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Liu Y, Yu M, LaMantia JN, Mason Lobo J, Boutilier JJ, Liu Y, Brennan MB. Associations between specialty care and improved outcomes among patients with diabetic foot ulcers. PLoS One 2023; 18:e0294813. [PMID: 38113202 PMCID: PMC10729988 DOI: 10.1371/journal.pone.0294813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/07/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE Specialty care may improve diabetic foot ulcer outcomes. Medically underserved populations receive less specialty care. We aimed to determine the association between specialty care and ulcer progression, major amputation, or death. If a beneficial association is found, increasing access to specialty care might help advance health equity. RESEARCH DESIGN AND METHODS We retrospectively analyzed a cohort of Wisconsin and Illinois Medicare patients with diabetic foot ulcers (n = 55,409), stratified by ulcer severity (i.e., early stage, osteomyelitis, or gangrene). Within each stratum, we constructed Kaplan-Meier curves for event-free survival, defining events as: ulcer progression, major amputation, or death. Patients were grouped based on whether they received specialty care from at least one of six disciplines: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, and vascular surgery. Multivariate Cox proportional hazard models estimated the association between specialty care and event-free survival, adjusting for sociodemographic factors and comorbidities, and stratifying on ulcer severity. RESULTS Patients who received specialty care had longer event-free survival compared to those who did not (log-rank p<0.001 for all ulcer severity strata). After adjusting, receipt of specialty care, compared to never, remained associated with improved outcomes for all ulcer severities (early stage adjusted hazard ratio 0.34, 95% CI 0.33-0.35, p<0.001; osteomyelitis aHR 0.22, 95% CI 0.20-0.23, p<0.001; gangrene aHR 0.22, 95% CI 0.20-0.24, p<0.001). CONCLUSIONS Specialty care was associated with longer event-free survivals for patients with diabetic foot ulcers. Increased, equitable access to specialty care might improve diabetic foot ulcer outcomes and disparities.
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Affiliation(s)
- Yingzhou Liu
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Menggang Yu
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Jamie N. LaMantia
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
| | - Justin J. Boutilier
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Yao Liu
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Meghan B. Brennan
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, United States of America
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Lobo JM, Kang H, Brennan MB, Kim S, McMurry TL, Balkrishnan R, Anderson R, McCall A, Sohn MW. Regional and racial disparities in major amputation rates among medicare beneficiaries with diabetes: a retrospective study in the southeastern USA. BMJ Public Health 2023; 1:e000206. [PMID: 38764700 PMCID: PMC11101188 DOI: 10.1136/bmjph-2023-000206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Objective While rates for non-traumatic lower extremity amputations (LEA) have been declining, concerns exist over disparities. Our objectives are to track major LEA (MLEA) rates over time among Medicare beneficiaries residing in a high diabetes prevalence region in the southeastern USA (the diabetes belt) and surrounding areas. Methods We used Medicare claims files for ~900 000 fee-for-service beneficiaries aged ≥65 years in 2006-2015 to track MLEA rates per 1000 patients with diabetes. We additionally conducted a cross-sectional analysis of data for 2015 to compare regional and racial disparities in major amputation risks after adjusting for demographic, socioeconomic, access-to-care and foot complications and other health factors. The Centers for Disease Control and Prevention defined the diabetes belt as 644 counties across Appalachian and southeastern US counties with high prevalence. Results MLEA rates were 3.9 per 1000 in the Belt compared with 2.8 in the surrounding counties in 2006 and decreased to 2.3 and 1.6 in 2015. Non-Hispanic black patients had 8.5 and 6.9 MLEAs per 1000 in 2006 and 4.8 and 3.5 in 2015 in the Belt and surrounding counties, respectively, while the rates were similar for non-Hispanic white patients in the two areas. Although amputation rates declined rapidly in both areas, non-Hispanic black patients in the Belt consistently had >3 times higher rates than non-Hispanic whites in the Belt. After adjusting for patient demographics, foot complications and healthcare access, non-Hispanic blacks in the Belt had about twice higher odds of MLEAs compared with non-Hispanic whites in the surrounding areas. Discussion Our data show persistent disparities in major amputation rates between the diabetes belt and surrounding counties. Racial disparities were much larger in the Belt. Targeted policies to prevent MLEAs among non-Hispanic black patients are needed to reduce persistent disparities in the Belt.
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Affiliation(s)
- Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | | | - Meghan B Brennan
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Soyoun Kim
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
- Department of Social Welfare, Ewha Womans University, Seoul, Korea (the Republic of)
| | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Rajesh Balkrishnan
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Roger Anderson
- Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Anthony McCall
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Min-Woong Sohn
- Health Management and Policy, University of Kentucky, Lexington, Kentucky, USA
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Fernandes JC, Pinho AR, Pereira PA, Madeira MD, Raposo FA, Sousa AN, Lobo JM. Anterolateral ligament of the knee-Cadaver study in a Caucasian population. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:134-138. [PMID: 35691577 DOI: 10.1016/j.recot.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/18/2022] [Accepted: 06/01/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Despite the recognized importance of the anterolateral ligament (ALL) in rotational stability of the knee, some studies still deny its role and even its existence. We studied the prevalence of the ALL in a Caucasian population, as well as its characteristics and anatomical relationships. MATERIALS AND METHODS The study was performed on 20 knees from 10 embalmed cadavers. A lateral approach, as described by Steven Claes, was used and the relations of the ALL with the lateral epicondyle, lateral inferior genicular artery, lateral meniscus, Gerdy's tubercle and fibular head were recorded. Its length and its width were also measured. RESULTS The ALL was identified in 16 knees. Its origin was at a distance inferior to 1mm posterior and proximal to the lateral femoral epicondyle and insertion within a mean distance of 2.1±0.6mm from de tibial articular surface, 20.6±1.3mm from the Gerdy's tubercle and 20.3±1.2mm from the fibular head. In all cases ALL presented mutual fibers with the lateral meniscus. The length was 35.8±4.6mm and the width was 4.2±1.3/4.9±1.0/6.5±1.5mm at its proximal, middle and distal third, respectively. No difference was found between gender and the dimensions of the ligament. CONCLUSIONS The ALL was found in 80% of the knees. Its origin is closely related to the lateral collateral ligament and its insertion is halfway between the fibular head and the Gerdy's tubercle. In all cases, we verified the connection between ALL and the lateral meniscus.
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Affiliation(s)
- J C Fernandes
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal.
| | - A R Pinho
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - P A Pereira
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal
| | - M D Madeira
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Portugal
| | - F A Raposo
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - A N Sousa
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - J M Lobo
- Unit of Anatomy, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
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Berg BP, Erdogan SA, Lobo JM, Pendleton K. A Method for Balancing Provider Schedules in Outpatient Specialty Clinics. MDM Policy Pract 2020; 5:2381468320963063. [PMID: 33178888 PMCID: PMC7592316 DOI: 10.1177/2381468320963063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background. Variability in outpatient specialty clinic schedules contributes to numerous adverse effects including chaotic clinic settings, provider burnout, increased patient waiting times, and inefficient use of resources. This research measures the benefit of balancing provider schedules in an outpatient specialty clinic. Design. We developed a constrained optimization model to minimize the variability in provider schedules in an outpatient specialty clinic. Schedule variability was defined as the variance in the number of providers scheduled for clinic during each hour the clinic is open. We compared the variance in the number of providers scheduled per hour resulting from the constrained optimization schedule with the actual schedule for three reference scenarios used in practice at M Health Fairview's Clinics and Surgery Center as a case study. Results. Compared to the actual schedules, use of constrained optimization modeling reduced the variance in the number of providers scheduled per hour by 92% (1.70-0.14), 88% (1.98-0.24), and 94% (1.98-0.12). When compared with the reference scenarios, the total, and per provider, assigned clinic hours remained the same. Use of constrained optimization modeling also reduced the maximum number of providers scheduled during each of the actual schedules for each of the reference scenarios. The constrained optimization schedules utilized 100% of the available clinic time compared to the reference scenario schedules where providers were scheduled during 87%, 92%, and 82% of the open clinic time, respectively. Limitations. The scheduling model's use requires a centralized provider scheduling process in the clinic. Conclusions. Constrained optimization can help balance provider schedules in outpatient specialty clinics, thereby reducing the risk of negative effects associated with highly variable clinic settings.
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Affiliation(s)
- Bjorn P. Berg
- Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota
| | - S. Ayca Erdogan
- Department of Industrial and Systems Engineering, San Jose State University, San Jose, California
| | - Jennifer Mason Lobo
- Division of Biomedical Informatics, University of Virginia, Charlottesville, Virginia
| | - Kathryn Pendleton
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota
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Logan JG, Kang H, Kim S, Duprez D, Kwon Y, Jacobs DR, Forbang N, Lobo JM, Sohn MW. Association of obesity with arterial stiffness: The Multi-Ethnic Study of Atherosclerosis (MESA). Vasc Med 2020; 25:309-318. [PMID: 32484395 DOI: 10.1177/1358863x20918940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Arterial stiffness (AS) and obesity are recognized as important risk factors of cardiovascular disease (CVD). The purpose of this study was to investigate the relationship between AS and obesity. AS was defined as high augmentation index (AIx) and low elasticity (C1, large artery elasticity; C2, small artery elasticity) in participants enrolled in the Multi-Ethnic Study of Atherosclerosis at baseline. We compared AIx, C1, and C2 by body mass index (BMI) (< 25, 25-29.9, 30-39.9, ⩾ 40 kg/m2) and waist-hip ratio (WHR) (< 0.85, 0.85-0.99, ⩾ 1). The obesity-AS association was tested across 10-year age intervals. Among 6177 participants (62 ± 10 years old, 52% female), a significant inverse relationship was observed between obesity and AS. After adjustments for CVD risk factors, participants with a BMI > 40 kg/m2 had 5.4% lower AIx (mean difference [Δ] = -0.82%; 95% CI: -1.10, -0.53), 15.4% higher C1 (Δ = 1.66 mL/mmHg ×10; 95% CI: 1.00, 2.33), and 40.2% higher C2 (Δ = 1.49 mL/mmHg ×100; 95% CI: 1.15, 1.83) compared to those with a BMI < 25 kg/m2 (all p for trend < 0.001). Participants with a WHR ⩾ 1 had 5.6% higher C1 (∆ = 0.92 mL/mmHg ×10; 95% CI: 0.47, 1.37) compared to those with a WHR < 0.85. The WHR had a significant interaction with age on AIx and C2, but not with BMI; the inverse relationships of the WHR with AIx and C2 were observed only in participants < 55 years between the normal (WHR < 0.85) and the overweight (0.85 ⩽ WHR < 0.99) groups. Different associations of WHR and BMI with arterial stiffness among older adults should be further investigated.
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Affiliation(s)
- Jeongok G Logan
- School of Nursing, University of Virginia, Charlottesville, VA, USA
| | - Hyojung Kang
- College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Soyoun Kim
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Daniel Duprez
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Younghoon Kwon
- UVA Heart and Vascular Center Fontaine, University of Virginia, Charlottesville, VA, USA
| | - David R Jacobs
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Nketi Forbang
- Department of Family Medicine and Public Health, Division of Preventive Medicine, UC San Diego, La Jolla, CA, USA
| | - Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Min-Woong Sohn
- Department of Health Management and Policy, University of Kentucky, Lexington, KY, USA
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Logan JG, Kang H, Lobo JM, Sohn MW, Lin GM, Lima JAC, Punjabi NM, Redline S, Kwon Y. Actigraphy-based sleep characteristics and aortic stiffness: the Multi-Ethnic Study of Atherosclerosis. ACTA ACUST UNITED AC 2018; 12:841-849. [PMID: 30396853 DOI: 10.1016/j.jash.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/16/2018] [Accepted: 09/19/2018] [Indexed: 12/21/2022]
Abstract
The study aimed to examine the association between objective estimates of sleep duration and quality and aortic stiffness while accounting for the potential confounding effect of sleep-disordered breathing. Participants were part of the Multi-Ethnic Study of Atherosclerosis Sleep study. Sleep duration and quality were assessed by 7-day wrist actigraphy, sleep-disordered breathing by home polysomnography, and aortic stiffness by magnetic resonance imaging-based aortic pulse wave velocity (aPWV), ascending and descending aorta distensibility. Aortic stiffness of participants with "normal" sleep duration (6-8 hours) were compared with those of "short" (<6 hours) and "long" sleep duration (>8 hours) adjusting for common cardiovascular risk factors and apnea-hypopnea index. The sample consisted of 908 participants (mean age 68.4 ± 9.1 years, 55.3% female). There was a significant linear trend of increased aPWV across short (n = 252), normal (n = 552), and long sleep durations (n = 104) (P for trend = .008). Multivariable analysis showed that people with short sleep duration had 0.94 m/s lower aPWV (95% CI: -1.54, -0.35), compared with those with normal sleep duration. In this ethnically diverse community cohort, habitual short sleep duration as estimated by actigraphy was associated with lower aortic stiffness.
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Affiliation(s)
- Jeongok G Logan
- Assistant Professor, University of Virginia School of Nursing, Charlottesville, VA, USA.
| | - Hyojung Kang
- Research Assistant Professor, Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
| | - Jennifer Mason Lobo
- Assistant Professor, Division of Biomedical Informatics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Min-Woong Sohn
- Associate Professor, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Gen-Min Lin
- Assistant Professor, Department of Medicine, Hualien Armed Forces General Hospital, Hualien, Taiwan
| | - Joao A C Lima
- Professor of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Naresh M Punjabi
- Professor, Johns Hopkins Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Susan Redline
- Peter C. Farrell Professor of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Younghoon Kwon
- Assistant Professor, University of Virginia, Fontaine Research Park, Charlottesville, VA, USA
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Kang H, Lobo JM, Kim S, Sohn MW. Cost-related medication non-adherence among U.S. adults with diabetes. Diabetes Res Clin Pract 2018; 143:24-33. [PMID: 29944967 PMCID: PMC6204232 DOI: 10.1016/j.diabres.2018.06.016] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/25/2018] [Accepted: 06/19/2018] [Indexed: 11/17/2022]
Abstract
AIMS To examine factors that affect cost-related medication non-adherence (CRN), defined as taking medication less than as prescribed because of cost, among adults with diabetes and to determine their relative contribution in explaining CRN. METHODS Behavioral Risk Factor Surveillance System data for 2013-2014 were used to identify individuals with diabetes and their CRN. We modeled CRN as a function of financial factors, regimen complexity, and other contextual factors including diabetes care, lifestyle, and health factors. Dominance analysis was performed to rank these factors by relative importance. RESULTS CRN among U.S. adults with diabetes was 16.5%. Respondents with annual income <$50,000 and without health insurance were more likely to report CRN, compared to those with income ≥$50,000 and those with insurance, respectively. Insulin users had 1.24 times higher risk of CRN compared to those not on insulin. Contextual factors that significantly affected CRN included diabetes care factors, lifestyle factors, and comorbid depression, arthritis, and COPD/asthma. Dominance analysis showed health insurance was the most important factor for respondents <65 and depression was the most important factor for respondents ≥65. CONCLUSIONS In addition to traditional risk factors of CRN, compliance with annual recommendations for diabetes and healthy lifestyle were associated with lower CRN. Policies and social supports that address these contextual factors may help improve CRN.
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Affiliation(s)
- Hyojung Kang
- Department of Systems and Information Engineering, School of Engineering, University of Virginia, Charlottesville, VA, United States.
| | - Jennifer Mason Lobo
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States.
| | - Soyoun Kim
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States.
| | - Min-Woong Sohn
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States.
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Grabowski M, Lobo JM, Gunnell B, Enfield K, Carpenter R, Barnes L, Mathers AJ. Characterizations of handwashing sink activities in a single hospital medical intensive care unit. J Hosp Infect 2018; 100:e115-e122. [PMID: 29738784 DOI: 10.1016/j.jhin.2018.04.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/29/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Handwashing sink drains are increasingly implicated as a potential reservoir of antibiotic-resistant bacteria in hospital outbreaks; however, usage patterns that may promote this source remain unknown. AIM To understand behaviours in the intensive care unit (ICU) that may facilitate establishment and nosocomial transmission of multidrug-resistant Gram negatives from a sink-trap reservoir to a patient. METHODS Motion-sensitive cameras captured anonymized activity paired with periodic in-person observations during a quality investigation from four ICU sinks (two patient rooms and two patient bathrooms) in a university hospital. FINDINGS We analysed 4810 sink videos from 60 days in patient rooms (3625) and adjoining bathrooms (1185). There was a false-positive rate of 38% (1837 out of 4810) in which the camera triggered but no sink interaction occurred. Of the 2973 videos with analysed behaviours there were 5614 observed behaviours which were assessed as: 37.4% medical care, 29.2% additional behaviours, 17.0% hand hygiene, 7.2% patient nutrition, 5.0% environmental care, 4.2% non-medical care. Handwashing was only 4% (224 out of 5614) of total behaviours. Sub-analysis of 2748 of the later videos further categorized 56 activities where a variety of nutrients, which could promote microbial growth, were disposed of in the sink. CONCLUSION Several non-hand hygiene activities took place regularly in ICU handwashing sinks; these may provide a mechanism for nosocomial transmission and promotion of bacterial growth in the drain. Redesigning hospital workflow and sink usage may be necessary as it becomes apparent that sink drains may be a reservoir for transmission of multidrug-resistant bacteria.
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Affiliation(s)
- M Grabowski
- Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA, USA
| | - J M Lobo
- Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA, USA
| | - B Gunnell
- Center for Telehealth, University of Virginia Health System, Charlottesville, VA, USA
| | - K Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - R Carpenter
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | - L Barnes
- Department of Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
| | - A J Mathers
- Division of Infectious Disease and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA; Clinical Microbiology Laboratory, Department of Pathology, University of Virginia Health System, Charlottesville, VA, USA.
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Capan M, Khojandi A, Denton BT, Williams KD, Ayer T, Chhatwal J, Kurt M, Lobo JM, Roberts MS, Zaric G, Zhang S, Schwartz JS. From Data to Improved Decisions: Operations Research in Healthcare Delivery. Med Decis Making 2017; 37:849-859. [PMID: 28423982 DOI: 10.1177/0272989x17705636] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The Operations Research Interest Group (ORIG) within the Society of Medical Decision Making (SMDM) is a multidisciplinary interest group of professionals that specializes in taking an analytical approach to medical decision making and healthcare delivery. ORIG is interested in leveraging mathematical methods associated with the field of Operations Research (OR) to obtain data-driven solutions to complex healthcare problems and encourage collaborations across disciplines. This paper introduces OR for the non-expert and draws attention to opportunities where OR can be utilized to facilitate solutions to healthcare problems. METHODS Decision making is the process of choosing between possible solutions to a problem with respect to certain metrics. OR concepts can help systematically improve decision making through efficient modeling techniques while accounting for relevant constraints. Depending on the problem, methods that are part of OR (e.g., linear programming, Markov Decision Processes) or methods that are derived from related fields (e.g., regression from statistics) can be incorporated into the solution approach. This paper highlights the characteristics of different OR methods that have been applied to healthcare decision making and provides examples of emerging research opportunities. EXAMPLES We illustrate OR applications in healthcare using previous studies, including diagnosis and treatment of diseases, organ transplants, and patient flow decisions. Further, we provide a selection of emerging areas for utilizing OR. CONCLUSIONS There is a timely need to inform practitioners and policy makers of the benefits of using OR techniques in solving healthcare problems. OR methods can support the development of sustainable long-term solutions across disease management, service delivery, and health policies by optimizing the performance of system elements and analyzing their interaction while considering relevant constraints.
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Affiliation(s)
- Muge Capan
- Christiana Care Health System, Value Institute, John H. Ammon Medical Education Center, Newark, DE, USA (MC, KDW)
| | - Anahita Khojandi
- Department of Industrial and Systems Engineering, University of Tennessee, Knoxville, TN, USA (AK)
| | - Brian T Denton
- Industrial and Operations Engineering and Urology, University of Michigan, Ann Arbor, MI, USA (BTD)
| | - Kimberly D Williams
- Christiana Care Health System, Value Institute, John H. Ammon Medical Education Center, Newark, DE, USA (MC, KDW)
| | - Turgay Ayer
- Christiana Care Health System, Value Institute, John H. Ammon Medical Education Center, Newark, DE, USA (MC, KDW).,Georgia Institute of Technology H Milton Stewart School of Industrial and Systems Engineering, Center for Health & Humanitarian Systems, Atlanta, GA, USA (TA)
| | - Jagpreet Chhatwal
- Harvard University, Harvard Medical School, Institute for Technology Assessment; Massachusetts General Hospital, Boston, MA, USA (JC)
| | - Murat Kurt
- Merck Research, Whitehouse Station, NJ, USA (MK)
| | - Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA (JML)
| | - Mark S Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA (MSR)
| | - Greg Zaric
- Richard Ivey School of Business University of Western Ontario, London, ON, Canada (GZ)
| | - Shengfan Zhang
- Department of Industrial Engineering, University of Arkansas, Fayetteville, AR, USA (SZ)
| | - J Sanford Schwartz
- General Internal Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA (JSS)
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Patek SD, Ortiz EA, Farhy LS, Lobo JM, Isbell J, Kirby JL, McCall A. Population-Specific Models of Glycemic Control in Intensive Care: Towards a Simulation-Based Methodology for Protocol Optimization. Proc Am Control Conf 2015; 2015:5084-5090. [PMID: 31787804 DOI: 10.1109/acc.2015.7172132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stress-induced hyperglycemia is common in critically ill patients, where elevated blood glucose and glycemic variability have been found to contribute to infection, slow wound healing, and short-term mortality. Early clinical studies demonstrated improvement in mortality and morbidity resulting from intensive insulin therapy targeting euglycemia. Follow-up clinical studies have shown mixed results suggesting that the risk of hypoglycemia may outweigh the benefits of aggressive glycemic control. None of the prior studies clarify whether euglycemic targets are in themselves harmful, or if the danger lies in the inadequacy of the available methods for achieving desired glycemic outcomes. In this paper, we use a recently developed simulation model of stress hyperglycemia to demonstrate that given an insulin protocol glycemic outcomes are specific to the patient population under consideration, and that there is a need to optimize insulin therapy at the population level. Next, we use the simulator to demonstrate that the performance of Adaptive Proportional Feedback (APF), a popular format for computerized insulin therapy, is sensitive to its parameters, especially to the parameters that govern the aggressiveness of adaptation. Finally, we propose a framework for simulation-based protocol optimization using an objective function that penalizes below-range deviations more heavily than comparable deviations above.
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Affiliation(s)
- Stephen D Patek
- S. D. Patek and E. A. Ortiz are with the Department of Systems and Information Engineering and the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - E Andy Ortiz
- S. D. Patek and E. A. Ortiz are with the Department of Systems and Information Engineering and the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - Leon S Farhy
- L. S. Farhy, J. L. Kirby, and A. McCall are with the Department of Medicine in the School of Medicine of the University of Virginia; L. S. Farhy and A. McCall are also affiliated with the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - Jennifer Mason Lobo
- J. M. Lobo is with the Department of Public Health Sciences in the School of Medicine of the University of Virginia, Charlottesville, VA, 22904
| | - James Isbell
- J. Isbell is with the Department of Surgery in the School of Medicine of the University of Virginia, Charlottesville, VA, 22904
| | - Jennifer L Kirby
- L. S. Farhy, J. L. Kirby, and A. McCall are with the Department of Medicine in the School of Medicine of the University of Virginia; L. S. Farhy and A. McCall are also affiliated with the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
| | - Anthony McCall
- L. S. Farhy, J. L. Kirby, and A. McCall are with the Department of Medicine in the School of Medicine of the University of Virginia; L. S. Farhy and A. McCall are also affiliated with the University of Virginia Center for Diabetes Technology, University of Virginia, Charlottesville, VA, 22904
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11
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Lobo JM, Dicker AP, Buerki C, Daviconi E, Karnes RJ, Jenkins RB, Patel N, Den RB, Showalter TN. Evaluating the clinical impact of a genomic classifier in prostate cancer using individualized decision analysis. PLoS One 2015; 10:e0116866. [PMID: 25837660 PMCID: PMC4383561 DOI: 10.1371/journal.pone.0116866] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/15/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Currently there is controversy surrounding the optimal way to treat patients with prostate cancer in the post-prostatectomy setting. Adjuvant therapies carry possible benefits of improved curative results, but there is uncertainty in which patients should receive adjuvant therapy. There are concerns about giving toxicity to a whole population for the benefit of only a subset. We hypothesized that making post-prostatectomy treatment decisions using genomics-based risk prediction estimates would improve cancer and quality of life outcomes. METHODS We developed a state-transition model to simulate outcomes over a 10 year horizon for a cohort of post-prostatectomy patients. Outcomes included cancer progression rates at 5 and 10 years, overall survival, and quality-adjusted survival with reductions for treatment, side effects, and cancer stage. We compared outcomes using population-level versus individual-level risk of cancer progression, and for genomics-based care versus usual care treatment recommendations. RESULTS Cancer progression outcomes, expected life-years (LYs), and expected quality-adjusted life-years (QALYs) were significantly different when individual genomics-based cancer progression risk estimates were used in place of population-level risk estimates. Use of the genomic classifier to guide treatment decisions provided small, but statistically significant, improvements in model outcomes. We observed an additional 0.03 LYs and 0.07 QALYs, a 12% relative increase in the 5-year recurrence-free survival probability, and a 4% relative reduction in the 5-year probability of metastatic disease or death. CONCLUSIONS The use of genomics-based risk prediction to guide treatment decisions may improve outcomes for prostate cancer patients. This study offers a framework for individualized decision analysis, and can be extended to incorporate a wide range of personal attributes to enable delivery of patient-centered tools for informed decision-making.
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Affiliation(s)
- Jennifer Mason Lobo
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
- * E-mail:
| | - Adam P. Dicker
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | | | - Elai Daviconi
- GenomeDx Biosciences, Vancouver, British Columbia, Canada
| | - R. Jeffrey Karnes
- Department of Urology, Mayo Clinic, Rochester, MN, United States of America
| | - Robert B. Jenkins
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Nirav Patel
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Robert B. Den
- Department of Radiation Oncology, Jefferson Medical College and Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Amaral MH, Lobo JM, Ferreira DC. Naproxen availability from variable-dose and weight sustained-release tablets. Drug Dev Ind Pharm 2001; 27:221-5. [PMID: 11291202 DOI: 10.1081/ddc-100000240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The aim of this work was to compare the naproxen availability from hydroxypropyl methylcellulose (HPMC) matrix tablets containing the same dose and a 2-fold weight variation (160 mg of naproxen in tablets weighting 250 and 500 mg) or with the same weight and a 2-fold dose variation (500 mg of weight and 160 or 320 mg of naproxen). The 2-fold weight variation in tablets with the same dose and also the 2-fold dose variation in tablets with the same weight did not affect the naproxen release. In addition, the release rate of two tablets of the same formulation and one tablet with a 2-fold dose and weight variation was not significantly different at the first minutes of the dissolution assay.
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Affiliation(s)
- M H Amaral
- Centro de Tecnologia do Medicamento, Faculty of Pharmacy of OPorto, Rua Aníbal Cunha, 164, 4050-Porto, Portugal
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Amaral MH, Lobo JM, Ferreira DC. Effect of hydroxypropyl methylcellulose and hydrogenated castor oil on naproxen release from sustained-release tablets. AAPS PharmSciTech 2001; 2:E6. [PMID: 14727881 PMCID: PMC2750472 DOI: 10.1208/pt020206] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The effect of the concentration of hydrophilic (hydroxypropyl methylcellulose [HPMC]) and hydrophobic (hydrogenated castor oil [HCO]) products, fillers (lactose and dibasic calcium phosphate), and buffers (sodium bicarbonate, calcium carbonate, and sodium citrate) on naproxen release rate was studied. Matrix tablets were prepared by double compression, and in vitro dissolution tests were performed. The dissolution results showed that an increased amount of HPMC or hydrogenated castor oil resulted in reduced drug release. The inclusion of buffers in the HPMC matrix tablets enhanced naproxen release. For HCO tablets, only sodium bicarbonate enhanced naproxen release. The presence of lactose on HPMC matrix tablets did not show a significantly different result from that obtained with the formulation containing dibasic calcium phosphate as a filler. However, for the tablets containing HCO, the presence of lactose significantly enhanced the naproxen release rate. The matrix-forming materials in this study were suitable for use in sustained-release tablets containing naproxen. The drug release can be modulated by adding suitable amounts of diluents and buffers.
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Affiliation(s)
- M H Amaral
- Centro de Tecnologia do Medicamento, Faculty of Pharmacy, University of Oporto, Rua Aníbal Cunha, 164, 4050-Porto, Portugal.
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Segal H, Francia MV, Lobo JM, Elisha G. Reconstruction of an active integron recombination site after integration of a gene cassette at a secondary site. Antimicrob Agents Chemother 1999; 43:2538-41. [PMID: 10508040 PMCID: PMC89516 DOI: 10.1128/aac.43.10.2538] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As the site of insertion of the aadB gene cassette on pRAY, from a clinical isolate of Acinetobacter, is almost identical to the preferred site on integrons, the composite 59-base element (59-BE) associated with this cassette is potentially recombinationally active. By using a conduction assay to quantitate site activity, the 59-BE was recognized by integrase with high frequency, indicating that the composite site is recombinationally active.
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Affiliation(s)
- H Segal
- Department of Medical Microbiology, University of Cape Town, South Africa
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