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Background Existing tools for rapid cognitive assessment in HIV-positive individuals with mild cognitive deficits lack sensitivity or do not meet psychometric requirements for tracking changes in cognitive ability over time. Methods Seventy-five nondemented HIV-positive patients were evaluated with the Montreal Cognitive Assessment (MoCA), a brief battery of standardized neuropsychological tests, and computerized tasks evaluating frontal-executive function and processing speed. Rasch analyses were applied to the MoCA data set and subsequently to the full set of data from all tests. Results The MoCA was found to adequately measure cognitive ability as a single, global construct in this HIV-positive cohort, although it showed poorer precision for measuring patients of higher ability. Combining the additional tests with the MoCA resulted in a battery with better psychometric properties that also better targeted the range of abilities in this cohort. Conclusion This application of modern test development techniques shows a path towards a quick, quantitative, global approach to cognitive assessment with promise both for initial detection and for longitudinal follow-up of cognitive impairment in patients with HIV infection. [ABSTRACT FROM AUTHOR]

Background: Qualitative health research has the potential to answer important applied health research questions to inform nutrition and dietetics practice, education and policy. Qualitative health research is a distinct subdiscipline of qualitative inquiry that purposefully draws upon the context of healthcare and emphasises health and wellness. Methods: Qualitative health research is defined by two parameters: (1) the focus of the study and (2) the methods used. When considering the methods to be used, decisions are required about the type of data to be generated (e.g., transcripts, images and notes) and the process involved in data generation (e.g., interviews, elicitation strategies and observations) to answer the research question(s). Drawing upon examples from nutrition and dietetics literature, this paper provides a framework to support decision‐making for nutrition and dietetics researchers and clinician researchers designing conducting qualitative health research. Results: The guiding questions of the framework include: What types of data will be generated? Who is involved in data generation? Where will data generation occur? When will data generation occur? How will data be recorded and managed? and How will participants' and researchers' emotional safety be promoted? Conclusion: Questions about the types of data, those involved, where and when, as well as how safety can be maintained in data generation, not only support a more robust design and description of data generation methods but also keep the person at the centre of the research. Key points: In the discipline of qualitative health research, researchers purposefully consider the person at the centre of the research; adapt methods to consider the healthcare context; and prioritise individual health, wellness and capabilities.This humanisation of research requires researchers to select strategies that minimise the burden placed on participants and to make methodological decisions informed through consideration of participants' well‐being. This includes attention to the promotion of both participants' and researchers' emotional safety.To guide data generation decision‐making in the design and conduct of qualitative health research studies, a framework is presented with practical considerations on the 'who, what, when, where and how?' associated with data collection procedures. [ABSTRACT FROM AUTHOR]

Objective: To report on the findings of a systematic review which examined the experiences and views of older people aged 65 years and over on health professionals’ recognition of sexuality and sexual health and whether these aspects of the person are incorporated into care. Review methods: The review followed the methods laid out by the Joanna Briggs Institute. Eleven electronic databases were searched using the terms sexual*, aged, ageing/aging, attitudes and care in any health‐care setting. Only quantitative and qualitative research and opinion papers written in English and offering unique commentary published between January 2004 and January 2015 were eligible. Results: A total of 999 papers were initially identified and of these, 148 were assessed by two reviewers. Eighteen studies – seven quantitative, eight qualitative and three opinion papers – met the inclusion criteria and were appraised. The importance of sexuality to well‐being, language used, expressing sexuality, discomfort discussing sexuality, inadequate sexuality health education and treatment and deficient communication with health‐care professionals were all identified as significant issues in a range of settings. Fourteen categories and five syntheses summarize the 43 findings. Conclusions: Sexuality remains important for many older people; however, embarrassment, dissatisfaction with treatment, negative attitudes and seeming disinterest by health professionals can all inhibit discussions. Professionals and health‐care services need to adopt strategies and demonstrate characteristics which create environments that are more supportive of sexuality. Issues related to sexuality and sexual health should be able to be discussed without anxiety or discomfort so that older people receive optimal care and treatment. [ABSTRACT FROM AUTHOR]

Electronic health records are valuable for clinical and translational research. Institutions must protect patient privacy and comply with applicable regulations while allowing appropriate access to clinical data for research. The processes that investigators must follow to access clinical data can be substantially different at different institutions. In this paper, we describe the process developed at our institution that has been active for 5 years and was used to satisfy over 200 requests for access to identified clinical data, usually within 1 day for internal requests and 3 days for visiting researchers. [ABSTRACT FROM AUTHOR]

Aim: To determine if walking ability and presence of intellectual disability and epilepsy change from childhood to 50 years of age in individuals with cerebral palsy (CP), and if such changes are related to age, sex, or CP subtype.Method: This was a population-based follow-up study of 142 adults born from 1959 to 1978 (82 males, 60 females; mean age 48y 4mo, range 37-58y; 44% unilateral, 35% bilateral, 17% dyskinetic, and 4% ataxic CP) listed in the CP register of western Sweden. We compared childhood data with a follow-up assessment in 2016.Results: At follow-up, walking ability had changed significantly (p<0.001). The proportion of participants walking without aids had decreased from 71% to 62%, and wheelchair ambulation increased from 18% to 25%. Walking ability was related to subtype (p=0.001), but not to age, sex, pain, fatigue, or body mass index. The proportion classified as having intellectual disability had increased from 16% to 22% (p=0.039) and the proportion with epilepsy from 9% to 18% (p=0.015). Of those with childhood epilepsy, 46% were seizure-free without medication.Interpretation: Walking ability and the presence of intellectual disability and epilepsy had changed significantly since childhood. Life-long access to specialized health care is warranted for re-evaluation of impairments, treatment, and assistance. What this paper adds Changes in impairments in individuals with cerebral palsy (CP) over time are related to CP subtype. After 50 years, walking ability in CP may have deteriorated or improved. Intellectual disability in CP may not always be detected in early childhood assessments. Epilepsy in CP may develop after childhood or may be outgrown. [ABSTRACT FROM AUTHOR]

Objective Randomized trials provide evidence that intensive lifestyle interventions leading to dietary and physical activity change can delay or prevent Type 2 diabetes. Translational studies have assessed the impact of interventions based on, but less intensive than, trial protocols delivered in community settings with high-risk populations. The aim of this review was to synthesize evidence from translational studies of any design to assess the impact of interventions delivered outside large randomized trials. Methods Medical and scientific databases were searched using specified inclusion and exclusion criteria. Studies were included that used a tested diabetes preventive study protocol with an adult population at risk from Type 2 diabetes. Included papers were quality assessed and data extracted using recommended methods. Results From an initial 793 papers, 19 papers reporting 17 studies were included. Translational studies from a range of settings utilized a variety of methods. All were based on the US Diabetes Prevention Programme protocol or the Finnish Diabetes Prevention Study, with modifications that increased feasibility and access. The main outcome that was reported in all studies was weight change. Weight loss, which occurred in all but one study, was greater in intervention arms than in control subjects. No consistent differences were found in blood glucose or waist circumference. Conclusions Translational studies based on the intensive diabetes prevention programmes showed that there is potential for less intensive interventions both to be feasible and to have an impact on future progression to diabetes in at-risk individuals. [ABSTRACT FROM AUTHOR]

This paper presents a discourse analysis of publications of the Christian Reformed Church regarding its Rehoboth Mission near Gallup, New Mexico, among the Navajo. All issues of The Banner, Acts of Synod of the Christian Reformed Church, the Rehoboth Hospital Bulletin, and the Annual Report of the Rehoboth Mission from 1880 to the present were reviewed for references to health-care at Rehoboth from 1903 to 1943. Four religiously framed discourses were identified: discourses justifying provision of health-care at the mission, discourses of the Navajos as immature and potentially dangerous, needing to be civilized, discourses of cleanliness, and discourses of calling. This paper adds to a growing body of knowledge about religious frames within which nurses have practiced in North America. [ABSTRACT FROM AUTHOR]

SUMMARY Sensor networks are being used for an increasing number of applications ranging from environmental monitoring and precision agriculture to manufacturing and health care. By gathering data at unprecedented temporal and spatial granularity, sensor networks are revolutionizing these applications. Given the scale and complexity of these systems, they face a critical challenge in software Operations and Management, that is, installing, configuring, and updating thousands of software components in a heterogeneous sensor network. In this paper, we discuss automating and simplifying the process of defining the software environment on a sensor node running the Android platform. Android has significant share in the mobile phone market and runs on a broad range of devices including embedded platforms. This paper outlines the use of a new method for configuring embedded devices and sensor networks by drawing from techniques used for defining the software environment in data centers. We have also developed a software prototype to allow for a simple, reproducible, and flexible configuration of the Android software stack on a sensor node. Our exploratory research provides an insight into the use of modular configuration techniques in embedded devices and how they can be applied to the Android ecosystem. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

To review the application of telehealth guidelines developed by Bondini et al for clinicians to determine patient suitability for telehealth in an outpatient Chronic Wound Service, including the proportion of patients suitable for telehealth, type and mode of telehealth encounters. Retrospective, random convenience sample of patients attending the Chronic Wound Service in 2021. Fifty‐six patients were included, most with leg/foot wounds (93%), median age 74 [54–84], 64% male. Four patients at admission and 19 patients at review met criteria for telehealth. Six percent of encounters were telehealth; phone‐only (82%), unscheduled nursing reviews (77%) in patients with healing wounds. Thirty patients (54%) received at least one telehealth encounter. Telehealth occurred 35.6 days later in the admission than face‐to‐face encounters (p < 0.05, 95% CI 14.9–56.3). There was a significant relationship between patients receiving telehealth and meeting telehealth suitability criteria on reviews (X2 (1) = 19.6*, p < 0.001). Eighteen percent of patients required wound‐related hospitalisation during their outpatient admission. Telehealth guidelines identified patients suitable for telehealth, although the proportion of patients was small. Telehealth was mostly utilised for nurse‐led telephone calls in patients with improving wounds. Future research into use of telephone review for clinical standards of wound care is warranted. [ABSTRACT FROM AUTHOR]

It is not known whether inequality in access to cardiac procedures translates into inequality in mortality. In this paper, we use a path analysis model to quantify both the direct effect of socio-economic status on mortality and the indirect effect of socio-economic status on mortality as mediated by the provision of cardiac procedures. The study links microdata from the Finnish and Norwegian national patient registers describing treatment episodes with data from prescription registers, causes-of-death registers and registers covering education and income. We show that socio-economic variables affect access to percutaneous coronary intervention in both countries, but that these effects are only moderate and that the indirect effects of the socio-economic factors on mortality through access to percutaneous coronary intervention are minor. The direct effects of income and education on mortality are significantly larger. We conclude that the socio-economic gradient in the use of percutaneous coronary intervention adds to socio-economic differences in mortality to little or no extent. [ABSTRACT FROM AUTHOR]

The article presents a systematic narrative review aimed at examining qualitative studies focused on the experiences of patients of health-care services for multiple sclerosis (MS) in Great Britain. It says that studies primarily focused on diagnosis or palliative care, with themes including emotional experience of health care, continuity of care, and support from health-care professionals. It highlights the need for future research to explore the experiences of care after diagnosis.

Objectives The objective was to develop and evaluate an early sepsis detection score for the prehospital setting. Methods A retrospective analysis of consecutive patients who were admitted by emergency medical services ( EMS) to the emergency department of the Jena University Hospital was performed. Because potential predictors for sepsis should be based on consensus criteria, the following parameters were extracted from the EMS protocol for further analysis: temperature, heart rate ( HR), respiratory rate ( RR), oxygen saturation (SaO2), Glasgow Coma Scale score, blood glucose, and systolic blood pressure ( sBP). Potential predictors were stratified based on inspection of Loess graphs. Backward model selection was performed to select risk factors for the final model. The Prehospital Early Sepsis Detection ( PRESEP) score was calculated as the sum of simplified regression weights. Its predictive validity was compared to the Modified Early Warning Score ( MEWS), the Robson screening tool, and the BAS 90-30-90. Results A total of 375 patients were included in the derivation sample; 93 (24.8%) of these had sepsis, including 60 patients with severe sepsis and 12 patients with septic shock. Backward model selection identified temperature, HR, RR, SaO2, and sBP for inclusion in the PRESEP score. Simplified weights were as follows: temperature > 38°C = 4, temperature < 36°C = 1, HR > 90 beats/min = 2, RR > 22 breaths/min = 1, SaO2 < 92% = 2, and sBP < 90 mm Hg = 2. The cutoff value for a possible existing septic disease based on maximum Youden's index was ≥4 (sensitivity 0.85, specificity 0.86, positive predictive value [ PPV] 0.66, and negative predictive value [ NPV] 0.95). The area under the receiver operating characteristic curve ( AUC) of the PRESEP score was 0.93 (95% confidence interval [ CI] = 0.89 to 0.96) and was larger than the AUC of the MEWS (0.93 vs. 0.77, p < 0.001). The PRESEP score surpassed MEWS and BAS 90-60-90 for sensitivity (0.74 and 0.62, respectively), specificity (0.75 and 0.83), PPV (0.45 and 0.51), and NPV (0.91 and 0.89). The Robson screening tool had a higher sensitivity and NPV (0.95 and 0.97), but its specificity and PPV were lower (0.43 and 0.32). Conclusions The PRESEP score could be a valuable tool for identifying septic patients in the prehospital setting in the case of suspected infection. It should be prospectively validated. [ABSTRACT FROM AUTHOR]

SUMMARY Background Many tools are used to examine the Quality of Life (QOL) of patients with kidney disease, but little is known about how culturally relevant they are and why one should utilise one tool over another. As part of a larger study on the QOL of dialysis patients in United Arab Emirates, the cultural relevance of two tools (SF-36 and the QOL Index) was examined. This paper suggests a model to establish cultural relevance of QOL tools. Method A descriptive comparative survey design using a mixed method design was used in 2007 to study the QOL of 161 patients on dialysis and 350 people from the community. The cultural relevance of each tool was assessed by (i) examining missed questions, (ii) asking respondents about the cultural relevance of each tool, (iii) asking respondents what questions could be added or deleted to make the tools more culturally relevant and (iv) asking respondents to identify the factors that might contribute to their QOL. Results Of respondents, 94.7% from the dialysis sample and 90.4% from the community sample considered both tools culturally relevant. The QOL Index tool had more missing data. Many of the themes generated from the analysis of the qualitative data were addressed by the subscales of both tools. Themes not addressed by either tool were concerned with values, safety and country. Conclusion Cultural adaptation of QOL tools needs to follow well-established guidelines. The target population should be involved in establishing the cultural relevance of QOL tools. [ABSTRACT FROM AUTHOR]

The rise of quality improvement research and comparative effectiveness research in health care settings constitutes progress toward the goal of what the Institute of Medicine has called a 'learning healthcare system,' in which we are 'drawing research closer to clinical practice by building knowledge development and application into each stage of the healthcare delivery process.' As clinical research and clinical practice move closer to a deliberately integrated system, the distinction between the two is increasingly blurred, although the sharp distinction in U.S. regulations and research ethics literature remains in place. In the 1970s and for two decades thereafter, this distinction was helpful: for some forms of research, it sheds light on which activities require ethical oversight. Research that is closely integrated with health care-notably, health delivery research-was then uncommon, however. That is no longer the case, and regulations and research ethics need to change to accommodate the new landscape. In this paper, we argue that conceptual, moral, and empirical problems surround the received view that we can and should draw sharp distinctions between clinical research and clinical practice. We start with the history of the research-practice distinction in the reports of a U.S. national commission and in U.S. federal regulations, and then offer a critical assessment of five characterizations of research that have been used in policy documents and the scholarly literature to try to make a sharp distinction between research and practice. We challenge the clarity and the tenability of these characterizations as a way of distinguishing research from practice. We argue that the received view of the research-practice distinction leads to overprotection of the rights and interests of patients in some cases and to underprotection in others. We contend that a new ethical foundation needs to be developed that facilitates both care and research likely to benefit patients, and that provides oversight that, rather than being based on a distinction between research and practice, is commensurate with risk and burden in both realms. [ABSTRACT FROM AUTHOR]

The lung cancer Optimal Care Pathway recommends supportive care and palliative care integration throughout its various steps, with early referral to appropriate services improving the quality of life in advanced stage non‐small cell lung cancer patients. Using Victorian Lung Cancer Registry data and linked administrative datasets, this retrospective cohort study mapped clinical care pathways of 525 Stage III–IV non‐small cell lung cancer patients in Victoria to 11 recommendations in the Optimal Care Pathway, identifying unwarranted variations in clinical care. Supportive care and palliative care delivery were further examined to understand the involvement and timing of specialist care teams. Our findings showed that palliative care utilization is highest at the time of treatment, despite recommendations that it should be provided early after diagnosis to improve patient outcomes and satisfaction. Early supportive care screening was observed in half the cohort and almost three‐quarters of the patients had been presented at a multidisciplinary meeting. Multidisciplinary meeting presentations and supportive care provide an opportunity to improve communication about palliative care needs and integration into routine clinical practice, such as at the time of treatment planning. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to assess the paediatric and adult diabetes care provided to adolescents and young adults with childhood‐onset type 1 diabetes during the transition. Methods: This nationwide population‐based cohort study included 776 individuals with type 1 diabetes who were last registered in the Norwegian Childhood Diabetes Registry (NCDR) between 2009 and 2012 and had received adult health care for at least 2 years. The patients' experiences were reported in a validated questionnaire. Clinical data from the annual registrations in the NCDR were coupled with data from the medical records in adult diabetes care. The longitudinal measures of glycaemic control were analysed using a growth mixture model. Results: A total of 321 young people answered the questionnaire and provided written informed consent for the collection of their data from their medical records. The mean age at transfer was 18.0 years (range = 15.0–23.5 years), and the mean age at participation was 22.7 years (range = 20.9–26.7 years). Significant differences (p < 0.001) in patient experiences were found between paediatric and adult diabetes care in several areas: contact with health‐care personnel, continuity of care, interval between consultations and overall satisfaction. Registry and medical records data confirmed the patient‐reported experiences. The longitudinal analyses identified two groups with distinctly different trajectories of glycaemic outcome over time. Patient–provider continuity and perceived preparedness for transfer were the most influential predictors. Conclusions: This study highlights several areas to be addressed for improving health care and the transition to adult diabetes care in adolescents and young adults with type 1 diabetes, including provider continuity, individualised care and involvement of multidisciplinary teams. [ABSTRACT FROM AUTHOR]

The papers by Nancy Kass, Ruth Faden, and colleagues describe an ethical imperative to study clinical care as it is being delivered. The goal of learning from each patient is attractive, but integrating research and clinical practice is not easy. The authors suggest that the bioethical framework in use for the past forty years to oversee clinical research may be as much an impediment to the development of a learning health care system as a means of protecting the interests of patients. This framework draws a bright line between clinical research and clinical care activities, subjecting clinical research to institutional review and ongoing oversight while assuming that clinical care is conducted primarily in the interests of patients and not in need of additional ethical oversight. The authors identify five characteristics that have been used to distinguish the two activities, and they conclude that none succeed. The practical implications of this conclusion are left unspecified, however. Should ethical oversight simply be eliminated for these kinds of research activities on the grounds that oversight is not mandated for clinical care and the two cannot be distinguished? [ABSTRACT FROM AUTHOR]

The article presents a study which investigated differences in post-acute care admissions before and during the COVID-19 pandemic in Sao Paulo, Brazil. Topics discussed include differences in admissions according to the study period, impact of the COVID-19 pandemic on the incipient post-acute care setting in Brazil, and characteristics and outcomes of post-acute care admissions before and during the pandemic.

The 2018 implementation guidance for the Baby‐Friendly Hospital Initiative (BFHI) recommends institutionalising the ten Steps through nine national responsibilities for universal coverage and sustainability. As countries adapt BFHI programmes to this paradigm shift away from traditional designation programmes, documenting and sharing policy and programme experience are critical and currently sparse. This qualitative case study included desk reviews of published and grey literature on BFHI programming, national plans and policy documents specific to the selected national responsibilities for universal coverage and key informant (KI) interviews across a range of actors. In the Kyrgyz Republic, the case study explored responsibility 5, development and implementation of incentives and/or sanctions, and responsibility 6 in Malawi, providing technical assistance (TA). In both countries, the three sustainability responsibilities (national monitoring [7] communication and advocacy [8] and financing [9]) as they relate to the universal coverage of the targeted responsibilities were also explored. Thirty‐eight respondents in the Kyrgyz Republic described approaches that were used in the health system, including BFHI designation plaques, performance‐based financing and financial sanctions. However, currently, there are no formal incentives and sanctions. In Malawi, TA was utilised for national planning and to introduce quality improvement processes. Forty‐seven respondents mostly described provisions of TA in building and strengthening the capacity of providers. More programmatic evidence to demonstrate which types of incentives or sanctions can be effective and sustained and more documentation of how TA is provided across multiple aspects of implementation are needed as countries institutionalise BFHI. Key messages: 1.National policies and national and subnational plans need to be effectively communicated throughout the health system and systematic coordination are important to institutionalising Baby‐Friendly Hospital Initiative (BFHI).2.Technical assistance, commonly provided for professional competency building, could support hospital practices, procedures and management.3.Understanding the motivations of providers and health systems and monitoring key indicators are important for incentives and sanctions to be effective.4.Documenting and sharing programmatic experiences are critical as countries adopt the new BFHI guidance.5.Multisectoral advocacy for the ten Steps is needed to secure national and local commitment and funding across and beyond the health system. [ABSTRACT FROM AUTHOR]

Background: Hypertension is a major risk factor for cardiovascular diseases, which contributes to the worldwide mortality rate. Successful blood pressure control requires adherence to medications and lifestyle modifications. However, motivating patients with primary hypertension to change and sustain behaviors long‐term is challenging. A web‐based self‐care program centered on self‐efficacy theory could provide feedback for effective control of blood pressure. Purpose: To examine the effect of a web‐based self‐care program for patients with primary hypertension on cardiovascular risk‐factors (pulse pressure and lipids), self‐efficacy, and self‐care behaviors (medication adherence and lifestyle). Design A two‐armed randomized controlled trial with 3‐month and 6‐month follow‐ups. Setting and Participants: A total of 222 patients with primary hypertension were recruited between February 2017 and August 2018 at a cardiology clinic of a medical center in Taipei, Taiwan. Methods: Eligible patients were randomized by permuted block randomization into the intervention group (n = 111) and control group (n = 111). Patients in the intervention group received a 6‐month web‐based self‐care program, based on the theory of self‐efficacy, while patients in the control group received usual care. Baseline and outcome measures (3 and 6 months) included self‐efficacy, evaluated with the Chinese version of the 6‐item Self‐Efficacy for Managing Chronic Diseases (SEMC6), self‐care, using subscales of the Hypertension Self‐Care Activity Level Effects Scale (H‐SCALE) for lifestyle and medication adherence, and blood pressure and serum lipid data, collected through web‐based self‐reports and chart review. Generalized estimating equations evaluated the effects of the intervention. Findings At baseline, the control group had higher scores on the SEMC6, and lower cholesterol (HDL) compared with the intervention group (t = −2.70, p < 0.05; and t = 1.76, p < 0.05, respectively). Pulse pressure decreased significantly (β = −20.30, 95% CI −23.76, −16.83), and serum triglycerides and low‐density lipoprotein cholesterol levels were significantly lower compared with controls at 6 months (all p < 0.001). At 6 months, the intervention group had significantly higher mean scores for the SEMC6 compared with the control group (β = 21.84, 95% confidence interval [CI] 19.25, 24.42) and H‐SCALE subscale for medication adherence, diet, weight management, and physical activity compared with controls at 6 months (all, p < 0.001). Conclusions and clinical relevance: The greatest benefit of this program was allowing participants to immediately consult with the researchers about self‐care issues via the website. Lifestyles vary from person to person; therefore, the individuality of each participant was considered when providing feedback. We provided devising interventions for participants that would increase their confidence in self‐care for hypertension and ultimately achieve home blood pressure control. We encourage incorporating this program into standard clinical care for patients with hypertension. [ABSTRACT FROM AUTHOR]

Background: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients. Methods: We prospectively identified patients ≥75 years admitted to the EGS service at an urban tertiary care hospital from January 2020–March 2021 who screened positive for frailty (FRAIL score ≥3 [scale 0–5, higher being worse]) or with cognitive impairment. A pilot geriatric surgical service, led by a dually‐board certified geriatric and palliative care specialist, conducted a comprehensive geriatric assessment and modified Rockwood Frailty Index calculation for each eligible patient. Patient, hospital admission, and geriatric consultation characteristics were collected via chart review. Results: Fifty consecutive patients (median age 82 years [IQR 78–90], 56% female) received geriatric consultation (median time 3 days [IQR 1–6] from admission). The most common admission diagnosis was bowel obstruction (32%). Sixty‐four percent of patients underwent ≥1 surgical procedure. Using the Frailty Index, 64% were moderately or severely frail. Interventions most frequently performed by the geriatric team included delirium prevention and management (66%), consideration of swallowing function (52%), individualized pain management (50%), and facilitation of serious illness conversations (58%). Conclusions: Geriatric service involvement addresses a high burden of both geriatric and palliative care needs in older EGS patients. Geriatric recommendations may direct interventions for surgical education in fundamental geriatric and palliative care knowledge to maximize geriatric resources for the most high‐risk patients. [ABSTRACT FROM AUTHOR]

Purpose: Nurses are on the forefront of delivering care to patients hospitalized with COVID‐19. Nurses' impact on patient care can be discerned through assessment and documentation strategies, including structured and unstructured narratives, clinical pathways, flowsheets, and problem‐based approaches. To date, there are no published reports regarding nursing assessment and documentation during the COVID‐19 pandemic using an assessment framework to capture clinical decision making, nursing diagnoses, and key social determinant of health (SDoH) data. Hence, the purpose of this investigation was to conduct an exploratory nursing documentation audit of patients hospitalized with COVID‐19 during the first surge to identify types and frequency of nurse‐sensitive indicators, including SDoH. Method: This pilot study utilized a retrospective chart review design at a single academic medical center, utilizing Gordon's Eleven Functional Health Patterns (FHP) framework to extract clinical, social, and nursing assessment data for patients hospitalized with COVID‐19. Descriptive statistics were computed for continuous variables and counts/percentages for categorical variables. Findings: Data from 94 patient records were analyzed. Most patients were male (59.6%), with a mean age of 58 years. Nearly 15% of patients were Black and 12.8% were Hispanic, most residing in four geographic areas. Nine of the 11 FHPs were reflected in nurse‐sensitive indicators documented in the electronic health record. SDoH data were inconsistently documented, including race, education, history of neglect/abuse, and occupation. Conclusion: The FHP framework captured many nurse‐sensitive indicators during the first COVID‐19 surge, although screening for and documenting SDoH data were limited. Implications for nursing practice: Findings can influence the development of nursing assessment and documentation during crisis care delivery that are inclusive of distinct sociodemographic factors, in addition to clinical factors, to provide comprehensive, culturally sensitive care. Such documentation will enhance the use of nursing knowledge guided by a nursing framework to make visible the essential contributions of nurses to healthcare delivery. [ABSTRACT FROM AUTHOR]

The article discusses the increase of for real-time goal concordant care (GCC) by the Your Care advanced care planning (ACP) website and advance directives (AD) in 2023. Topics covered include the latter's effectivity in increasing self-reported, real-time GCC among older English- and Spanish-speaking patients and mitigation of disparities among those with limited health literacy. Also noted are ACP's likelier result of GCC as they focus on quality of life and informed decision making.

This study examined the association between adding nurse aides and patient mortality in acute care settings. We conducted a retrospective cohort study using a national healthcare administrative claims database. We identified patients who underwent planned surgery for six types of cancer from 2010 to 2017. Multivariable logistic analyses were used to examine the association between the nurse aide staffing level and patient outcomes. The primary outcomes were failure to rescue and 30‐day hospital mortality. We examined 330 666 in‐hospital patients. The median number of nurse aides per 100 occupied beds was 6.60 (interquartile range, 4.61–8.43). In the multivariable analysis, nurse aide staffing level was not significantly associated with failure to rescue or 30‐day hospital mortality. The Japanese government provides economic incentives to hospitals that hire more nurse aides, expecting that a higher nurse aide staffing level will help licensed nurses concentrate on the tasks that need their specialties. However, our findings suggest that adding nurse aides may not be associated with lower rates of failure to rescue or 30‐day hospital mortality in acute care settings. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:959-967 © 2012 by the Society for Academic Emergency Medicine Abstract Background: Many decisions in the emergency department (ED) may benefit from patient involvement, even though this setting has been considered least conducive to shared decision-making (SDM). Objectives: The objective was to conduct a systematic review to evaluate the approaches, methods, and tools used to engage patients or their surrogates in SDM in the ED. Methods: Five electronic databases were searched in conjunction with contacting content experts, reviewing selected bibliographies, and conducting citation searches using the Web of Knowledge database. Two reviewers independently selected eligible studies that addressed patient involvement and engagement in decision-making in the ED setting via the use of decision support interventions (DSIs), defined as decision aids or decision support designed to communicate probabilistic information on the risks and benefits of treatment options to patients as part of an SDM process. Eligible studies described and assessed at least one of the following outcomes: patient knowledge, experiences and perspectives on participating in treatment or management decisions, clinician or patient satisfaction, preference for involvement and/or degree of engagement in decision-making and treatment preferences, and clinical outcomes (e.g., rates of hospital admission/readmission, rates of medical or surgical interventions). Two reviewers extracted data on study characteristics, methodologic quality, and outcomes. The authors also assessed the extent to which SDM interventions adhered to good practice for the presentation of information on outcome probabilities (eight probability items from the International Patient Decision Aid Standards Instrument [IPDASi]) and had comprehensive development processes. Results: Five studies met inclusion criteria and were synthesized using a narrative approach. Each study was of satisfactory methodologic quality and used a DSI to engage patients or their surrogates in decision-making in the ED across four domains: 1) management options for children with small lacerations; 2) options for rehydrating children presenting with vomiting or diarrhea or both; 3) risk of bacteremia (and associated complications), tests, and treatment options for febrile children; and 4) short-term risk of acute coronary syndrome (ACS) in adults with low-risk nontraumatic chest pain. Three studies had poor IPDASi probabilities and development process scores and lacked development informed by theory or involvement of clinicians and patients in development and usability testing. Overall, DSIs were associated with improvements in patients' knowledge and satisfaction with the explanation of their care, preferences for involvement, and engagement in decision-making and demonstrated utility for eliciting patients' preferences and values about management and treatment options. Two computerized DSIs (designed to predict risk of ACS in adults presenting to the ED with chest pain) were shown to reduce health care use without evidence of harm. None of the studies reported lack of feasibility of SDM in the ED. Conclusions: Early investigation of SDM in the ED suggests that patients may benefit from involvement in decision-making and offers no empirical evidence to suggest that SDM is not feasible. Future work is needed to develop and test additional SDM interventions in the ED and to identify contextual barriers and facilitators to implementation in practice. [ABSTRACT FROM AUTHOR]

Background: NHS case note data are a potential source of practice-based evidence which could be used to investigate the effectiveness of different interventions for individuals with a range of speech, language and communication needs. Consistency in pre- and post-intervention data as well as the collection of relevant variables would need to be demonstrated as a precursor to adopting this approach in future investigations of speech and language therapy intervention. Aims: To explore whether routine clinical data collection for children with speech sound disorder (SSD) could be a potential source for examining the effectiveness of intervention(s). Methods & Procedures:We examined case notes from three UK NHS services, reviewing 174 sets of case notes and 234 blocks of therapy provided for school-age children with SSD. Main contribution: We found there was significant variation in pre- and postintervention data and variables collected by the services. The assessment data available in the case notes across all sites were insufficient to be used to compare the effectiveness of different interventions. Specific issues included lack of consistent reporting of pre- and post-intervention data, and use of a variety of both formal and informal assessment tools. Conclusions & Implications: The case notes reviewed were from three sites and may not represent wider clinical practice, nevertheless the findings suggest the sample explored indicates the need for more consistent and contemporaneous collection of data for children with SSD to facilitate the investigation of different interventions in practice. Researchers should work with the clinical community to determine a minimal dataset that includes a core outcome set and potential variables. This should be feasible to collect in clinical practice and provide a dataset for future investigations of clinically relevant research questions. This would provide an invaluable resource to the clinical academic and research communities enabling research questions to be addressed that have the potential to lead to improved outcomes and more cost-effective services. [ABSTRACT FROM AUTHOR]

Aim: To link routinely collected health data to a cerebral palsy (CP) register in order to enable analysis of healthcare use by severity of CP.Method: The Northern Ireland Cerebral Palsy Register was linked to hospital data. Data for those on the CP register born between 1st January 1981 and 31st December 2009 and alive in 2004 were extracted, forming a CP cohort (n=1684; 57% males, 43% females; aged 0-24y). Frequencies of healthcare events, and the reasons for them, were reported according to CP severity and compared with those without CP who had had at least one hospital attendance in Northern Ireland within the study period.Results: Cases of CP represented 0.3% of the Northern Ireland population aged 0 to 24 years but accounted for 1.6% of hospital admissions and 1.6% of outpatient appointments. They had higher rates of elective admissions and multi-day hospital stays than the general population. Respiratory conditions were the most common reason for emergency admissions. Those with most severe CP were 10 times more likely to be admitted, and four times more likely to attend outpatients, than those with mild CP.Interpretation: Linkage between a register and routinely collected healthcare data provided a confirmed cohort of cases of CP that was sufficiently detailed to analyse healthcare use by disease severity. [ABSTRACT FROM AUTHOR]

With heighted interest in causal inference based on real-world evidence, this empirical study sought to understand differences between the results of observational analyses and long-term randomized clinical trials. We hypothesized that patients deemed "eligible" for clinical trials would follow a different survival trajectory from those deemed "ineligible" and that this factor could partially explain results. In a large observational registry dataset, we estimated separate survival trajectories for hypothetically trial-eligible vs ineligible patients under both coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI). We also explored whether results would depend on the causal inference method (inverse probability of treatment weighting vs optimal full propensity matching) or the approach to combine propensity scores from multiple imputations (the "across" vs "within" approaches). We found that, in this registry population of PCI/CABG multivessel patients, 32.5% would have been eligible for contemporaneous RCTs, suggesting that RCTs enroll selected populations. Additionally, we found treatment selection bias with different distributions of propensity scores between PCI and CABG patients. The different methodological approaches did not result in different conclusions. Overall, trial-eligible patients appeared to demonstrate at least marginally better survival than ineligible patients. Treatment comparisons by eligibility depended on disease severity. Among trial-eligible three-vessel diseased and trial-ineligible two-vessel diseased patients, CABG appeared to have at least a slight advantage with no treatment difference otherwise. In conclusion, our analyses suggest that RCTs enroll highly selected populations, and our findings are generally consistent with RCTs but less pronounced than major registry findings. [ABSTRACT FROM AUTHOR]

Objective: To compare different methods of indexing health care service prices for the commercially insured population across geographic markets.Data Sources: Health Care Cost Institute commercial claims data from 2012 to 2016.Study Design: We compare price indices computed using methods with differing levels of computational intensity: weighted-average versus regression-based methods. We separately compute indices of the prices paid for set of common inpatient and set of common outpatient services in different markets across the United States using each type of method. We subsequently examined the variation of and correlations between the resulting index values.Data Collection/extraction Methods: We computed health care service price indices separately using samples of inpatient and outpatient facility claims from 2012 to 2016 across 112 Core-Based Statistical Areas. Within each category of services, claims were limited to members under the age of 65 with employer-sponsored insurance. Both samples were limited to a common set of services that made up nearly 80 percent of the service use in the full sample every year.Principal Findings: We found that the methods studied produced highly correlated price indices (r > .94) with similar distributions across years for both inpatient and outpatient services.Conclusions: Our findings suggest that weighted-average methods, which are much less computationally intensive, will generate results similar to regression-based methods. [ABSTRACT FROM AUTHOR]

Aim: Recent evidence is emerging indicating long-term effects in infants born after an episode of preterm labour (PTL), even if birth is at term. This population-based study compared long-term rates of outcomes and health-care utilisation (HCU) in children born following spontaneous preterm labour, irrespective of gestational age at delivery or of an uncomplicated pregnancy (SPTLu), with children born following full-term labour (FTL), overall stratified by comorbidity status and assessed using a composite morbidity measure (CM).Methods: Retrospective data on mother-neonate pairs were collected from a patient-linked dataset from the Netherlands Perinatal Registry and the PHARMO Database Network. Children born between 2000 and 2010 were followed until 2012.Results: Of pregnancies in 134 006 mother-neonate pairs, 122 894 (92%) pregnancies resulted in FTL, and 11 112 (8%) resulted in PTL. Of the PTL pregnancies, 6599 (59%) were SPTLu. Mean follow-up after birth was 6.6-6.7 years. Children from SPTLu pregnancies were at increased risk of neurodevelopmental and respiratory conditions compared with those from FTL pregnancies. In children from SPTLu pregnancies, the presence of the CM was associated with an increased risk of respiratory conditions and failure to thrive. Post-natal hospitalisations (incidence rate (IR) per 100 patient-years: 18.1 vs. 11.7) and specialist referrals (IR per 1000 patient-years: 290.6 vs. 184.5) occurred significantly more frequently in children from SPTLu versus FTL pregnancies.Conclusion: The increased risk of morbidities and HCU in children born following SPTLu pregnancy in this population-based setting reinforces the need for safe interventions that can effectively halt labour and lead to an improvement in childhood outcomes. [ABSTRACT FROM AUTHOR]

Event data are collected in logistics, manufacturing, finance, health care, customer relationship management, e‐learning, e‐government, and many other domains. The events found in these domains typically refer to activities executed by resources at particular times and for a particular case (i.e., process instances). Process mining techniques are able to exploit such data. In this article, we focus on process discovery. However, process mining also includes conformance checking, performance analysis, decision mining, organizational mining, predictions, recommendations, and so on. These techniques help to diagnose problems and improve processes. All process mining techniques involve both event data and process models. Therefore, a typical first step is to automatically learn a control‐flow model from the event data. This is very challenging, but in recent years, many powerful discovery techniques have been developed. It is not easy to compare these techniques since they use different representations and make different assumptions. Users often need to resort to trying different algorithms in an ad‐hoc manner. Developers of new techniques are often trying to solve specific instances of a more general problem. Therefore, we aim to unify existing approaches by focusing on log and model abstractions. These abstractions link observed and modeled behavior: Concrete behaviors recorded in event logs are related to possible behaviors represented by process models. Hence, such behavioral abstractions provide an “interface” between both of them. We discuss four discovery approaches involving three abstractions and different types of process models (Petri nets, block‐structured models, and declarative models). The goal is to provide a comprehensive understanding of process discovery and show how to develop new techniques. Examples illustrate the different approaches and pointers to software are given. The discussion on abstractions and process representations is also presented to reflect on the gap between process mining literature and commercial process mining tools. This facilitates users to select an appropriate process discovery technique. Moreover, structuring the role of internal abstractions and representations helps broaden the view and facilitates the creation of new discovery approaches. This article is categorized under: Algorithmic Development > Spatial and Temporal Data Mining Application Areas > Business and Industry Technologies > Machine Learning Application Areas > Data Mining Software Tools [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of proxy survey responses on cancer care experience reports and quality ratings.Data Sources/study Setting: Secondary analysis of data from Cancer Care Outcomes Research and Surveillance (CanCORS). Recruitment occurred from 2003 to 2005.Study Design: The study was a cross-sectional observational study. The respondents were patients with incident colorectal or lung cancer or their proxies.Data Collection/extraction Methods: Analyses used linear regression models with an independent variable for proxy versus patient responses as well as study site and clinical covariates. The outcomes were experiences with medical care, nursing care, care coordination, and care quality rating. Multiple imputation was used for missing data.Principal Findings: Among 6,471 respondents, 1,011 (16 percent) were proxies. The proportion of proxy respondents varied from 6 percent to 28 percent across study sites. Adjusted proxy scores were modestly higher for medical care experiences (+1.28 points [95 percent CI:+ 0.05 to +2.51]), but lower for nursing care (-2.81 [95 percent CI: -4.11 to -1.50]) and care coordination experiences (-2.98 [95 percent CI: -4.15 to -1.81]). There were no significant differences between adjusted patient and proxy ratings of quality.Conclusions: Proxy responses have small but statistically significant differences from patient responses. However, if ratings of care are used for financial incentives, such differences could be exaggerated across practices or areas if proxy use varies. [ABSTRACT FROM AUTHOR]

Context: The seeking and incorporating of feedback are necessary for continuous performance improvement in medicine. We know that beginning feedback conversations with resident self‐assessment may reduce some of the tensions experienced by faculty staff. However, we do not fully understand how residents experience feedback that begins with self‐assessment, and whether any existing theoretical frameworks can explain their experiences. Methods: We conducted a constructivist grounded theory study exploring physical medicine and rehabilitation residents' experiences as they engaged in a structured self‐assessment and faculty staff feedback programme. Utilising purposive sampling, we conducted 15 individual interviews and analysed verbatim transcripts iteratively. We implemented several procedures to enhance the credibility of the findings and the protection of participants during recruitment, data collection and data analysis. After defining the themes, we reviewed a variety of existing frameworks to determine if any fitted the data. Results: Residents valued self‐assessment followed by feedback (SAFF) and had clear ideas of what makes the process useful. Time pressures and poor feedback quality could lead to a process of ‘just going through the motions’. Motivation coloured residents' experiences, with more internalised motivation related to a more positive experience. There were no gender‐ or year of training‐related patterns. Conclusions: Self‐determination theory provided the clearest lens for framing our findings and fitted into a conceptual model linking the quality of the SAFF experience and residents' motivational loci. We identified several study limitations including time in the field, evolving characteristics of the SAFF programme and the absence of faculty voices. We believe that by better understanding residents' experiences of SAFF, educators may be able to tailor the feedback process, enhance clinical performance and ultimately improve patient care. [ABSTRACT FROM AUTHOR]

Background Over 35 million alcohol-impaired ( AI) patients are cared for in emergency departments ( EDs) annually. Emergency physicians are charged with ensuring AI patients' safety by identifying resolution of alcohol-induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients. Objective The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack's Impairment Index ( HII score), in a busy urban ED. Methods A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both 'usual' and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated. Results A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R2 = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients' visits. Conclusions The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations. [ABSTRACT FROM AUTHOR]

Objective The present study aimed to determine whether the time of out-of-hospital cardiac arrest ( OHCA) is associated with survival rate and neurological outcome after OHCA, as well as to compare the effect size of time of OHCA across six Asian regions. Methods We collected data from the Pan-Asian Resuscitation Outcomes Study registry, six Asian regions (Tokyo, Osaka, Aichi, Seoul, Taipei and Singapore) from 2009 to 2012. Adult OHCA cases were divided depending on the arrest time: I (00.01-06.00 hours), II (06.01-12.00 hours), III (12.01-18.00 hours) and IV (18.01-24.00 hours). Using a multivariable logistic regression analysis, we compared the outcomes of survival and good neurological recovery. Results Of 65 413 cases treated by the emergency medical service, 36 706 (56.1%) cases were analysed. There was the lowest OHCA incidence in time block I. Compared with time block I, the adjusted odds ratios and 95% confidence intervals for the standardised survival rate were 1.6 (1.3-1.9) in time block II, 1.4 (1.2-1.7) in time block III and 1.2 (1.0-1.4) in time block IV. Regarding the good neurological recovery rate, compared with time block I, the adjusted odds ratios and 95% confidence intervals were 1.9 (1.5-2.4) in time block II, 1.7 (1.3-2.1) in time block III and 1.4 (1.1-1.7) in time block IV. However, in the subgroup analysis, there were regional differences between Japan and the other regions. Conclusions We found diurnal similarities in OHCA occurrence, as well as differences in survival rate and good neurological recovery rate among Asian regions. [ABSTRACT FROM AUTHOR]

Background The current subclassification of migraine is according to headache frequency and aura status. The variability in migraine symptoms, disease course, and response to treatment suggest the presence of additional heterogeneity or subclasses within migraine. Objective The study objective was to subclassify migraine via a data-driven approach, identifying latent factors by jointly exploiting multiple sets of brain structural features obtained via magnetic resonance imaging (MRI). Methods Migraineurs ( n = 66) and healthy controls ( n = 54) had brain MRI measurements of cortical thickness, cortical surface area, and volumes for 68 regions. A multimodality factor mixture model was used to subclassify MRIs and to determine the brain structural factors that most contributed to the subclassification. Clinical characteristics of subjects in each subgroup were compared. Results Automated MRI classification divided the subjects into two subgroups. Migraineurs in subgroup #1 had more severe allodynia symptoms during migraines (6.1 ± 5.3 vs. 3.6 ± 3.2, P = .03), more years with migraine (19.2 ± 11.3 years vs 13 ± 8.3 years, P = .01), and higher Migraine Disability Assessment (MIDAS) scores (25 ± 22.9 vs 15.7 ± 12.2, P = .04). There were not differences in headache frequency or migraine aura status between the two subgroups. Conclusions Data-driven subclassification of brain MRIs based upon structural measurements identified two subgroups. Amongst migraineurs, the subgroups differed in allodynia symptom severity, years with migraine, and migraine-related disability. Since allodynia is associated with this imaging-based subclassification of migraine and prior publications suggest that allodynia impacts migraine treatment response and disease prognosis, future migraine diagnostic criteria could consider allodynia when defining migraine subgroups. [ABSTRACT FROM AUTHOR]

Research in sociology suggests that the effects of standards are not nearly as straightforward or as homogenising as they first appear. The present study extends these insights by demonstrating how even standards designed simply to collect data can produce extensive and unanticipated effects in medical fields as their uses evolve across actors and contexts. We draw on an embedded case study exploring the multifaceted consequences of the use of a practice-driven voluntary documentation standard: the Swedish rheumatology quality registry from 1995-2014. Data collection included document analysis; 100 interviews with specialists, patients and stakeholders in the field; fieldwork; and observations of physician-patient encounters. Our findings show that the scope and influence of the registry increased over time, and that this standard and its evolution contributed to changes in rheumatologist clinical practice, research practice, and governmental practice. These findings suggest that even initially 'weak', voluntary forms of standardisation can generate far-reaching and unpredictable consequences for the performance and delivery of care as well as for the development of a medical field. Future work about how standards can contribute both to uniformity and diversity is warranted. [ABSTRACT FROM AUTHOR]

Objectives To examine caregiver factors associated with unmet needs for care of older adults. Design Population-based surveys of caregivers and older adult care recipients in the United States in 2011. Setting 2011 National Health and Aging Trends Study and National Study of Caregiving. Participants Family caregivers (n = 1,996) of community-dwelling older adults with disabilities (n = 1,366). Measurements Disabled care recipient reports of unmet needs for care in the past month with activities of daily living ( ADLs; e.g., wet or soiled clothing), mobility (e.g., have to stay inside), or instrumental activities of daily living ( IADLs; e.g., medication errors). Caregiver reported sociodemographic characteristics, caregiving intensity and tasks performed, health, and psychosocial effects. Results Of the care recipients, 44.3% reported at least one unmet need for care in the past month (38.2% ADL related, 14.6% IADL related). Younger caregivers, caregiving sons, caregivers not living with care recipients, and having supplemental paid caregivers were associated with more unmet needs. Caregivers with recipients reporting two or more unmet needs were more likely to spend more than 100 hours per month caregiving, help with skin care and wounds, report caregiving as emotionally and physically difficult, and report restricted participation in valued activities (all P < .001). Conclusion Unmet ADL needs are prevalent among older adults with family caregivers. Caregivers experiencing high levels of burden, stress, and negative physical and psychosocial impacts may provide substandard or poor care to older adults, which may be a risk factor for neglect. Clinicians caring for disabled older adults should assess their unmet needs and the capacity of caregivers to address them. [ABSTRACT FROM AUTHOR]

Aim: To identify the prevalence, management and complications associated with central venous access devices (CVADs) within Australian paediatric facilities, providing a map for clinicians, researchers and managers to focus solutions.Methods: A point prevalence audit and survey of CVAD practices in Australian tertiary paediatric hospitals between September and November 2015, using validated data collection tools.Results: Across the six sites, 1027 patients were screened with CVADs prevalent in 26.1% (n = 268), and 261 CVADs in 248 patients available for audit. Variations in management were evident with dressings not meeting the basic criteria of clean, dry and intact for 13.5% of CVADs (n = 35), and non-sterile dressings used to reinforce 26.4% of CVADs (n = 69). Almost half of CVADs (49.4%; n = 132) had no documentation regarding site assessment in the previous 4 h, and 13.4% had no planned use in the next 24 h (35 CVAD). CVAD-associated complications within the previous 7 days were evident in 9.5% of CVADs (n = 27), most commonly catheter blockage (5.7% CVAD, n = 15), and bloodstream infection (1.9% CVAD, n = 5). Peripherally inserted central catheters (16.9%) in comparison to other catheter types (7.4%; P = 0.04), and subsequent CVADs (14.1%) in comparison to initial CVADs (6.5%; P = 0.04), had significantly higher proportions of CVAD-associated complications in the previous 7 days. Variation between the sites' guidelines was evident across many practices.Conclusions: CVADs are prevalent and essential for paediatric health care; however, complications remain a significant problem. Areas identified for improvement were local CVAD guidelines, regular documentation of CVAD site assessment and review of dressing products to improve integrity. [ABSTRACT FROM AUTHOR]

Objective: To improve pharmaceutical care delivery in Malaysia, the Ministry of Health (MOH) had introduced the concept of value added services (VAS). Despite its reported convenience and advantages, VAS utilization rate is low in the country. The study aims to explore patients’ understanding, beliefs and expectations towards VAS in Malaysia using the theory of planned behaviour (TPB) as the theoretical model. Methods: A qualitative methodology was used whereby face‐to‐face interviews were conducted with 12 patients who collected partial medicine supplies from government pharmacies. Participants were recruited using purposive and snowball sampling method in the state of Negeri Sembilan, Malaysia. Interviews were audio‐recorded. Verbatim transcription and thematic content analysis were performed on the data. Results: Thematic content analysis yielded five major themes: (i) attitudes towards using VAS, (ii) subjective norms, (iii) perceived behavioural control, (iv) lack of knowledge and understanding of VAS and (v) expectations towards VAS. Conclusion: The interviews explored and informed new information about salient beliefs towards pharmacy VAS. The findings suggest that VAS is still in its infancy and a more robust and effective advertising and marketing campaign is needed to boost the adoption rate. Behavioural attitudes, subjective norms and perceived control elements were discussed and serve as important variables of interest in future study. Expectations towards VAS serve as an important guideline to further improve patient‐oriented services. [ABSTRACT FROM AUTHOR]

Background Variations in syncope management exist. Our objective was to identify the reasons for consultations and hospitalizations and outcomes among emergency department ( ED) syncope patients. Methods We conducted a prospective cohort study to enroll adult syncope patients at five EDs. We collected baseline characteristics, reasons for consultation and hospitalization, and hospital length of stay. Adjudicated 30-day serious adverse events ( SAEs) including death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage, and procedural intervention. We used descriptive analysis. Results From 4,064 enrolled patients (mean ± SD age = 53.1 ± 23.2 years; 55.9% female), 3,255 (80.1%) were discharged directly by the ED physician. Of those with no SAEs identified in the ED ( n = 600), 42.8% of referrals and 46.5% of hospitalizations were for suspected arrhythmias, and 71.2% of patients hospitalized for arrhythmias had no cause identified. SAEs among groups were 9.7% in total, 2.5% discharged by ED physician, 3.4% discharged by consultant, 21.7% as inpatient, and 4.8% following discharge from hospital. The median hospital length of stay for suspected arrhythmias was 5 days (interquartile range = 3 to 8 days). Conclusion Cardiac syncope, particularly suspected arrhythmia, was the major reason for ED referrals and hospitalization. The majority of patients hospitalized for cardiac monitoring had no identified cause. An important number of patients suffered SAEs, particularly arrhythmias, outside the hospital. Development of a risk-stratification tool and out-of-hospital cardiac monitoring strategy should improve patient safety and save substantial resources. [ABSTRACT FROM AUTHOR]

Objectives Risk stratification of emergency department ( ED) patients with upper gastrointestinal bleeding ( UGIB) using preendoscopic risk scores can aid ED physicians in disposition decision-making. We conducted a systematic review to assess the predictive value of preendoscopic risk scores for 30-day serious adverse events. Methods We searched MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception to March 2015. We included studies involving adult ED UGIB patients evaluating preendoscopic risk scores and excluded reviews, case reports, and animal studies. The composite outcome included 30-day mortality, recurrent bleeding, and need for intervention. In two phases (screening and full review), two reviewers independently screened articles for inclusion and extracted patient-level data. The consensus data were used for analysis. We reported sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios with 95% confidence intervals. Results We identified 3,173 articles, of which 16 were included: three studied Glasgow Blatchford score ( GBS); one studied clinical Rockall score ( cRockall); two studied AIMS65; six compared GBS and cRockall; three compared GBS, a modification of the GBS, and cRockall; and one compared the GBS and AIMS65. Overall, the sensitivity and specificity of the GBS were 0.98 and 0.16, respectively; for the cRockall they were 0.93 and 0.24, respectively; and for the AIMS65 they were 0.79 and 0.61, respectively. The GBS with a cutoff point of 0 had a sensitivity of 0.99 and a specificity of 0.08. Conclusion The GBS with a cutoff point of 0 was superior over other cutoff points and risk scores for identifying low-risk patients but had a very low specificity. None of the risk scores identified by our systematic review were robust and, hence, cannot be recommended for use in clinical practice. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB. [ABSTRACT FROM AUTHOR]

Aims To assess the management of diabetic ketoacidosis in young people, which differs in the UK between paediatric and adult services, and to evaluate outcomes and extent to which national guidelines are used. Methods A standardized questionnaire was sent to all paediatric and adult diabetes services in England, requesting details of all diabetic ketoacidosis admissions in young people aged > 14 years in paediatric services ('paediatric' patients), and in young adults up to the age of 22 years in adult services ('adult' patients). Results A total of 64 adult patients aged ≤ 22 years (mean age 19.2 years) were reported, of whom seven were aged between 10 and 16 years. A total of 71 paediatric patients were reported [mean (range) age 14.9 (11-18) years]. We found that 85% of paediatric and 69% of adult patients were treated according to national guidelines, 99% of paediatric and 89% of adult patients were treated with 0.9% saline and fixed-rate insulin infusions and 16% of adult patients received an insulin bolus. Insulin treatment was initiated later in paediatric patients than in adult patients (100 vs 39 min; P < 0.001). In 23% of adult patients and 8.8% of paediatric patients, potassium levels were < 3.5 mmol/l ( P < 0.005). The lowest mean potassium levels were 3.8 mmol/l in paediatric and 3.5 mmol/l in adult patients ( P < 0.005). Hypoglycaemia occurred in 42.3% of paediatric and 36% of adult patients. Time to resolution was similar in paediatric and adult patients (16.0 vs 18.2 h), as was duration of hospital stay (2.35 vs 2.53 days). Conclusions Young people were treated according to national guidelines, but the quality of monitoring was variable in both paediatric and adult settings. The incidence of hypoglycaemia and hypokalaemia was unacceptably high. [ABSTRACT FROM AUTHOR]

Aims To explore patients' perceptions and experiences of taking oral medications for the pharmacological management of Type 2 diabetes mellitus. Methods Cinahl, EMBASE, Medline and Psyc INFO databases were searched in 2014 to identify qualitative studies exploring patients' perceptions or experiences of taking medications for the management of Type 2 diabetes. Key concepts and themes were extracted and synthesized using meta-ethnography. Results Eight studies were included. Primary study findings were synthesized to develop three higher-order constructs that moved beyond the results of individual studies. The first construct, Medications for diabetes: a necessary evil, outlines how patients' negative perceptions of medication risks co-exist with a resounding view that medications are beneficial. Passive patients but active experimenters highlights the contrast between patients' passive acceptance of medication prescriptions and the urge to actively experiment and adjust doses to optimize medication use in daily life. Finally, Taking oral medication for Type 2 diabetes: a unique context describes features specific to the Type 2 diabetes medication experience, including lack of symptoms and the perceived relationship between medication and diet, which may influence adherence. Conclusions Medication-taking for Type 2 diabetes is a unique adherence context, which requires the development of condition-specific interventions. The present findings indicate patients understand the need for medications but adjust dosage and timing in their daily lives. This review suggests providers should acknowledge patient preferences in the development of management strategies, and highlights an opportunity to direct the motivation evident in patients' experimentation towards potentially more beneficial medication-taking behaviours. [ABSTRACT FROM AUTHOR]

Objective Fall-related visits to emergency departments ( EDs) are common among older individuals. We aimed to assess effectiveness of a healthcare intervention program for the management of elderly patients admitted to EDs after a fall. Methods Using a before-after observation method, we investigated ED healthcare staff practices related to fall-related injuries in 2010 (period 1) and 2012 (period 2) in 13 centers participating in the Northern French Alps Emergency Network. Following the identification of initial weaknesses, several information and training tools were introduced between the two periods to improve patient management. All individuals aged 75 years or over who presented to an ED after a fall were included in the study. We reviewed the completeness and quality of medical records during both periods and compared the rate of clinical-paraclinical check-ups performed, geriatric evaluation/assessment in the ED, and the 1-month recurrence of visits to the ED for the same reason. Results During period 1, a total of 2,425 falls were recorded, while 2,684 were reported in period 2. The 2012 medical charts contained significantly more information about risk factors than those of 2010. An electrocardiogram (64% vs. 53%; p < 0.001), biologic check-up (65% vs. 57%; p < 0.001), balance, orthostatic hypotension, and cognitive impairment tests were more often performed in 2012. There was no change in the hospitalization rate, although short-duration hospitalization in the ED was more frequent in 2012. Geriatrists were more often consulted by patients in 2012 (18% vs. 13%; p < 0.001) and more involved in ED evaluation and hospitalization. The intervention program had a beneficial impact on the fall recurrence rate ( n = 29 [3.6%] in period 1 and n = 17 [2.0%] in period 2; odds ratio = 0.52; p = 0.037), which significantly decreased between 2010 and 2012. Conclusions The intervention program was associated with a decrease of fall recurrence. Further efforts should be made in EDs to ensure a sustained level of satisfactory and long-lasting management of the elderly. [ABSTRACT FROM AUTHOR]

Objectives The objective was to obtain a commitment to adopt a common set of definitions for emergency department ( ED) demographic, clinical process, and performance metrics among the ED Benchmarking Alliance ( EDBA), ED Operations Study Group ( EDOSG), and Academy of Academic Administrators of Emergency Medicine ( AAAEM) by 2017. Methods A retrospective cross-sectional analysis of available data from three ED operations benchmarking organizations supported a negotiation to use a set of common metrics with identical definitions. During a 1.5-day meeting-structured according to social change theories of information exchange, self-interest, and interdependence-common definitions were identified and negotiated using the EDBA's published definitions as a start for discussion. Methods of process analysis theory were used in the 8 weeks following the meeting to achieve official consensus on definitions. These two lists were submitted to the organizations' leadership for implementation approval. Results A total of 374 unique measures were identified, of which 57 (15%) were shared by at least two organizations. Fourteen (4%) were common to all three organizations. In addition to agreement on definitions for the 14 measures used by all three organizations, agreement was reached on universal definitions for 17 of the 57 measures shared by at least two organizations. The negotiation outcome was a list of 31 measures with universal definitions to be adopted by each organization by 2017. Conclusion The use of negotiation, social change, and process analysis theories achieved the adoption of universal definitions among the EDBA, EDOSG, and AAAEM. This will impact performance benchmarking for nearly half of US EDs. It initiates a formal commitment to utilize standardized metrics, and it transitions consistency in reporting ED operations metrics from consensus to implementation. This work advances our ability to more accurately characterize variation in ED care delivery models, resource utilization, and performance. In addition, it permits future aggregation of these three data sets, thus facilitating the creation of more robust ED operations research data sets unified by a universal language. Negotiation, social change, and process analysis principles can be used to advance the adoption of additional definitions. [ABSTRACT FROM AUTHOR]

Objective: To improve the predictions provided by Medicare's Hospital Compare (HC) to facilitate better informed decisions regarding hospital choice by the public.Data Sources/setting: Medicare claims on all patients admitted for Acute Myocardial Infarction between 2009 through 2011.Study Design: Cohort analysis using a Bayesian approach, comparing the present assumptions of HC (using a constant mean and constant variance for all hospital random effects), versus an expanded model that allows for the inclusion of hospital characteristics to permit the data to determine whether they vary with attributes of hospitals, such as volume, capabilities, and staffing. Hospital predictions are then created using directly standardized estimates to facilitate comparisons between hospitals.Data Collection/extraction Methods: Medicare fee-for-service claims.Principal Findings: Our model that included hospital characteristics produces very different predictions from the current HC model, with higher predicted mortality rates at hospitals with lower volume and worse characteristics. Using Chicago as an example, the expanded model would advise patients against seeking treatment at the smallest hospitals with worse technology and staffing.Conclusion: To aid patients when selecting between hospitals, the Centers for Medicare and Medicaid Services (CMS) should improve the HC model by permitting its predictions to vary systematically with hospital attributes such as volume, capabilities, and staffing. [ABSTRACT FROM AUTHOR]

Objective: To describe the current state of the public reporting field and provide guidance to public report producers based on the evidence.Principal Findings: Public reports should address the questions and priorities that consumers actually have; present information credibly and in a way that is understood by the intended audience; reach the intended audience; and enable consumers to act on the information.Conclusions: Public reports have advanced greatly in recent years, but there remains much room for improvement. Report producers should continually evaluate their reports and apply the latest evidence to maximize their usefulness and impact. [ABSTRACT FROM AUTHOR]