart failure patients receiving valsartan at the recall date had a greater likelihood of unfavorable outcomes than patients using comparable antihypertensives.

METHODS

We conducted a cohort study of Optum's de-identified Clinformatics® Datamart (July 2017-January 2019). Heart failure patients with commercial or Medicare Advantage insurance who received valsartan were compared to persons who received non-recalled angiotensin receptor blockers (ARBs) and angiotensin converting enzyme-inhibitors (ACE-Is) for 1 year prior and including the recall date. Outcomes included a composite for all-cause hospitalization, emergency department (ED), and urgent care (UC) use and a measure of cardiac events which included hospitalizations for acute myocardial infarction and hospitalizations/ED/UC visits for stroke/transient ischemic attack, heart failure or hypertension at 6-months post-recall. Cox proportional hazard models with propensity score weighting compared the risk of outcomes between groups.

RESULTS

Of the 87 130 adherent patients, 15% were valsartan users and 85% were users of non-recalled ARBs/ACE-Is. Valsartan use was not associated with an increased risk of all-cause hospitalization/ED/UC use six-months post-recall (HR 1.00; 95% CI 0.96-1.03), compared with individuals taking non-recalled ARBs/ACE-Is. Similarly, cardiac events 6-months post-recall did not differ between individuals on valsartan and non-recalled ARBs/ACE-Is (HR 1.04; 95% CI 0.97-1.12).

CONCLUSIONS

The valsartan recall did not affect short-term outcomes of heart failure patients. However, the recall potentially disrupted the medication regimens of patients, possibly straining the healthcare system.

Heterogeneity of Benefit from Earlier Time-to-Antibiotics for Sepsis

Rationale: Shorter time-to-antibiotics improves survival from sepsis, particularly among patients in shock. There may be other subgroups for whom faster antibiotics are particularly beneficial.Objectives: Identify patient characteristics associated with greater benefit from shorter time-to-antibiotics.Methods: Observational cohort study of patients hospitalized with community-onset sepsis at 173 hospitals and treated with antimicrobials within 12 hours. We used three approaches to evaluate heterogeneity of benefit from shorter time-to-antibiotics: 1) conditional average treatment effects of shorter (⩽3 h) versus longer (>3-12 h) time-to-antibiotics on 30-day mortality using multivariable Poisson regression; 2) causal forest to identify characteristics associated with greatest benefit from shorter time-to-antibiotics; and 3) logistic regression with time-to-antibiotics modeled as a spline.Measurements and Main Results: Among 273,255 patients with community-onset sepsis, 131,094 (48.0%) received antibiotics within 3 hours. In Poisson models, shorter time-to-antibiotics was associated with greater absolute mortality reduction among patients with metastatic cancer (5.0% [95% confidence interval; CI: 4.3-5.7] vs. 0.4% [95% CI: 0.2-0.6] for patients without cancer, P < 0.001); patients with shock (7.0% [95% CI: 5.8-8.2%] vs. 2.8% [95% CI: 2.7-3.5%] for patients without shock, P = 0.005); and patients with more acute organ dysfunctions (4.8% [95% CI: 3.9-5.6%] for three or more dysfunctions vs. 0.5% [95% CI: 0.3-0.8] for one dysfunction, P < 0.001). In causal forest, metastatic cancer and shock were associated with greatest benefit from shorter time-to-antibiotics. Spline analysis confirmed differential nonlinear associations of time-to-antibiotics with mortality in patients with metastatic cancer and shock.Conclusions: In patients with community-onset sepsis, the mortality benefit of shorter time-to-antibiotics varied by patient characteristics. These findings suggest that shorter time-to-antibiotics for sepsis is particularly important among patients with cancer and/or shock.

Development of a hospital coding intensity measure based on sepsis diagnoses

Significant variation in coding intensity among hospitals has been observed and can lead to reimbursement inequities and inadequate risk adjustment for quality measures. Reliable tools to quantify hospital coding intensity are needed. We hypothesized that coded sepsis rates among patients hospitalized with common infections may serve as a useful surrogate for coding intensity and derived a hospital-level sepsis coding intensity measure using prevalence of "sepsis" primary diagnoses among patients hospitalized with urinary tract infection, cellulitis, and pneumonia. This novel measure was well correlated with the hospital mean number of discharge diagnoses, which has historically been used to quantify hospital-level coding intensity. However, it has the advantage of inferring hospital coding intensity without the strong association with comorbidity that the mean number of discharge diagnoses has. Our measure may serve as a useful tool to compare coding intensity across institutions.

Association of Medicare eligibility with access to and affordability of care among older cancer survivors

PURPOSE

Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65.

METHODS

In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65.

RESULTS

Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80.

CONCLUSIONS

Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.

Assessing the potential for improved predictive capacity of antimicrobial resistance in outpatient Staphylococcus aureus isolates using seasonal and spatial antibiograms

BACKGROUND

While the use of cumulative susceptibility reports, antibiograms, is recommended for improved empiric therapy and antibiotic stewardship, the predictive ability of antibiograms has not been well-studied. While enhanced antibiograms have been shown to better capture variation in susceptibility profiles by characteristics such as infection site or patient age, the potential for seasonal or spatial variation in susceptibility has not been assessed as important in predicting likelihood of susceptibility.

METHODS

Utilizing Staphylococcus aureus isolates obtained in outpatient settings from a nationwide provider of care, the Veterans Health Administration, and a local provider of care, the University of Iowa Hospitals and Clinics, standard, seasonal and spatial antibiograms were created for five commonly used antibiotic classes: cephalosporins, clindamycin, macrolides, tetracycline, trimethoprim/sulfamethoxazole.

RESULTS

A total of 338,681 S. aureus isolates obtained in VHA outpatient settings from 2010 to 2019 and 6,817 isolates obtained in UIHC outpatient settings from 2014 to 2019 were used to generate and test antibiograms. Logistic regression modeling determined the capacity of these antibiograms to predict isolate resistance to each antibiotic class. All models had low predictive capacity, with areas under the curve of < 0.7.

CONCLUSIONS

Standard antibiograms are poor in predicting S. aureus susceptibility to antibiotics often chosen by clinicians, and seasonal and spatial antibiograms do not provide an improved tool in anticipating non-susceptibility. These findings suggest that further refinements to antibiograms may be necessary to improve their utility in informing choice of effective antibiotic therapy.

Alternative Payment Models and Patient-Reported Quality of Preparation for Discharge: A Retrospective Longitudinal Study

Preparing patients for posthospital care may improve readmission risk. Alternative payment models (APMs) incent hospitals to reduce readmissions by tying payment to outcomes. The impact of APMs on preparation for discharge is not well understood. We assessed whether patient-reported preparation for posthospital care was associated with reduced readmissions, and whether APM participation was associated with improved preparation for posthospital care. We used mixed-effects regression on retrospective (2013-2017) observational data for 2685 U.S. hospitals. We measured patient-reported preparation for posthospital care using the 3-Item Care Transition Measure and readmission using 30-day all-cause risk-adjusted readmissions from Hospital Compare. Participation in accountable care organizations (ACOs), Medical Homes, and Medicare's Bundled Payments for Care Improvement program was obtained from Medicare, the American Hospital Association's Annual Survey, and Leavitt Partner's ACO database. We found that APMs are not associated with improved preparation for posthospital care, even though it was associated with reduced readmissions (Marginal Effect: -0.012 percentage points). This may be because hospitals are not investing in patient engagement. This study has limited insight into causality and reduced generalizability among smaller, rural, and non-teaching hospitals.

Health-related social needs information in the emergency department: clinician and patient perspectives on availability and use

BACKGROUND

Patient health-related social needs (HRSN) complicate care and drive poor outcomes in emergency department (ED) settings. This study sought to understand what HRSN information is available to ED physicians and staff, and how HRSN-related clinical actions may or may not align with patient expectations.

METHODS

We conducted a qualitative study using in-depth semi-structured interviews guided by HRSN literature, the 5 Rights of Clinical Decision Support (CDS) framework, and the Contextual Information Model. We asked ED providers, ED staff, and ED patients from one health system in the mid-Western United Stated about HRSN information availability during an ED encounter, HRSN data collection, and HRSN data use. Interviews were recorded, transcribed, and analyzed using modified thematic approach.

RESULTS

We conducted 24 interviews (8 per group: ED providers, ED staff, and ED patients) from December 2022 to May 2023. We identified three themes: (1) Availability: ED providers and staff reported that HRSNs information is inconsistently available. The availability of HRSN data is influenced by patient willingness to disclose it during an encounter. (2) Collection: ED providers and staff preferred and predominantly utilized direct conversation with patients to collect HRSNs, despite other methods being available to them (e.g., chart review, screening questionnaires). Patients' disclosure preferences were based on modality and team member. (3) Use: Patients wanted to be connected to relevant resources to address their HRSNs. Providers and staff altered clinical care to account for or accommodate HRSNs. System-level challenges (e.g., limited resources) limited provider and staff ability to address patients HRSNs.

CONCLUSIONS

In the ED, HRSNs information was inconsistently available, collected, or disclosed. Patients and ED providers and staff differed in their perspectives on how HSRNs should be collected and acted upon. Accounting for such difference in clinical and administrative decisions will be critical for patient acceptance and effective usage of HSRN information.

The emergency department trigger tool: Multicenter trigger query validation

OBJECTIVES

We previously described derivation and validation of the emergency department trigger tool (EDTT) for adverse event (AE) detection. As the first step in our multicenter study of the tool, we validated our computerized screen for triggers against manual review, establishing our use of this automated process for selecting records to review for AEs.

METHODS

This is a retrospective observational study of visits to three urban, academic EDs over 18 months by patients ≥ 18 years old. We reviewed 912 records: 852 with at least one of 34 triggers found by the query and 60 records with none. Two first-level reviewers per site each manually screened for triggers. After completion, computerized query results were revealed, and reviewers could revise their findings. Second-level reviewers arbitrated discrepancies. We compare automated versus manual screening by positive and negative predictive values (PPVs, NPVs), present population trigger frequencies, proportions of records triggered, and how often manual ratings were changed to conform with the query.

RESULTS

Trigger frequencies ranged from common (>25%) to rare (1/1000) were comparable at U.S. sites and slightly lower at the Canadian site. Proportions of triggered records ranged from 31% to 49.4%. Overall query PPV was 95.4%; NPV was 99.2%. PPVs for individual trigger queries exceeded 90% for 28-31 triggers/site and NPVs were >90% for all but three triggers at one site. Inter-rater reliability was excellent, with disagreement on manual screening results less than 5% of the time. Overall, reviewers amended their findings 1.5% of the time when discordant with query findings, more often when the query was positive than when negative (47% vs. 23%).

CONCLUSIONS

The EDTT trigger query performed very well compared to manual review. With some expected variability, trigger frequencies were similar across sites and proportions of triggered records ranged 31%-49%. This demonstrates the feasibility and generalizability of implementing the EDTT query, providing a solid foundation for testing the triggers' utility in detecting AEs.

Feasibility of precision smoking treatment in a low-income community setting: results of a pilot randomized controlled trial in The Southern Community Cohort Study

BACKGROUND

The feasibility of precision smoking treatment in socioeconomically disadvantaged communities has not been studied.

METHODS

Participants in the Southern Community Cohort Study who smoked daily were invited to join a pilot randomized controlled trial of three smoking cessation interventions: guideline-based care (GBC), GBC plus nicotine metabolism-informed care (MIC), and GBC plus counseling guided by a polygenic risk score (PRS) for lung cancer. Feasibility was assessed by rates of study enrollment, engagement, and retention, targeting > 70% for each. Using logistic regression, we also assessed whether feasibility varied by age, sex, race, income, education, and attitudes toward precision smoking treatment.

RESULTS

Of 92 eligible individuals (79.3% Black; 68.2% with household income < $15,000), 67 (72.8%; 95% CI 63.0-80.9%) enrolled and were randomized. Of these, 58 (86.6%; 95% CI 76.4-92.8%) engaged with the intervention, and of these engaged participants, 43 (74.1%; 95% CI 61.6-83.7%) were retained at 6-month follow-up. Conditional on enrollment, older age was associated with lower engagement (OR 0.83, 95% CI 0.73-0.95, p = 0.008). Conditional on engagement, retention was significantly lower in the PRS arm than in the GBC arm (OR 0.18, 95% CI 0.03-1.00, p = 0.050). No other selection effects were observed.

CONCLUSIONS

Genetically informed precision smoking cessation interventions are feasible in socioeconomically disadvantaged communities, exhibiting high enrollment, engagement, and retention irrespective of race, sex, income, education, or attitudes toward precision smoking treatment. Future smoking cessation interventions in this population should take steps to engage older people and to sustain participation in interventions that include genetic risk counseling.

TRIAL REGISTRATION

ClinicalTrials.gov No. NCT03521141, Registered 27 April 2018, https://www.

CLINICALTRIALS

gov/study/NCT03521141.

A Data-Driven Approach to Optimizing Medical-Legal Partnership Performance and Joint Advocacy

Medical-legal partnerships connect legal advocates to healthcare providers and settings. Maintaining effectiveness of medical-legal partnerships and consistently identifying opportunities for innovation and adaptation takes intentionality and effort. In this paper, we discuss ways in which our use of data and quality improvement methods have facilitated advocacy at both patient (client) and population levels as we collectively pursue better, more equitable outcomes.

Feasibility of a family-oriented mHealth intervention for Chinese Americans with type 2 diabetes: A pilot randomized control trial

OBJECTIVES

To test the feasibility, acceptability, and potential efficacy of a mHealth intervention tailored for Chinese immigrant families with type 2 diabetes (T2D).

METHODS

We conducted a pilot randomized controlled trial (RCT) with baseline, 3-, and 6-month measurements. Participating dyads, T2D patients and families/friends from NYC, were randomized into the intervention group (n = 11) or the wait-list control group (n = 12). Intervention includes 24 videos covering T2D self-management, behavioral techniques, and family-oriented sessions. Feasibility and acceptability were measured respectively by the retention rate and video watch rate, and a satisfaction survey. Patients' HbA1c, weight, and self-management were also assessed to test potential efficacy.

RESULTS

Most T2D patients (n = 23; mean age 56.2±9.4 years; 52.2% male) and families/friends (n = 23, mean age 54.6±11.2 years; 52.2% female) had high school education or less (69.6% and 69.6%), annual household income < $25,000 (65.2% and 52.2%), and limited English proficiency (95.7% and 95.7%). The retention rates were not significantly different between the intervention and the control groups for both the patients (90.91% vs 83.3%, p = 0.589); and their families/friends (3-month: 90.9% vs 75%, p = 0.313; 6-month: 90.9% vs 83.3%, p = 0.589). The mean video watch rate was 76.8% (7%). T2D patients and families/friends rated satisfaction as 9.4 and 10 out of 10, respectively. Despite no between-group differences, the intervention group had significantly lower HbA1c (p = 0.014) and better self-management (p = 0.009), and lost 12 lbs. on average at 6 months (p = 0.079), compared to their baseline levels.

CONCLUSIONS

A culturally-tailored, family-based mHealth intervention is feasible and acceptable among low-income, limited English-proficient Chinese families with T2D in NYC. Significant changes in HbA1c and self-management within the intervention group indicate this intervention may have potential efficacy. Given the small sample size of this study, a future RCT with adequate power is needed to test efficacy.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up

BACKGROUND

High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years.

METHODS

The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis.

RESULTS

The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time.

CONCLUSIONS

The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Motivational interviewing skills practice enhanced with artificial intelligence: ReadMI

BACKGROUND

Finding time in the medical curriculum to focus on motivational interviewing (MI) training is a challenge in many medical schools. We developed a software-based training tool, "Real-time Assessment of Dialogue in Motivational Interviewing" (ReadMI), that aims to advance the skill acquisition of medical students as they learn the MI approach. This human-artificial intelligence teaming may help reduce the cognitive load on a training facilitator.

METHODS

During their Family Medicine clerkship, 125 third-year medical students were scheduled in pairs to participate in a 90-minute MI training session, with each student doing two role-plays as the physician. Intervention group students received both facilitator feedback and ReadMI metrics after their first role-play, while control group students received only facilitator feedback.

RESULTS

While students in both conditions improved their MI approach from the first to the second role-play, those in the intervention condition used significantly more open-ended questions, fewer closed-ended questions, and had a higher ratio of open to closed questions.

CONCLUSION

MI skills practice can be gained with a relatively small investment of student time, and artificial intelligence can be utilized both for the measurement of MI skill acquisition and as an instructional aid.

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial

BACKGROUND

Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection.

METHODS

This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment.

DISCUSSION

Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06106204 on 10/30/23.

Palliative surgery: state of the science and future directions

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients.

Personalized Infant Risk Prediction for Severe Respiratory Syncytial Virus Lower Respiratory Tract Infection Requiring Intensive Care Unit Admission

Background

Currently, there are no available tools to identify infants at the highest risk of significant morbidity and mortality from respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) who would benefit most from RSV prevention products. The objective was to develop and internally validate a personalized risk prediction tool for use among all newborns that uses readily available birth/postnatal data to predict RSV LRTI requiring intensive care unit (ICU) admission.

Methods

We conducted a population-based birth cohort study of infants born from 1995 to 2007, insured by the Tennessee Medicaid Program, and who did not receive RSV immunoprophylaxis during the first year of life. The primary outcome was severe RSV LRTI requiring ICU admission during the first year of life. We built a multivariable logistic regression model including demographic and clinical variables available at or shortly after birth to predict the primary outcome.

Results

In a population-based sample of 429 365 infants, 713 (0.2%) had severe RSV LRTI requiring ICU admission. The median age of admission was 66 days (interquartile range, 37-120). Our tool, including 19 variables, demonstrated good predictive accuracy (area under the curve, 0.78; 95% confidence interval, 0.77-0.80) and identified infants who did not qualify for palivizumab, based on American Academy of Pediatrics guidelines, but had higher predicted risk levels than infants who qualified (27% of noneligible infants with >0.16% predicted probabilities [lower quartile for eligible infants]).

Conclusions

We developed a personalized tool that identified infants at increased risk for severe RSV LRTI requiring ICU admission, expected to benefit most from immunoprophylaxis.

An Evidence Map for Social and Structural Determinants for Maternal Morbidity and Mortality: A Systematic Review

OBJECTIVE

To identify the social-structural determinants of health risk factors associated with maternal morbidity and mortality in the United States during the prenatal and postpartum periods.

DATA SOURCES

We searched MEDLINE, CINAHL, and Social Sciences Citation Index through November 2022 for eligible studies that examined exposures related to social and structural determinants of health and at least one health or health care-related outcome for pregnant and birthing people.

METHODS OF STUDY SELECTION

After screening 8,378 unique references, 118 studies met inclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

We grouped studies by social and structural determinants of health domains and maternal outcomes. We used alluvial graphs to summarize results and provide additional descriptions of direction of association between potential risk exposures and outcomes. Studies broadly covered risk factors including identity and discrimination, socioeconomic, violence, trauma, psychological stress, structural or institutional, rural or urban, environment, comorbidities, hospital, and health care use. However, these risk factors represent only a subset of potential social and structural determinants of interest. We found an unexpectedly large volume of research on violence and trauma relative to other potential exposures of interest. Outcome domains included maternal mortality, severe maternal morbidity, hypertensive disorders, gestational diabetes, cardiac and metabolic disorders, weathering depression, other mental health or substance use disorders, and cost per health care use outcomes. Patterns between risk factors and outcomes were highly mixed. Depression and other mental health outcomes represented a large proportion of medical outcomes. Risk of bias was high, and rarely did studies report the excess risk attributable to a specific exposure.

CONCLUSION

Limited depth and quality of available research within each risk factor hindered our ability to understand underlying pathways, including risk factor interdependence. Although recently published literature showed a definite trend toward improved rigor, future research should emphasize techniques that improve the ability to estimate causal effects. In the longer term, the field could advance through data sets designed to fully ascertain data required to robustly examine racism and other social and structural determinants of health, their intersections, and feedback loops with other biological and medical risk factors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022300617.

Diagnosis and Treatment of Pneumonia in Urgent Care Clinics: Opportunities for Improving Care

Background

Community-acquired pneumonia is a well-studied condition; yet, in the urgent care setting, patient characteristics and adherence to guideline-recommended care are poorly described. Within Intermountain Health, a nonprofit integrated US health care system based in Utah, more patients present to urgent care clinics (UCCs) than emergency departments (EDs) for pneumonia care.

Methods

We performed a retrospective cohort study 1 January 2019 through 31 December 2020 in 28 UCCs within Utah. We extracted electronic health record data for patients aged ≥12 years with ICD-10 pneumonia diagnoses entered by the bedside clinician, excluding patients with preceding pneumonia within 30 days or missing vital signs. We compared UCC patients with radiographic pneumonia (n = 4689), without radiographic pneumonia (n = 1053), without chest imaging (n = 1472), and matched controls with acute cough/bronchitis (n = 15 972). Additional outcomes were 30-day mortality and the proportion of patients with ED visits or hospital admission within 7 days after the index encounter.

Results

UCC patients diagnosed with pneumonia and possible/likely radiographic pneumonia by radiologist report had a mean age of 40 years and 52% were female. Almost all patients with pneumonia (93%) were treated with antibiotics, including those without radiographic confirmation. Hospital admissions and ED visits within 7 days were more common in patients with radiographic pneumonia vs patients with "unlikely" radiographs (6% vs 2% and 10% vs 6%, respectively). Observed 30-day all-cause mortality was low (0.26%). Patients diagnosed without chest imaging presented similarly to matched patients with cough/acute bronchitis. Most patients admitted to the hospital the same day after the UCC visit (84%) had an interim ED encounter. Pneumonia severity scores (pneumonia severity index, electronic CURB-65, and shock index) overestimated patient need for hospitalization.

Conclusions

Most UCC patients with pneumonia were successfully treated as outpatients. Opportunities to improve care include clinical decision support for diagnosing pneumonia with radiographic confirmation and development of pneumonia severity scores tailored to the UCC.

Latent Tuberculosis Screening Among New Users of a Biologic or Targeted Synthetic Disease-Modifying Antirheumatic Drug: Gaps in Screening Overall and Among Janus Kinase Inhibitors

OBJECTIVE

We combined claims and electronic health record (EHR) data to provide contemporary and accurate estimates of latent tuberculosis (TB) screening among new users of a biologic or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) and assess potential gaps in testing by drug type, patient characteristics, and practice.

METHODS

Our denominator population was patients in the Rheumatology Informatics System for Effectiveness (RISE) registry and Medicare using a b/tsDMARD in 2018 without a claim or prescription in the year prior. TB screening was assessed in both Medicare and RISE 1 and 3 years before the medication start date. We calculated the proportion screened overall, by medication class, and by practice. We tested for demographic differences in screening using logistic regression.

RESULTS

In the year before drug starts, 65.6% of patients had any TB screening; in a 3-year window, 72.9% had any TB screening. Rates of screening within 1 year by drug type were greater or equal to the overall screening rate for most drugs except for JAK inhibitors (JAKis) (46%) and interleukin-17 inhibitors (IL-17is) (11.5%). A lower proportion of Hispanic and Asian patients were screened compared with White patients. Practice screening rates ranged from 20.0% to 92.9% of patients within 1 year.

CONCLUSION

We report higher screening rates than have previously been published because of combining claims and EHR data. However, important safety gaps remain, namely, reduced screening among new users of a JAKi or IL-17i and among Asian and Hispanic patients, as well as low-performing practices. Educational initiatives, team-based care delivery, task shifting, and technological interventions to address observed gaps in patient safety procedures are needed.

Omicron Infections in Vaccinated Pediatric Solid Organ Transplant Recipients

SARS-CoV-2 infection during the Omicron period was frequent amongst a cohort of vaccinated pediatric solid organ transplant recipients (pSOTRs) despite robust anti-receptor-binding domain (anti-RBD) antibody response, suggesting poor neutralizing capacity against Omicron subvariants. Breakthrough infections among pSOTRs were overall limited in severity.

Usability Testing of Situation Awareness Clinical Decision Support in the ICU

OBJECTIVE

Our objective was to evaluate the usability of an automated clinical decision support (CDS) tool previously implemented in the pediatric intensive care unit (PICU) to promote shared situation awareness among the medical team to prevent serious safety events within children's hospitals.

METHODS

We conducted a mixed-methods usability evaluation of a CDS tool in a PICU at a large, urban, quaternary, free-standing children's hospital in the Midwest. Quantitative assessment was done using the System Usability Scale, while qualitative assessment involved think-aloud usability testing. The System Usability Scale was scored according to survey guidelines. For think-aloud testing, task times were calculated, and means and standard deviations were determined, stratified by role. Qualitative feedback from participants and moderator observations were summarized.

RESULTS

Fifty-one PICU staff members, including physicians, advanced practice providers, nurses, and respiratory therapists, completed the System Usability Scale, while ten participants underwent think-aloud usability testing. The overall median usability score was 87.5 (IQR: 80-95), with over 96% rating the tool's usability as "good" or "excellent". Task completion times ranged from 2 to 92 seconds, with the quickest completion for reviewing high-risk criteria and the slowest for adding to high-risk criteria. Observations and participant responses from think-aloud testing highlighted positive aspects of learnability and clear display of complex information that is easily accessed, as well as opportunities for improvement in tool integration into clinical workflows.

Using explainable machine learning to uncover the kinase-substrate interaction landscape

MOTIVATION

Phosphorylation, a post-translational modification regulated by protein kinase enzymes, plays an essential role in almost all cellular processes. Understanding how each of the nearly 500 human protein kinases selectively phosphorylates their substrates is a foundational challenge in bioinformatics and cell signaling. Although deep learning models have been a popular means to predict kinase-substrate relationships, existing models often lack interpretability and are trained on datasets skewed toward a subset of well-studied kinases.

RESULTS

Here we leverage recent peptide library datasets generated to determine substrate specificity profiles of 300 serine/threonine kinases to develop an explainable Transformer model for kinase-peptide interaction prediction. The model, trained solely on primary sequences, achieved state-of-the-art performance. Its unique multitask learning paradigm built within the model enables predictions on virtually any kinase-peptide pair, including predictions on 139 kinases not used in peptide library screens. Furthermore, we employed explainable machine learning methods to elucidate the model's inner workings. Through analysis of learned embeddings at different training stages, we demonstrate that the model employs a unique strategy of substrate prediction considering both substrate motif patterns and kinase evolutionary features. SHapley Additive exPlanation (SHAP) analysis reveals key specificity determining residues in the peptide sequence. Finally, we provide a web interface for predicting kinase-substrate associations for user-defined sequences and a resource for visualizing the learned kinase-substrate associations.

AVAILABILITY AND IMPLEMENTATION

All code and data are available at https://github.com/esbgkannan/Phosformer-ST. Web server is available at https://phosformer.netlify.app.

Variability in surgical approaches to hernias in patients with ascites

BACKGROUND

Hernias in patients with ascites are common, however we know very little about the surgical repair of hernias within this population. The study of these repairs has largely remained limited to single center and case studies, lacking a population-based study on the topic.

STUDY DESIGN

The Michigan Surgical Quality Collaborative and its corresponding Core Optimization Hernia Registry (MSQC-COHR) which captures specific patient, hernia, and operative characteristics at a population level within the state was used to conduct a retrospective review of patients with ascites undergoing ventral or inguinal hernia repair between January 1, 2020 and May 3, 2022. The primary outcome observed was incidence and surgical approach for both ventral and inguinal hernia cohorts. Secondary outcomes included 30-day adverse clinical outcomes as listed here: (ED visits, readmission, reoperation and complications) and surgical priority (urgent/emergent vs elective).

RESULTS

In a cohort of 176 patients with ascites, surgical repair of hernias in patients with ascites is a rare event (1.4% in ventral hernia cohort, 0.2% in inguinal hernia cohort). The post-operative 30-day adverse clinical outcomes in both cohorts were greatly increased compared to those without ascites (ventral: 32% inguinal: 30%). Readmission was the most common complication in both inguinal (n = 14, 15.9%) and ventral hernia (n = 17, 19.3%) groups. Although open repair was most common for both cohorts (ventral: 86%, open: 77%), minimally invasive (MIS) approaches were utilized. Ventral hernias presented most commonly urgently/emergently (60%), and in contrast many inguinal hernias presented electively (72%).

CONCLUSION

A population-level, ventral and incisional hernia database capturing operative details for 176 patients with ascites. There was variation in the surgical approaches performed for this rare event and opportunities for optimization in patient selection and timing of repair.

Ketamine Use in the Intubation of Critically Ill Children with Neurological Indications: A Multicenter Retrospective Analysis

BACKGROUND

Ketamine has traditionally been avoided for tracheal intubations (TIs) in patients with acute neurological conditions. We evaluate its current usage pattern in these patients and any associated adverse events.

METHODS

We conducted a retrospective observational cohort study of critically ill children undergoing TI for neurological indications in 53 international pediatric intensive care units and emergency departments. We screened all intubations from 2014 to 2020 entered into the multicenter National Emergency Airway Registry for Children (NEAR4KIDS) registry database. Patients were included if they were under the age of 18 years and underwent TI for a primary neurological indication. Usage patterns and reported periprocedural composite adverse outcomes (hypoxemia < 80%, hypotension/hypertension, cardiac arrest, and dysrhythmia) were noted.

RESULTS

Of 21,562 TIs, 2,073 (9.6%) were performed for a primary neurological indication, including 190 for traumatic brain injury/trauma. Patients received ketamine in 495 TIs (23.9%), which increased from 10% in 2014 to 41% in 2020 (p < 0.001). Ketamine use was associated with a coindication of respiratory failure, difficult airway history, and use of vagolytic agents, apneic oxygenation, and video laryngoscopy. Composite adverse outcomes were reported in 289 (13.9%) Tis and were more common in the ketamine group (17.0% vs. 13.0%, p = 0.026). After adjusting for location, patient age and codiagnoses, the presence of respiratory failure and shock, difficult airway history, provider demographics, intubating device, and the use of apneic oxygenation, vagolytic agents, and neuromuscular blockade, ketamine use was not significantly associated with increased composite adverse outcomes (adjusted odds ratio 1.34, 95% confidence interval CI 0.99-1.81, p = 0.057). This paucity of association remained even when only neurotrauma intubations were considered (10.6% vs. 7.7%, p = 0.528).

CONCLUSIONS

This retrospective cohort study did not demonstrate an association between procedural ketamine use and increased risk of peri-intubation hypoxemia and hemodynamic instability in patients intubated for neurological indications.

Is primary care ready for a potential new public health emergency in the wake of the COVID-19 pandemic, now subsided?

INTRODUCTION

The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity.

METHODS

From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions.

RESULTS

An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had.

CONCLUSION

These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs.

Assessing the Impact of the 340B Drug Pricing Program: A Scoping Review of the Empirical, Peer-Reviewed Literature

Policy Points The 340B Drug Pricing Program accounts for roughly 1 out of every 100 dollars spent in the $4.3 trillion US health care industry. Decisions affecting the program will have wide-ranging consequences throughout the US safety net. Our scoping review provides a roadmap of the questions being asked about the 340B program and an initial synthesis of the answers. The highest-quality evidence indicates that nonprofit, disproportionate share hospitals may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements.

CONTEXT

Despite remarkable growth and relevance of the 340B Drug Pricing Program to current health care practice and policy debate, academic literature examining 340B has lagged. The objectives of this scoping review were to summarize i) common research questions published about 340B, ii) what is empirically known about 340B and its implications, and iii) remaining knowledge gaps, all organized in a way that is informative to practitioners, researchers, and decision makers.

METHODS

We conducted a scoping review of the peer-reviewed, empirical 340B literature (database inception to March 2023). We categorized studies by suitability of their design for internal validity, type of covered entity studied, and motivation-by-scope category.

FINDINGS

The final yield included 44 peer-reviewed, empirical studies published between 2003 and 2023. We identified 15 frequently asked research questions in the literature, across 6 categories of inquiry-motivation (margin or mission) and scope (external, covered entity, and care delivery interface). Literature with greatest internal validity leaned toward evidence of margin-motivated behavior at the external environment and covered entity levels, with inconsistent findings supporting mission-motivated behavior at these levels; this was particularly the case among participating disproportionate share hospitals (DSHs). However, included case studies were unanimous in demonstrating positive effects of the 340B program for carrying out a provider's safety net mission.

CONCLUSIONS

In our scoping review of the 340B program, the highest-quality evidence indicates nonprofit, DSHs may be using the 340B program in margin-motivated ways, with inconsistent evidence for increased safety net engagement; however, this finding is not consistent across other hospital types and public health clinics, which face different incentive structures and reporting requirements. Future studies should examine heterogeneity by covered entity types (i.e., hospitals vs. public health clinics), characteristics, and time period of 340B enrollment. Our findings provide additional context to current health policy discussion regarding the 340B program.