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ObjectiveHospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups.DesignCost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon.SettingPatient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries.ParticipantsHospitalised adults with Braden scores classified into five risk levels: very high risk (6–9), high risk (10–11), moderate risk (12–14), at-risk (15–18), minimal risk (19–23).InterventionsStandard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations.Main outcome measuresCosts (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty.ResultsSimulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores 99% of probabilistic simulations.ConclusionOur analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

Purpose: To explore the methods through which physicians deliver compassionate care during end-of-life (EOL). Compassionate care provides benefits to patients and providers and is particularly important for patients with serious illnesses, yet its practice remains limited. We aim to qualitatively characterize methods utilized by physicians that facilitate the delivery of compassionate care at EOL. Methods: We conducted 13 semi-structured interviews with physicians from palliative care and medical oncology subspecialities at a rural academic medical centre in New Hampshire. Interviews were transcribed and analysed using a qualitative research design. Results: Participants described methods of compassionate care ranging from symptom control to less tangible, non-verbal methods. Primary barriers to the delivery of compassionate care were described as within the broader healthcare system and within the inherent emotional difficulty of EOL care. Physicians from both subspecialities emphasized the importance of successful inter-provider relationships. Conclusions: Methods for delivering compassionate care at EOL are wide ranging, but barriers on a systemic and individual level should be addressed to make its practice more widespread. This can be accomplished, in part, by the standardization of EOL conversations, training physicians how to have meaningful EOL conversations, and integration of such conversations into electronic medical records.

Background People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics. Methods A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation. Results An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents. Conclusions The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation. Electronic supplementary material The online version of this article (10.1186/s12888-018-1707-x) contains supplementary material, which is available to authorized users.