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Exposure to urban greenspaces has been linked to improved health outcomes for prevalent conditions. Studies have observed traditional block greenspaces, whereas linear trail systems could maximise health impacts by reaching greater population percentages. We assessed the temporal effects of linear greenspace exposure on health by examining the impact of the Bayou Greenways (BGs) linear trail implementation on health conditions and hospitalisations. We retrospectively analysed inpatient hospitalisation records for Harris County, Texas, from 2015–2019. Thirteen health conditions were explored with hospital admission rates per zip code as the primary outcome. Primary exposure variables were attributes of the BGs interconnected trail system: access duration, ten-minute walk proximity, and access point density. Models were evaluated to assess associations between admission rates in zip codes with and without BGs. Unadjusted analyses for zip codes with high access to trails had reduced odds of admission for obesity (OR, 95%CI: 0.18, 0.10–0.30), ischaemic heart disease (IHD; OR, 95%CI: 0.56, 0.34–0.93), and acute myocardial infarction (AMI; OR, 95%CI: 0.59, 0.37–0.94). Zip codes with >30% of the population within a ten-minute walk showed significant reduction in odds of hospital admission for obesity, (OR, 95%CI: 0.07, 0.03-0.17), IHD (OR, 95%CI: 0.23, 0.12–0.44), and AMI (OR, 95%CI: 0.29, 0.14–0.62). Analysis of socio-economic status (SES) demonstrated that low income and less densely populated areas showed increased admissions for obesity, IHD, AMI, and all-cause hospitalisations. Access to trails may be important in lower SES areas. These findings can inform public policy to integrate greenspace to support healthier communities.

Background The use of mobile health (mHealth) technologies has dramatically increased in the past year. A critical component in the discussion about telehealth and mHealth technologies is the importance of integrating the voices of patients, caregivers, and their clinicians. Methods This study was performed at a tertiary center in Houston consisting of 7 hospitals (1 academic and 6 community hospitals). The clinically integrated mHealth technology consisted of a mHealth education and monitoring platform that used patient-centered emails and text messages over a 50-day period, from prior to the orthopaedic total joint replacement surgery to posthospital discharge to provide education and health monitoring at home. Study participants included patients who were scheduled for total joint replacement surgery between July 2018 and November 2019, and their caregivers. The study involved two components: (1) focus group study (n = 15); split into two groups of participants who had not used the mHealth technology (α-testing during the design phase, prior to implementation); and (2) a content analysis of 377 free-text comments from patients who used the mHealth technology, and who responded to questions about their use of the mHealth platform (β-testing; after implementation, during the execution phase). Thematic analyses methods were used. Results Three key themes emerged during the design phase including: (1) monitoring, bidirectional questions asking patients to respond to a question can feel invasive and/or annoying unless framed in a reciprocal, contextual-based way; (2) text messages should be used selectively for time-sensitive, critical information; and (3) information should be contained within the body of the message. Three themes emerged during the execution phase include: (1) the content should be divided into small, digestible chunks at the times that patients need that information; (2) the tone of the messages should be approachable and friendly, as opposed to detached and professional; and (3) mHealth technologies make patients calmer and more confident and less inclined to draw on hospital personnel, enabling patients to be managed by the automated program without escalating to human care. Limited, bidirectional engagement can foster interactivity and patient monitoring without becoming excessive or burdensome to health care professionals. Conclusion The use of mHealth for patient care is likely to be more effective and used in this multihospital mHealth technology study of patients undergoing orthopaedic surgery, if they are clinically integrated with staff who can respond to escalated problems as needed, to enable better adoption, uptake, and sustainability of technology.

This study evaluated the utility and performance of the LACE index and HOSPITAL score with consideration of the type of diagnoses and assessed the accuracy of these models for predicting readmission risks in patient cohorts from 2 large academic medical centers. Admissions to 2 hospitals from 2011 to 2015, derived from the Vizient Clinical Data Base and regional health information exchange, were included in this study (291 886 encounters). Models were assessed using Bayesian information criterion and area under the receiver operating characteristic curve. They were compared in CMS diagnosis-based cohorts and in 2 non-CMS cancer diagnosis-based cohorts. Overall, both models for readmission risk performed well, with LACE performing slightly better (area under the receiver operating characteristic curve 0.73 versus 0.69; P ≤ 0.001). HOSPITAL consistently outperformed LACE among 4 CMS target diagnoses, lung cancer, and colon cancer. Both LACE and HOSPITAL predict readmission risks well in the overall population, but performance varies by salient, diagnosis-based risk factors.

ObjectivePast literature establishes high prevalence of burn-out among intensive care unit (ICU) nurses, and the influence of the COVID-19 pandemic in intensifying burn-out. However, the specific pandemic-related contributors and practical approaches to address burn-out have not been thoroughly explored. To address this gap, this work focuses on investigating the effect of the COVID-19 pandemic on the burn-out experiences of ICU nurses and identifying practical approaches for burn-out mitigation.DesignSemistructured focus group interviews were conducted via convenience sampling and qualitatively analysed to identify burn-out contributors and mitigators. Maslach Burnout Inventory for Medical Personnel (MBI-MP) and Post-traumatic Stress Disorder Checklist (PCL-5) were employed to quantify the prevalence of burn-out of the participants at the time of study.SettingTwo ICUs designated as COVID-19 ICUs in a large metropolitan tertiary care hospital in the Greater Houston area (Texas, USA).ParticipantsTwenty registered ICU nurses (10 from each unit).ResultsParticipants experienced high emotional exhaustion (MBI-MP mean score 32.35, SD 10.66), moderate depersonalisation (M 9.75, SD 7.10) and moderate personal achievement (M 32.05, SD 7.59) during the pandemic. Ten out of the 20 participants exhibited post-traumatic stress disorder symptoms (PCL-5 score >33). Regarding contributors to burn-out in nurses during the pandemic, five thematic levels emerged—personal, patient related, coworker related, organisational and societal—with each factor comprising several subthemes (eg, emotional detachment from patients, constant need to justify motives to patients’ family, lack of staffing and resources, and politicisation of COVID-19 and vaccination). Participants revealed several practical interventions to help overcome burn-out, ranging from mental health coverage to educating public on the severity of the pandemic and importance of vaccination.ConclusionsBy identifying the contributors to burn-out in ICU nurses at a systems level, the study findings inform the design and implementation of effective interventions to prevent or mitigate pandemic-related burn-out among nurses.

This study fills a void in the literature by both validating images of nature for use in future research experiments and examining which characteristics of these visual stimuli are found to be most representative of nature. We utilized a convenience sample of university students to assess 129 different nature images on which best represented nature. Participants (n = 40) viewed one image per question (n = 129) and were asked to rate images using a 5-point Likert scale, with the anchors “best represents nature” (5) and “least represents nature” (1). Average ratings across participants were calculated for each image. Canopies, mountains, bodies of water, and unnatural elements were identified as semantic categories of interest, as well as atmospheric perspectives and close-range views. We conducted the ordinary least squares (OLS) regression and the ordered logistic regression analyses to identify semantic categories highly representative of nature, controlling for the presence/absence of other semantic categories. The results showed that canopies, bodies of water, and mountains were found to be highly representative of nature, whereas unnatural elements and close-range views were inversely related. Understanding semantic categories most representative of nature is useful in developing nature-centered interventions in behavioral performance research and other neuroimaging modalities. All images are housed in an online repository and we welcome the use of the final 10 highly representative nature images by other researchers, which will hopefully prompt and expedite future examinations of nature across multiple research formats.

Highlights • Social determinants of health may improve identification of atherosclerotic cardiovascular disease – beyond traditional risk factors. • We provide the first, validated, polysocial risk score – the PsRS – for atherosclerotic cardiovascular disease. • PsRS is a robust tool to quantify cumulative social disadvantage. • PsRS offers unique opportunities to improve cardiovascular risk prediction algorithms. • Our findings may help highlight, and address disparities in cardiovascular disease., Objective To date, the extent to which social determinants of health (SDOH) may help identify individuals with atherosclerotic cardiovascular disease (ASCVD) – beyond traditional risk factors – has not been quantified using a cumulative social disadvantage approach. The objective of this study was to develop, and validate, a polysocial risk score (PsRS) for prevalent ASCVD in a nationally representative sample of adults in the United States (US). Methods We used data from the 2013–2017 National Health Interview Survey. A total of 38 SDOH were identified from the database. Stepwise and criterion-based selection approaches were applied to derive PsRS, after adjusting for traditional risk factors. Logistic regression models were fitted to assign risk scores to individual SDOH, based on relative effect size magnitudes. PsRS was calculated by summing risk scores for individual SDOH, for each participant; and validated using a separate validation cohort. Results Final sample comprised 164,696 adults. PsRS included 7 SDOH: unemployment, inability to pay medical bills, low income, psychological distress, delayed care due to lack of transport, food insecurity, and less than high school education. PsRS ranged from 0–20 and exhibited excellent calibration and discrimination. Individuals with the highest PsRS (5th quintile) had nearly 4-fold higher ASCVD prevalence, relative to those with the lowest risk scores (1st quintile). Area under receiver operating curve (AU-ROC) for PsRS with SDOH alone was 0.836. Addition of SDOH to the model with only demographic and clinical risk factors (AU-ROC=0.852) improved overall discriminatory power, with AU-ROC for final PsRS (demographics + clinical + SDOH) = 0.862. Conclusions Cumulatively, SDOH may help identify individuals with ASCVD, beyond traditional cardiovascular risk factors. In this study, we provide a unique validated PsRS for ASCVD in a national sample of US adults. Future study should target development of similar scores in diverse populations, and incorporate longitudinal study designs.

Background: Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence. Methods: In a nationally representative survey of US adults in the National Health Interview Survey (2013–2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates. Results: Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1–2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age 1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies. Conclusions: One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality.

Background Disparate racial/ethnic burdens of the Coronavirus Disease 2019 (COVID-19) pandemic may be attributable to higher susceptibility to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or to factors such as differences in hospitalization and care provision. Methods In our cross-sectional analysis of lab-confirmed COVID-19 cases from a tertiary, eight-hospital healthcare system across greater Houston, multivariable logistic regression models were fitted to evaluate hospitalization and mortality odds for non-Hispanic Blacks (NHBs) vs. non-Hispanic Whites (NHWs) and Hispanics vs. non-Hispanics. Results Between March 3rd and July 18th, 2020, 70,496 individuals were tested for SARS-CoV-2; 12,084 (17.1%) tested positive, of whom 3536 (29.3%) were hospitalized. Among positive cases, NHBs and Hispanics were significantly younger than NHWs and Hispanics, respectively (mean age NHBs vs. NHWs: 46.0 vs. 51.7 years; p p p p p = 0.001). Both minority groups resided in lower median income (median income [USD]; NHBs vs. NHWs: 63,489 vs. 75,793; p p p p Conclusions Our data did not demonstrate racial and ethnic differences in care provision and hospital outcomes. Higher susceptibility of racial and ethnic minorities to SARS-CoV-2 and subsequent hospitalization may be driven primarily by social determinants.

Background: Social determinants of health (SDOH) may limit the practice of coronavirus disease 2019 (COVID-19) risk mitigation guidelines with health implications for individuals with underlying cardiovascular disease (CVD). Population-based evidence of the association between SDOH and practicing such mitigation strategies in adults with CVD is lacking. We used the National Opinion Research Center’s COVID-19 Household Impact Survey conducted between April and June 2020 to evaluate sociodemographic disparities in adherence to COVID-19 risk mitigation measures in a sample of respondents with underlying CVD representing 18 geographic areas of the United States. Methods: CVD status was ascertained by self-reported history of receiving heart disease, heart attack, or stroke diagnosis. We built de novo, a cumulative index of SDOH burden using education, insurance, economic stability, 30-day food security, urbanicity, neighborhood quality, and integration. We described the practice of measures under the broad strategies of personal protection (mask, hand hygiene, and physical distancing), social distancing (avoiding crowds, restaurants, social activities, and high-risk contact), and work flexibility (work from home, canceling/postponing work). We reported prevalence ratios and 95% CIs for the association between SDOH burden (quartiles of cumulative indices) and practicing these measures adjusting for age, sex, race/ethnicity, comorbidity, and interview wave. Results: Two thousand thirty-six of 25 269 (7.0%) adults, representing 8.69 million in 18 geographic areas of the United States, reported underlying CVD. Compared with the least SDOH burden, fewer individuals with the greatest SDOH burden practiced all personal protection (75.6% versus 89.0%) and social distancing measures (41.9% versus 58.9%) and had any flexible work schedule (26.2% versus 41.4%). These associations remained statistically significant after full adjustment: personal protection (prevalence ratio, 0.83 [95% CI, 0.73–0.96]; P =0.009), social distancing (prevalence ratio, 0.69 [95% CI, 0.51–0.94]; P =0.018), and work flexibility (prevalence ratio, 0.53 [95% CI, 0.36–0.79]; P =0.002). Conclusions: SDOH burden is associated with lower COVID-19 risk mitigation practices in the CVD population. Identifying and prioritizing individuals whose medical vulnerability is compounded by social adversity may optimize emerging preventive efforts, including vaccination guidelines.

Background Diabetes mellitus affects almost 10% of U.S. adults, leading to human and financial burden. Underserved populations experience a higher risk of diabetes and related complications resulting from a combination of limited disposable income, inadequate diet, and lack of insurance coverage. Without the requisite resources, underserved populations lack the ability to access healthcare and afford prescription drugs to manage their condition. The aim of this systematic review is to synthesize the findings from cost-effectiveness studies of diabetes management in underserved populations. Methods Original, English, peer-reviewed cost-effectiveness studies of diabetes management in U.S. underserved populations were obtained from 8 databases, and PRISMA 2009 reporting guidelines were followed. Evidence was categorized as strong or weak based on a combination of GRADE and American Diabetes Association guidelines. Internal validity was assessed by the Cochrane methodology. Studies were classified by incremental cost-effectiveness ratio as very cost-effective (ICER≤US$25,000), cost-effective (US$25,000US$100,000). Reporting and quality of economic evaluations was assessed using the CHEERS guidelines and Recommendations of Second Panel for Cost-Effectiveness in Health and Medicine, respectively. Findings Fourteen studies were included. All interventions were found to be cost-effective or very cost-effective. None of the studies reported all 24 points of the CHEERS guidelines. Given the considered cost categories vary significantly between studies, assessing cost-effectiveness across studies has many limitations. Program costs were consistently analyzed, and a third of the included studies (n = 5) only examined these costs, without considering other costs of diabetes care. Interpretation Cost-effectiveness studies are not based on a standardized methodology and present incomplete or limited analyses. More accurate assessment of all direct and indirect costs could widen the gap between intervention and usual care. This demonstrates the urgent need for a more standardized and comprehensive cost-effectiveness framework for future studies.

Introduction Sex is increasingly recognized as an important factor in the epidemiology and outcome of many diseases. This also appears to hold for coronavirus disease 2019 (COVID-19). Evidence from China and Europe has suggested that mortality from COVID-19 infection is higher in men than women, but evidence from US populations is lacking. Utilizing data from a large healthcare provider, we determined if males, as compared to females have a higher likelihood of SARS-CoV-2 susceptibility, and if among the hospitalized COVID-19 patients, male sex is independently associated with COVID-19 severity and poor in-hospital outcomes. Methods and findings Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, we conducted a cross-sectional analysis of data from a COVID-19 Surveillance and Outcomes Registry (CURATOR). Data were extracted from Electronic Medical Records (EMR). A total of 96,473 individuals tested for SARS-CoV-2 RNA in nasopharyngeal swab specimens via Polymerized Chain Reaction (PCR) tests were included. For hospital-based analyses, all patients admitted during the same time-period were included. Of the 96,473 patients tested, 14,992 (15.6%) tested positive, of whom 4,785 (31.9%) were hospitalized and 452 (9.5%) died. Among all patients tested, men were significantly older. The overall SARS-CoV-2 positivity among all tested individuals was 15.5%, and was higher in males as compared to females 17.0% vs. 14.6% [OR 1.20]. This sex difference held after adjusting for age, race, ethnicity, marital status, insurance type, median income, BMI, smoking and 17 comorbidities included in Charlson Comorbidity Index (CCI) [aOR 1.39]. A higher proportion of males (vs. females) experienced pulmonary (ARDS, hypoxic respiratory failure) and extra-pulmonary (acute renal injury) complications during their hospital course. After adjustment, length of stay (LOS), need for mechanical ventilation, and in-hospital mortality were significantly higher in males as compared to females. Conclusions In this analysis of a large US cohort, males were more likely to test positive for COVID-19. In hospitalized patients, males were more likely to have complications, require ICU admission and mechanical ventilation, and had higher mortality than females, independent of age. Sex disparities in COVID-19 vulnerability are present, and emphasize the importance of examining sex-disaggregated data to improve our understanding of the biological processes involved to potentially tailor treatment and risk stratify patients.

BACKGROUND The COVID-19 pandemic has exacerbated the challenges of meaningful health care digitization. The need for rapid yet validated decision-making requires robust data infrastructure. Organizations with a focus on learning health care (LHC) systems tend to adapt better to rapidly evolving data needs. Few studies have demonstrated a successful implementation of data digitization principles in an LHC context across health care systems during the COVID-19 pandemic. OBJECTIVE We share our experience and provide a framework for assembling and organizing multidisciplinary resources, structuring and regulating research needs, and developing a single source of truth (SSoT) for COVID-19 research by applying fundamental principles of health care digitization, in the context of LHC systems across a complex health care organization. METHODS Houston Methodist (HM) comprises eight tertiary care hospitals and an expansive primary care network across Greater Houston, Texas. During the early phase of the pandemic, institutional leadership envisioned the need to streamline COVID-19 research and established the retrospective research task force (RRTF). We describe an account of the structure, functioning, and productivity of the RRTF. We further elucidate the technical and structural details of a comprehensive data repository—the HM COVID-19 Surveillance and Outcomes Registry (CURATOR). We particularly highlight how CURATOR conforms to standard health care digitization principles in the LHC context. RESULTS The HM COVID-19 RRTF comprises expertise in epidemiology, health systems, clinical domains, data sciences, information technology, and research regulation. The RRTF initially convened in March 2020 to prioritize and streamline COVID-19 observational research; to date, it has reviewed over 60 protocols and made recommendations to the institutional review board (IRB). The RRTF also established the charter for CURATOR, which in itself was IRB-approved in April 2020. CURATOR is a relational structured query language database that is directly populated with data from electronic health records, via largely automated extract, transform, and load procedures. The CURATOR design enables longitudinal tracking of COVID-19 cases and controls before and after COVID-19 testing. CURATOR has been set up following the SSoT principle and is harmonized across other COVID-19 data sources. CURATOR eliminates data silos by leveraging unique and disparate big data sources for COVID-19 research and provides a platform to capitalize on institutional investment in cloud computing. It currently hosts deeply phenotyped sociodemographic, clinical, and outcomes data of approximately 200,000 individuals tested for COVID-19. It supports more than 30 IRB-approved protocols across several clinical domains and has generated numerous publications from its core and associated data sources. CONCLUSIONS A data-driven decision-making strategy is paramount to the success of health care organizations. Investment in cross-disciplinary expertise, health care technology, and leadership commitment are key ingredients to foster an LHC system. Such systems can mitigate the effects of ongoing and future health care catastrophes by providing timely and validated decision support.

Few studies have examined factors affecting the high frequency of hospitalization for pediatric asthma. This study identifies individual and environmental characteristics of children with asthma fr...

Background The COVID-19 pandemic has necessitated a rapid increase of space in highly infectious disease intensive care units (ICUs). At Houston Methodist Hospital (HMH), a virtual intensive care unit (vICU) was used amid the COVID-19 outbreak. Objective The aim of this paper was to detail the novel adaptations and rapid expansion of the vICU that were applied to achieve patient-centric solutions while protecting staff and patients’ families during the pandemic. Methods The planned vICU implementation was redirected to meet the emerging needs of conversion of COVID-19 ICUs, including alterations to staged rollout timing, virtual and in-person staffing, and scope of application. With the majority of the hospital critical care physician workforce redirected to rapidly expanded COVID-19 ICUs, the non–COVID-19 ICUs were managed by cardiovascular surgeons, cardiologists, neurosurgeons, and acute care surgeons. HMH expanded the vICU program to fill the newly depleted critical care expertise in the non–COVID-19 units to provide urgent, emergent, and code blue support to all ICUs. Results Virtual family visitation via the Consultant Bridge application, palliative care delivery, and specialist consultation for patients with COVID-19 exemplify the successful adaptation of the vICU implementation. Patients with COVID-19, who were isolated and separated from their families to prevent the spread of infection, were able to virtually see and hear their loved ones, which bolstered the mental and emotional status of those patients. Many families expressed gratitude for the ability to see and speak with their loved ones. The vICU also protected medical staff and specialists assigned to COVID-19 units, reducing exposure and conserving personal protective equipment. Conclusions Telecritical care has been established as an advantageous mechanism for the delivery of critical care expertise during the expedited rollout of the vICU at Houston Methodist Hospital. Overall responses from patients, families, and physicians are in favor of continued vICU care; however, further research is required to examine the impact of innovative applications of telecritical care in the treatment of critically ill patients.

IntroductionData on race and ethnic susceptibility to SARS-CoV-2 infection are limited. We analyzed socio-demographic factors associated with higher likelihood of SARS-CoV-2 infection and explore mediating pathways for race disparities in the SARS-CoV-2 pandemic.MethodsCross sectional analysis of COVID-19 Surveillance and Outcomes Registry (CURATOR), which captures data for a large healthcare system comprising of one central tertiary care, seven large community hospitals, and an expansive ambulatory / emergency care network in the Greater Houston area. Nasopharyngeal samples for individuals inclusive of all ages, races, ethnicities and sex were tested for SARS-CoV-2. We analyzed, socio-demographic (age, sex, race, ethnicity, household income, residence population density) and comorbidity (hypertension, diabetes, obesity, cardiac disease) factors. Multivariable logistic regression models were fitted to provide adjusted Odds Ratios (aOR), 95% confidence intervals (CI) for likelihood of positive SARS-CoV-2 test. Structural Equation Modeling (SEM) framework was utilized to explore three mediation pathways (low income, high population density, high comorbidity burden) for association between African American race and SARS-CoV-2 infection.ResultsAmong 4,513 tested individuals, 754 (16.7%) tested positive. Overall mean (SD) age was 50.6 (18.9) years, 62% females and 26% were African American. African American race was associated with lower socio-economic status, higher comorbidity burden, and population density residence. In the fully adjusted model, African American race (vs. White; aOR, CI: 1.84, 1.49-2.27) and Hispanic ethnicity (vs. non-Hispanic; aOR, CI: 1.70, 1.35-2.14) had a higher likelihood of infection. Older individuals and males were also at a higher risk of SARS-CoV-2 infection. The SEM framework demonstrated a statistically significant (p = 0.008) indirect effect of African American race on SARS-CoV-2 infection mediated via a pathway that included residence in densely populated zip code.ConclusionsThere is strong evidence of race and ethnic disparities in the SARS-CoV-2 pandemic potentially mediated through unique social determinants of health.Strengths and limitations of this studyOne of the first studies to systematically evaluate race and ethnic disparities in susceptibility to SARS-CoV-2 infection, while accounting for multiple sociodemographic characteristics and comorbiditiesStudy population represents a large and diverse metropolitan of the U.S. with data from one of the largest healthcare providers across the greater metropolitan areaStudy evaluates potential mediation pathways for race disparities and demonstrates that residence in areas with high population density may mediate race disparities in susceptibility to SARS-CoV-2 infectionSingle center study with limited information about true burden of comorbidity and lifestyle factors

As the demand for telepsychiatry increases during the COVID-19 pandemic, the strengths and challenges of telepsychiatry implementation must be articulated to improve clinical practices in the long term. Currently, observations within US contexts are lacking; therefore, we report on the rapid implementation of telepsychiatry and workflow experiences in a psychiatric practice based within a large health care system in southeast Texas with a national catchment area. We discuss the logistics of the implementation, including modes of communication, scheduling, coordination, and capacity; the psychological effects of web-based services, including both the loss of the physical therapeutic environment and the unique interpersonal dynamics experienced in the virtual environment; and postadoption patterns of engagement with our services and with other clinical functions affected by the rapid adaptation to telemedicine. Our art therapy group programming serves as an applied case study, demonstrating the value of a well-managed web-based program (eg, patients were receptive and well-engaged, and they appreciated the continuity of accessible service) as well as the challenges (eg, the need for backup plans and technological fallbacks, managing interruptions and telecommunication learning curves, and working around the difference in resources for art and music therapy between a well-stocked clinical setting versus clients’ home spaces). We conclude from our experience that the overall strengths of telepsychiatry include receptive and well-engaged responses from patients as well as the expansion of boundaries, which provides a directly contextualized view into patients’ home lives. Challenges and corresponding recommendations include the need for more careful safety planning for high-risk patients; maintaining professional boundaries in the newly informal virtual setting; designing the physical space to both frame the patient encounter and maintain work-life balance for the therapist; allowing for delays and interruptions (including an initial acclimation session); and preserving interprofessional care team collaboration when the physical locations that normally facilitate such encounters are not accessible. We believe that careful observations of the strengths and challenges of telepsychiatry during this pandemic will better inform practices that are considering telepsychiatry adoption both within pandemic contexts and more broadly thereafter.

ObjectiveTo determine the prevalence of SARS-CoV-2 infection among asymptomatic COVID-19 facing and non-COVID-19 facing Healthcare Workers (HCWs), with varying job categories across different hospitals.DesignCross-sectional analysis of a healthcare system surveillance program that included asymptomatic clinical (COVID-19 facing and non-COVID-19 facing), and non-clinical HCWs. A convenience sample of asymptomatic community residents (CR) was also tested. Proportions and 95% confidence Intervals (CI) of SARS-CoV-2 positive HCWs are reported. Proportional trend across HCW categories was tested using Chi Square trend test. Logistic regression model-based likelihood estimates of SARS-CoV-2 prevalence among HCWs with varying job functions and across different hospitals are reported as adjusted odds ratios (aOR) and CI.SettingHealthcare system comprising one tertiary care academic medical center and six large community hospitals across Greater Houston and a community sample.Participants2,872 self-reported asymptomatic adult (> 18 years) HCWs and CRs.ExposureClinical HCWs in COVID-19 and non-COVID-19 units, non-Clinical HCWs, and CRs. Job categories of Nursing, Providers, Allied Health, Support, and Administration / Research. Seven hospitals in the healthcare system.Main OutcomesPositive reverse transcriptase polymerized chain reaction (RT-PCR) test for SARS-CoV-2ResultsAmong 2,872 asymptomatic HCWs and CRs, 3.9% (CI: 3.2 – 4.7) tested positive for SARS-CoV-2. Mean (SD) age was 40.9 (11.7) years and 73% were females. Among COVID-19 facing HCWs 5.4% (CI: 4.5 – 6.5) were positive, whereas 0.6% (CI: 0.2 – 1.7%) of non COVID-19 facing HCWs and none of the non-clinical HCWs or CRs were positive (Ptrend < 0.001). Among COVID-19 facing HCWs, SARS-CoV-2 positivity was similar for all job categories (p = 0.74). However, significant differences in positivity were observed across hospitals.Conclusions and RelevanceAsymptomatic HCWs with COVID-19 patient exposure had a higher rate of SARS-CoV-2 positive testing than those not routinely exposed to COVID-19 patients and those not engaged in patient care. Among HCWs with routine COVID-19 exposure, all job types had relatively similar infection rates. These data can inform hospital surveillance and infection control practices for patient-facing job classifications and suggest that general environmental exposure within hospitals is not a significant source of asymptomatic SARS-CoV-2 infection.What is already known on this topicA sizeable proportion of individuals who contract the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can remain largely asymptomatic.Though such individuals may not develop symptoms, they continue to shed enough viral particles to trigger positive reverse transcriptase polymerized chain reaction (RT PCR) test for SARS-CoV-2Prior reports on proportion of asymptomatic SARS-CoV-2 individuals are highly variable with positivity ranging across < 1% to 36%Asymptomatic SARS-CoV-2 infection among healthcare workers is specifically critical to understandWhat this study addsThis study demonstrates that overall rate of SARS-CoV-2 infection among asymptomatic healthcare workers in a large healthcare system of a metropolitan city in the United States was 3.9%The rate of SARS-CoV-2 infection among healthcare workers who provided direct care to COVID-19 patients was 5.4% whereas it was 0.6% among those healthcare workers who did not provide direct care to COVID-19 patientsThere was no difference in SARS-CoV-2 positivity rate for different job categories of healthcare workers who provided direct care to COVID-19 patients

Although hospital length of stay (LOS) has been identified as a proxy measure of healthcare expenditures in the United States, there are limited studies investigating the potentially important association between outdoor air pollution and LOS for pediatric asthma. This study aims to examine the effect of ambient air pollution on LOS among children with asthma in South Texas. It included retrospective data on 711 children aged 5&ndash, 18 years old admitted for asthma to a pediatric tertiary care hospital in South Texas between 2010 and 2014. Air pollution data including particulate matter (PM2.5) and ozone were collected from the U.S. Centers for Disease Control and Prevention. The multivariate binomial logistic regression analyses were performed to determine the association between each air pollutant and LOS, controlling for confounders. The regression models showed the increased ozone level was significantly associated with prolonged LOS in the single- and two-pollutant models (p &lt, 0.05). Furthermore, in the age-stratified models, PM2.5 was positively associated with LOS among children aged 5&ndash, 11 years old (p &lt, 0.05). In conclusion, this study revealed a concerning association between ambient air pollution and LOS for pediatric asthma in South Texas.

Introduction: Stroke is a leading cause of death and disability worldwide. While most prevalent in elderly, it’s not uncommon in the non-elderly ( Methods: We analyzed the National Health Interview Survey (2012-2018), a nationally representative study sample. Stroke, as well as CVD risk factors (CRF) [diabetes, hypertension, ever-smoker, insufficient physical activity, obesity and high cholesterol] were self-reported. A CRF profile was then created, with the following categories: “Optimal”, “Average” and “Poor” (0-1, 2-3 & ≥ 4 CRFs, respectively). All analyses took into consideration the survey’s complex design. Results: The 2012-2018 survey population consisted of 224,638 adults ≥ 18 yrs, ≈ 242 million US adults annually. Overall 2.8% (≈ 7 million) reported ever having history of stroke, with 45% noted in the non-elderly (< 65). Among non-elderly, 21% of stroke-history was allocated among the young (18-44 years) adults, translating to nearly 642,810 individuals reporting ever having history of stroke per year. The most common risk factors noted in these patients were insufficient physical activity (56%), current/past smoking (48%), obesity (45%), and hypertension (44%). Overall among the young ( Conclusion: More than half a million adults 18-44 years of age reported a history stroke in US. Individuals with sub-optimal CRF profiles are highly susceptible, and population-level strategies emphasizing cardiovascular health may significantly reduce risk of stroke among young adults in US.

BACKGROUND: Aging may detrimentally affect cognitive and motor function. However, age is also associated with experience, and how these factors interplay and affect outcomes following surgery is unclear. We sought to evaluate the effect of surgeon age on postoperative outcomes in patients undergoing common surgical procedures. METHODS: We performed a retrospective cohort study of patients undergoing 1 of 25 common surgical procedures in Ontario, Canada, from 2007 to 2015. We evaluated the association between surgeon age and a composite outcome of death, readmission and complications. We used generalized estimating equations for analysis, accounting for relevant patient-, procedure-, surgeon- and hospital-level factors. RESULTS: We found 1 159 676 eligible patients who were treated by 3314 surgeons and ranged in age from 27 to 81 years. Modelled as a continuous variable, a 10-year increase in surgeon age was associated with a 5% relative decreased odds of the composite outcome (adjusted odds ratio [OR] 0.95, 95% confidence interval [CI] 0.92 to 0.98, p = 0.002). Considered dichotomously, patients receiving treatment from surgeons who were older than 65 years of age had a 7% lower odds of adverse outcomes (adjusted OR 0.93, 95% CI 0.88–0.97, p = 0.03; crude absolute difference = 3.1%). INTERPRETATION: We found that increasing surgeon age was associated with decreasing rates of postoperative death, readmission and complications in a nearly linear fashion after accounting for patient-, procedure-, surgeon- and hospital-level factors. Further evaluation of the mechanisms underlying these findings may help to improve patient safety and outcomes, and inform policy about maintenance of certification and retirement age for surgeons.

Purpose This paper aims to present a literature review of the health workforce, hospital and clinic systems, infrastructure, primary care, regulatory climate, the pharmaceutical industry and community health behavior of the Kenyan health-care system with the purpose of providing a thorough background on the health-care environment in Kenya. Design/methodology/approach A systematic literature review was conducted using Pub Med, searching for “Kenya” in the title of articles published from January 1, 2015 to February 24, 2016; this provided a broad overview of the type of research being conducted in Kenya. Other data provided by governmental agencies and non-governmental agencies was also reviewed to describe the current state of population health in Kenya. Findings An initial review of 615 Pubmed articles included 455 relevant articles. A complete review of these studies was conducted, resulting in a final sample of 389 articles. These articles were categorized into three main subject areas with 14 secondary subject areas (Figure 1). Research limitations/implications The narrow scope of the search parameters set for the systematic review was a necessary limitation to focus on the most relevant literature. The findings of this study provide a thorough background on health care in Kenya to researchers and practitioners. Originality/value This compilation of data specific to Kenya provides a detailed summary of both the country’s health-care services and health status, focusing on potential means of realizing increased quality and length of life.

Purpose The purpose of this article is to provide a general review of the health-care needs in Kenya which focuses on the role of community engagement in facilitating access and diminishing barriers to quality care services. Health-care concerns throughout Kenya and the culture of Kenyan’s health-care practices care are considered. Design/methodology/approach A comprehensive review covered studies of community engagement from 2000 till present. Studies are collected using Google Scholar, PubMed, EBSCOhost and JSTOR and from government and nongovernment agency websites. The approach focuses on why various populations seek health care and how they seek health care, and on some current health-care delivery models. Findings Suggestions for community engagement, including defining the community, are proposed. A model for improved health-care delivery introduces community health workers (CHWs), mHealth technologies and the use of mobile clinics to engage the community and improve health and quality of care in low-income settings. Practical implications The results emphasize the importance of community engagement in building a sustainable health-care delivery model. This model highlights the importance of defining the community, setting goals for the community and integrating CHWs and mobile clinics to improve health status and decrease long-term health-care costs. The implementation of these strategies contributes to an environment that promotes health and wellness for all. Originality/value This paper evaluates health-care quality and access issues in Kenya and provides sustainable solutions that are linked to effective community engagement. In addition, this paper adds to the limited number of studies that explore health-care quality and access alongside community engagement in low-income settings.

Purpose The purpose of this paper is to present proposed solutions and interventions to some of the major barriers to providing adequate access to healthcare in Kenya. Specific business models are proposed to improve access to quality healthcare in low- and middle-income countries. Finally, strategies are developed for the retail clinic concept (RCC). Design/methodology/approach Google Scholar, PubMed and EBSCOhost were among the databases used to collect articles relevant to the purpose in Kenya. Various governmental and news articles were collected from Google searches. Relevant business models from other sectors were considered for potential application to healthcare and the retail clinic concept. Findings After a review of current methodologies and approaches to business and franchising models in various settings, the most relevant models are proposed as solutions to improving quality healthcare in Kenya through the RCC. For example, authors reviewed physician recruitment strategies, insurance plans and community engagement. The paper is informed by existing literature and reports as well as key informants. Research limitations/implications This paper lacks primary data collection within Kenya and is limited to a brief scoping review of literature. The findings provide effective strategies for various business and franchising models in healthcare. Originality/value The assembling of relevant information specific to Kenya and potential business models provides effective means of improving health delivery through business and franchising, focusing on innovative approaches and models that have proven effective in other settings.

Purpose This paper aims to critically analyze the empirical literature on health and human development in high-, middle- and low-income countries to develop a sustainable model for investing in human health. The model is critical in building a comprehensive health-care system that fosters the stakeholders’ financial stability, economic growth and high-quality education for the local community. Design/methodology/approach A comprehensive literature review was carried out on health, human development and sustainable health investment. After thoroughly examining theoretical frameworks underlying the strategies of successful human health systems, a summary of empirical articles is created. Summaries provided in this paper represent relevant health-care strategies for Kenya. Findings Based on the empirical review of literature, a Nexus Health Care model focusing on human development, social and cultural development, economic development and environmental development in high-, middle- and low-income countries is proposed. The goal of this model is to enhance sustainable development where wealth creation is accompanied with environmental uplifting and protection of social and material well-being. Research limitations/implications This paper is limited to a comprehensive literature review presenting empirical evidence of human development and sustainability. Originality/value Kenya like other developing nations aspires to contribute significantly in improving health through development of health products but the approaches used have been limiting. In most cases, the use of Western theories, lack of empowering the community and dependence on donor support have hindered the country from achieving comprehensive health and human development. This papers seeks to develop a model for health-care investment and provide strategies, operations and structure of successful health systems and human development for a developing country, such as Kenya.

Objective Research on the implementation of health information exchange (HIE) organizations has identified both positive and negative effects of laws relating to governance, incentives, mandates, sustainability, stakeholder participation, patient engagement, privacy, confidentiality, and security. We fill a substantial research gap by describing whether comprehensive state and territorial HIE legal frameworks address identified legal facilitators and barriers. Materials and Methods We used the Westlaw database to identify state and territorial laws relating to HIEs in effect on June 7, 2016 (53 jurisdictions). We blind-coded all laws and addressed coding discrepancies in peer-review meetings. We recorded a consensus code for each law in a master database. We compared 20 HIE legal attributes with identified barriers to and enablers of HIE activity in the literature. Results Forty-two states, the District of Columbia, and 2 territories have laws relating to HIEs. On average, jurisdictions address 8.32 of the 20 criteria selected in statutes and regulations. Twenty jurisdictions unambiguously address ≤5 criteria in statutes and regulations. None of the significant legal criteria are unambiguously addressed in >60% of the 53 jurisdictions. Discussion Laws can be barriers to or enablers of HIEs. However, jurisdictions are not addressing many significant issues identified by researchers. Consequently, there is a substantial risk that existing legal frameworks are not adequately supporting HIEs. Conclusion The current evidence base is insufficient for comparative assessments or impact rankings of the various factors. However, the detailed Centers for Disease Control and Prevention dataset of HIE laws could enable investigations into the types of laws that promote or impede HIEs.

Introduction Following bariatric surgery, ongoing postoperative testing is required to measure nutritional deficiencies; the purpose of this study was to quantify the prevalence of these nutritional deficiencies based on two-year follow-up tests at recommended time points. Methods and procedures A retrospective data analysis was conducted of all laboratory tests for bariatric patients who underwent surgery between May 2016 and January 2018 with available lab data (n = 397). Results for nine different nutritional labs were categorized into six recommended postoperative time periods based on time elapsed since the procedure date. Binary variables were created for each laboratory result to calculate descriptive statistics of abnormalities for each lab test over time and used in the individual GEE logistic regression models. Grouped logistic regression examined the total nutritional deficiencies of the nine combined nutrients considering total available labs. Results Multiple lab tests indicated a very low frequency of abnormalities (e.g., Vitamin A, Vitamin B12, Copper, and Folate). Many of the nine included nutritional labs had an average deficiency of less than 10% across all time points. The grouped logistic model found preoperative nutritional deficiency to be predictive of postoperative nutritional deficiency (OR 3.70, p Conclusions We found the vast majority of routine lab test results to be normal at multiple time points. Current practice can add up to significant lab expenses over time. The frequency of postoperative testing in this population may be redundant and of very little value. Unnecessary follow-up laboratory testing costs the patients and the health care system in both time and resources. Patients with preoperative deficiencies appear to be at higher risk for nutritional deficiencies when compared to bariatric surgery patients that did not have preoperative nutritional deficiencies. Future research should focus on defining cost effective postoperative lab testing guidelines for at risk bariatric patients.

Evidence suggests that health information exchange (HIE) is an effective strategy to improve efficiency and quality of care, as well as reduce costs. A complex patchwork of federal and state legislation has developed over time to encourage HIE activity. Hospitals and health systems have adopted various HIE models to meet the requirements of these statutes and regulations. Given the complexity of HIE laws, it is important to understand how these legal levers influence HIE engagement. We combined data from two unique data sources to examine the association between state-level HIE laws and hospital engagement in community HIEs. Our results identified three legal provisions of state laws (HIE authorization, financial & non-financial incentives, opt-out consent) that increased the likelihood of community HIE engagement. Other provisions decreased the likelihood of engagement. This analysis provides foundational evidence about the utility of HIE laws. More research is needed to determine causal relationships.

Background The COVID-19 pandemic has exacerbated the challenges of meaningful health care digitization. The need for rapid yet validated decision-making requires robust data infrastructure. Organizations with a focus on learning health care (LHC) systems tend to adapt better to rapidly evolving data needs. Few studies have demonstrated a successful implementation of data digitization principles in an LHC context across health care systems during the COVID-19 pandemic. Objective We share our experience and provide a framework for assembling and organizing multidisciplinary resources, structuring and regulating research needs, and developing a single source of truth (SSoT) for COVID-19 research by applying fundamental principles of health care digitization, in the context of LHC systems across a complex health care organization. Methods Houston Methodist (HM) comprises eight tertiary care hospitals and an expansive primary care network across Greater Houston, Texas. During the early phase of the pandemic, institutional leadership envisioned the need to streamline COVID-19 research and established the retrospective research task force (RRTF). We describe an account of the structure, functioning, and productivity of the RRTF. We further elucidate the technical and structural details of a comprehensive data repository—the HM COVID-19 Surveillance and Outcomes Registry (CURATOR). We particularly highlight how CURATOR conforms to standard health care digitization principles in the LHC context. Results The HM COVID-19 RRTF comprises expertise in epidemiology, health systems, clinical domains, data sciences, information technology, and research regulation. The RRTF initially convened in March 2020 to prioritize and streamline COVID-19 observational research; to date, it has reviewed over 60 protocols and made recommendations to the institutional review board (IRB). The RRTF also established the charter for CURATOR, which in itself was IRB-approved in April 2020. CURATOR is a relational structured query language database that is directly populated with data from electronic health records, via largely automated extract, transform, and load procedures. The CURATOR design enables longitudinal tracking of COVID-19 cases and controls before and after COVID-19 testing. CURATOR has been set up following the SSoT principle and is harmonized across other COVID-19 data sources. CURATOR eliminates data silos by leveraging unique and disparate big data sources for COVID-19 research and provides a platform to capitalize on institutional investment in cloud computing. It currently hosts deeply phenotyped sociodemographic, clinical, and outcomes data of approximately 200,000 individuals tested for COVID-19. It supports more than 30 IRB-approved protocols across several clinical domains and has generated numerous publications from its core and associated data sources. Conclusions A data-driven decision-making strategy is paramount to the success of health care organizations. Investment in cross-disciplinary expertise, health care technology, and leadership commitment are key ingredients to foster an LHC system. Such systems can mitigate the effects of ongoing and future health care catastrophes by providing timely and validated decision support.

Policy Points: Community health information exchanges have the characteristics of a public good, and they support population health initiatives at the state and national levels. However, current policy equally incentivizes health systems to create their own information exchanges covering more narrowly defined populations. Noninteroperable electronic health records and vendors’ expensive custom interfaces are hindering health information exchanges. Moreover, vendors are imposing the costs of interoperability on health systems and community health information exchanges. Health systems are creating networks of targeted physicians and facilities by funding connections to their own enterprise health information exchanges. These private networks may change referral patterns and foster more integration with outpatient providers. Context The United States has invested billions of dollars to encourage the adoption of and implement the information technologies necessary for health information exchange (HIE), enabling providers to efficiently and effectively share patient information with other providers. Health care providers now have multiple options for obtaining and sharing patient information. Community HIEs facilitate information sharing for a broad group of providers within a region. Enterprise HIEs are operated by health systems and share information among affiliated hospitals and providers. We sought to identify why hospitals and health systems choose either to participate in community HIEs or to establish enterprise HIEs. Methods We conducted semistructured interviews with 40 policymakers, community and enterprise HIE leaders, and health care executives from 19 different organizations. Our qualitative analysis used a general inductive and comparative approach to identify factors influencing participation in, and the success of, each approach to HIE. Findings Enterprise HIEs support health systems' strategic goals through the control of an information technology network consisting of desired trading partners. Community HIEs support obtaining patient information from the broadest set of providers, but with more dispersed benefits to all participants, the community, and patients. Although not an either/or decision, community and enterprise HIEs compete for finite organizational resources like time, skilled staff, and money. Both approaches face challenges due to vendor costs and less-than-interoperable technology. Conclusions Both community and enterprise HIEs support aggregating clinical data and following patients across settings. Although they can be complementary, community and enterprise HIEs nonetheless compete for providers’ attention and organizational resources. Health policymakers might try to encourage the type of widespread information exchange pursued by community HIEs, but the business case for enterprise HIEs clearly is stronger. The sustainability of a community HIE, potentially a public good, may necessitate ongoing public funding and supportive regulation.

Few studies have evaluated the association between ambient air pollution and hospital readmissions among children with asthma, especially in low-income communities. This study examined the short-term effects of ambient air pollutants on hospital readmissions for pediatric asthma in South Texas. A time-stratified case-crossover study was conducted using the hospitalization data from a children&rsquo, s hospital and the air pollution data, including particulate matter 2.5 (PM2.5) and ozone concentrations, from the Centers for Disease Control and Prevention between 2010 and 2014. A conditional logistic regression analysis was performed to investigate the association between ambient air pollution and hospital readmissions, controlling for outdoor temperature. We identified 111 pediatric asthma patients readmitted to the hospital between 2010 and 2014. The single-pollutant models showed that PM2.5 concentration had a significant positive effect on risk for hospital readmissions (OR = 1.082, 95% CI = 1.008&ndash, 1.162, p = 0.030). In the two-pollutant models, the increased risk of pediatric readmissions for asthma was significantly associated with both elevated ozone (OR = 1.023, 95% CI = 1.001&ndash, 1.045, p = 0.042) and PM2.5 concentrations (OR = 1.080, 95% CI = 1.005&ndash, 1.161, p = 0.036). The effects of ambient air pollutants on hospital readmissions varied by age and season. Our findings suggest that short-term (4 days) exposure to air pollutants might increase the risk of preventable hospital readmissions for pediatric asthma patients.

IntroductionType 2 diabetes prevalence is increasing in the USA, especially in underserved populations. Patient outcomes can be improved by providing access to specialty care within Federally Qualified Health Centers, possibly improving the cost-effectiveness of diabetes care.Methods and analysisA new model of diabetes care based on multidisciplinary teams of clinical fellows, supported by an endocrinologist for underserved adult populations, is presented. The study uses a retrospective, non-randomised cohort of patients with diabetes who visited the community clinic between 1 January 2012 and 31 December 2018. A quasi-experimental method to analyse the causal evidence of the effect of the new model is presented. Discontinuity regression is used to compare two interventions, the intervention by a Clinical Fellow Endocrinology Programme and usual care by a primary care physician. Patients are referred to the Clinical Fellow Endocrinology Programme in case of uncontrolled diabetes (glycated haemoglobin (HbA1c)≥9%). The regression discontinuity design allows the construction of a treatment group for patients with an HbA1c equal or above the threshold in comparison with a control group for patients with an HbA1c below the threshold. The patient outcomes and cost-effectiveness of the new model are analysed. Regression models will be used to assess the differences between treatment and control groups.Ethics and disseminationQuantitative patient data are received by the study team in a de-identified format for analysis via an institutional review board-approved protocol. The quantitative study has been approved by the Houston Methodist Research Institute Institutional Review Board, Houston, Texas, USA. Anticipated results will not only provide evidence about the impact of patient outcomes in underserved diabetic populations, but also give an idea of the cost-effectiveness of the new model and whether or not cost savings can be attained for patients, third-party payers and society. The results will help set up evidence-based policy guidelines in diabetes care. Results will be disseminated through papers, conferences and public health/policy fora.

Stroke, a leading cause of death and disability, is most prevalent in elderly, but occurs not uncommonly in the young (

Thus, any of these specialties could take the lead in provid-ing perioperative care.However, the 2014 Institute of Medicine report on gradu-ate medical education in the United States noted that there is “a gap between new physicians’ knowledge and skills and the competencies required for current medical practice.”

Purpose The health of rural America is more important than ever to the health of the United States and the world. Rural Healthy People 2020's goal is to serve as a counterpart to Healthy People 2020, providing evidence of rural stakeholders’ assessment of rural health priorities and allowing national and state rural stakeholders to reflect on and measure progress in meeting those goals. The specific aim of the Rural Healthy People 2020 national survey was to identify rural health priorities from among the Healthy People 2020's (HP2020) national priorities. Methods Rural health stakeholders (n = 1,214) responded to a nationally disseminated web survey soliciting identification of the top 10 rural health priorities from among the HP2020 priorities. Stakeholders were also asked to identify objectives within each national HP2020 priority and express concerns or additional responses. Findings and Conclusions Rural health priorities have changed little in the last decade. Access to health care continues to be the most frequently identified rural health priority. Within this priority, emergency services, primary care, and insurance generate the most concern. A total of 926 respondents identified access as the no. 1 rural health priority, followed by, no. 2 nutrition and weight status (n = 661), no. 3 diabetes (n = 660), no. 4 mental health and mental disorders (n = 651), no. 5 substance abuse (n = 551), no. 6 heart disease and stroke (n = 550), no. 7 physical activity and health (n = 542), no. 8 older adults (n = 482), no. 9 maternal infant and child health (n = 449), and no. 10 tobacco use (n = 429).

BACKGROUND Telemedicine and telehealth solutions are emerging rapidly in health care and have the potential to decrease costs for insurers, providers, and patients in various settings. Pediatric populations that require specialty care are disadvantaged socially or economically or have chronic health conditions that will greatly benefit from results of studies utilizing telemedicine technologies. This paper examines the emerging trends in pediatric populations as part of a systematic literature review and provides a scoping review of the type, extent, and quantity of research available. OBJECTIVE This paper aims to examine the role of remote patient monitoring (RPM) and telemedicine in neonatal and pediatric settings. Findings can be used to identify strengths, weaknesses, and gaps in the field. The identification of gaps will allow for interventions or research to improve health care quality and costs. METHODS A systematic literature review is being conducted to gather an adequate amount of relevant research for telehealth in pediatric populations. The fields of RPM and telemedicine are not yet very well established by the health care services sector, and definitions vary across health care systems; thus, the terms are not always defined similarly throughout the literature. Three databases were scoped for information for this specific review, and 56 papers were included for review. RESULTS Three major telemedicine trends emerged from the review of 45 relevant papers—RPM, teleconsultation, and monitoring patients within the hospital, but without contact—thus, decreasing the likelihood of infection or other adverse health effects. CONCLUSIONS While the current telemedicine approaches show promise, limited studied conditions and small sample sizes affect generalizability, therefore, warranting further research. The information presented can inform health care providers of the most widely implemented, studied, and effective forms of telemedicine for patients and their families and the telemedicine initiatives that are most cost efficient for health systems. While the focus of this review is to summarize some telehealth applications in pediatrics, we have also presented research studies that can inform providers about the importance of data sharing of remote monitoring data between hospitals. Further reports will be developed to inform health systems as the systematic literature review continues.

Community health information exchanges have the characteristics of a public good, and they support population health initiatives at the state and national levels. However, current policy equally incentivizes health systems to create their own information exchanges covering more narrowly defined populations. Noninteroperable electronic health records and vendors' expensive custom interfaces are hindering health information exchanges. Moreover, vendors are imposing the costs of interoperability on health systems and community health information exchanges. Health systems are creating networks of targeted physicians and facilities by funding connections to their own enterprise health information exchanges. These private networks may change referral patterns and foster more integration with outpatient providers.The United States has invested billions of dollars to encourage the adoption of and implement the information technologies necessary for health information exchange (HIE), enabling providers to efficiently and effectively share patient information with other providers. Health care providers now have multiple options for obtaining and sharing patient information. Community HIEs facilitate information sharing for a broad group of providers within a region. Enterprise HIEs are operated by health systems and share information among affiliated hospitals and providers. We sought to identify why hospitals and health systems choose either to participate in community HIEs or to establish enterprise HIEs.We conducted semistructured interviews with 40 policymakers, community and enterprise HIE leaders, and health care executives from 19 different organizations. Our qualitative analysis used a general inductive and comparative approach to identify factors influencing participation in, and the success of, each approach to HIE.Enterprise HIEs support health systems' strategic goals through the control of an information technology network consisting of desired trading partners. Community HIEs support obtaining patient information from the broadest set of providers, but with more dispersed benefits to all participants, the community, and patients. Although not an either/or decision, community and enterprise HIEs compete for finite organizational resources like time, skilled staff, and money. Both approaches face challenges due to vendor costs and less-than-interoperable technology.Both community and enterprise HIEs support aggregating clinical data and following patients across settings. Although they can be complementary, community and enterprise HIEs nonetheless compete for providers' attention and organizational resources. Health policymakers might try to encourage the type of widespread information exchange pursued by community HIEs, but the business case for enterprise HIEs clearly is stronger. The sustainability of a community HIE, potentially a public good, may necessitate ongoing public funding and supportive regulation.

Context The United States has invested substantially in technologies that enable health information exchange (HIE), which in turn can be deployed to reduce avoidable hospital readmission rates in many communities. With avoidable hospital readmissions as the primary focus, this study profiles successful hospital readmission rate reduction initiatives that integrate HIE as a strategy. We hypothesized that the use of HIE is associated with decreased hospital readmissions beyond other observed population health benefits. Results of this systematic review are used to describe and profile successful readmission reduction programs that integrate HIE as a tool. Methods A systematic review of literature provided an understanding of the use of HIE as a strategy to reduce hospital readmission rates. We conducted a review of 4,862 citations written in English about readmission reduction strategies from January 2006 to September 2016 in the MEDLINE-PubMed database. Of these, 106 studies reported 30-day readmission rates as an outcome and only 13 articles reported using HIE. Results Only a very small number (12%) of hospitals incorporated HIE as a primary tool for evidence-based readmission reduction initiatives. Information exchange between providers has been suggested to play a key role in reducing avoidable readmission rates, yet there is not currently evidence supporting current HIE-enabled readmission initiatives. Most successful readmission reduction programs demonstrate collaboration with primary care providers to augment transitions of care to existing care management functions without additional staff while using effective information exchange capabilities. Conclusions This research confirms there is very little integration of HIE into health systems readmissions initiatives. There is a great opportunity to achieve population health targets using the HIE infrastructure. Hospitals should consider partnering with primary care clinics to implement multifaceted transitions of care programs to significantly reduce 30-day readmission rates.

The United States spends about $180 billion per year on inpatient surgical procedures in nonfederal hospitals alone.1 The average cost of surgery continues to climb—from $13,000 per hospitalization in 2000 to $18,000 (inflation adjusted) in 2010—and patient safety, outcomes, and readmissions are ongoing concerns.1 Is the perioperative surgical home (PSH) a part of the solution? The concept of a more rigorously coordinated and integrated perioperative patient management system has been implemented, studied, and reported primarily in Canada, Europe, Australia, and the United States within the last 40 years, but the evolution of the PSH concept in the United States seems to be more recent. Earlier, surgical care in the United States followed a general trend of surgical specialties and capabilities moving toward same-day surgery admissions2; market expectations for high-quality surgical outcomes while controlling cost of surgeries by pursuing service-line strategies3; and value-based payment programs launched as a result of the Patient Protection and Affordable Care Act, which could yield significant savings for payers.4 The PSH continues to be defined in both the literature and clinical practice. One of its most recent definitions is based on the PSH model adopted by the University of Alabama at Birmingham, which describes the PSH model as “an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making.”5 PSH programs in the United States have a variety of names, such as “center for perioperative services,” “reengineered perioperative services,” and “perioperative care pathways.” An initial examination of the literature suggests that most definitions feature 2 points of emphasis: stronger continuity, coordination, and integration of surgical care; and greater patient-focused and shared decision making. Because the terminology used to describe the PSH varies widely, we looked at the most recent comprehensive reviews and definitions of this new concept of perioperative medicine and surgical care. In one, Lee and colleagues broadly use the umbrella term “perioperative system” to encompass all the PSH's activities and developments.6 Consistently emerging evidence in the health care literature supports care coordination models like the well-established patient-centered medical home (PCMH), with its underlying principle of a single physician who coordinates the patient's care and engages a team of health care providers and their patient in an individualized treatment and management plan.7 The PCMH embodies principles laid out by the Institute of Medicine intended to improve care coordination and patient satisfaction.8 The PCMH and the PSH share a vision of higher quality and lower cost while at the same time incorporating similar elements of patient engagement and care coordination.5 Unfortunately, surgical care often is not standardized or coordinated, resulting in duplicative or unnecessary preoperative testing and procedures, which cost an estimated $18 billion annually in the United States alone.9 The PSH concept provides a model that addresses this need for perioperative care standardization and coordination, and its impact on both clinical outcomes and cost has recently been evaluated.10

Key Points Question What are the prevalence and characteristics of adults in the United States who remain unaware of the symptoms of and the appropriate response to a myocardial infarction? Findings In this cross-sectional study of 25 271 US adults, 5.8% were not aware of any myocardial infarction symptoms, and 4.5% chose a different response than calling emergency medical services in response to these symptoms. These numbers were substantially higher in certain sociodemographic groups. Meaning Many individuals in the United States remain unaware of the symptoms of and appropriate response to a myocardial infarction., This cross-sectional study evaluates the prevalence and characteristics of US adults who are unaware of the symptoms of and appropriate response to myocardial infarction., Importance Prompt recognition of myocardial infarction symptoms is critical for timely access to lifesaving emergency cardiac care. However, patients with myocardial infarction continue to have a delayed presentation to the hospital. Objective To understand the variation and disparities in awareness of myocardial infarction symptoms among adults in the United States. Design, Setting, and Participants This cross-sectional study used data from the 2017 National Health Interview Survey among adult residents of the United States, assessing awareness of the 5 following common myocardial infarction symptoms among different sociodemographic subgroups: (1) chest pain or discomfort, (2) shortness of breath, (3) pain or discomfort in arms or shoulders, (4) feeling weak, lightheaded, or faint, and (5) jaw, neck, or back pain. The response to a perceived myocardial infarction (ie, calling emergency medical services vs other) was also assessed. Main Outcomes and Measures Prevalence and characteristics of individuals who were unaware of myocardial infarction symptoms and/or chose not to call emergency medical services in response to these symptoms. Results Among 25 271 individuals (13 820 women [51.6%; 95% CI, 50.8%-52.4%]; 17 910 non-Hispanic white individuals [69.9%; 95% CI, 68.2%-71.6%]; and 21 826 individuals [82.7%; 95% CI, 81.5%-83.8%] born in the United States), 23 383 (91.8%; 95% CI, 91.0%-92.6%) considered chest pain or discomfort a symptom of myocardial infarction; 22 158 (87.0%; 95% CI, 86.1%-87.8%) considered shortness of breath a symptom; 22 064 (85.7%; 95% CI, 84.8%-86.5%) considered pain or discomfort in arm a symptom; 19 760 (77.0%; 95% CI, 76.1%-77.9%) considered feeling weak, lightheaded, or faint a symptom; and 16 567 (62.6%; 95% CI, 61.6%-63.7%) considered jaw, neck, or back pain a symptom. Overall, 14 075 adults (53.0%; 95% CI, 51.9%-54.1%) were aware of all 5 symptoms, whereas 4698 (20.3%; 95% CI, 19.4%-21.3%) were not aware of the 3 most common symptoms and 1295 (5.8%; 95% CI, 5.2%-6.4%) were not aware of any symptoms. Not being aware of any symptoms was associated with male sex (odds ratio [OR], 1.23; 95% CI, 1.05-1.44; P = .01), Hispanic ethnicity (OR, 1.89; 95% CI, 1.47-2.43; P

In selected patients diagnosed with Breast Cancer (BC), adjuvant chemotherapy might reduce local and systemic recurrence risk, as well as cancer death rate. The combination of Docetaxel and Cyclophosphamide (TC) is a wellrecognized effective adjuvant chemotherapy regimen. Nonetheless, a considerable high rate of febrile neutropenia (FN) is associated with this regimen. We sought to investigate hematologic toxicity associated with adjuvant TC in a non-selected, “real world” cohort of BC patients. Methods: We reviewed the electronic medical records of patients who presented to the Oncology Center from Hospital Sirio-Libanes (HSL) and Instituto do Câncer do Estado de Sao Paulo (ICESP). Patients included in the analysis received adjuvant chemotherapy with TC regimen after definitive breast surgery. Results: 95 patients with were included in our analysis. Median age was 55.5 years. All patients had a good performance status (either ECOG 0 or 1), and the great majority had no comorbidities. Most patients received 4 cycles of chemotherapy (80%). Data on granulocyte colony stimulating factor (G-CSF) administration was available in 85 patients from our cohort. G-CSF was used as primary prophylaxis in 31 patients, and as secondary prophylaxis in 13 patients, following a prior episode of febrile neutropenia. Overall, fifteen women (15.8%) had a documented FN episode. Among women who received G-CSF as primary prophylaxis, the rate of FN was 6.45% (2 patients). In contrast, among patients who did not receive primary prophylaxis with G-CSF, FN rate was considerably higher, namely 24.07% (13 patients). Patients who received primary prophylaxis with G-CSF had a statistically significant lower risk of experiencing a FN episode (p=0.049). Conclusion: Febrile Neutropenia rate in this group of non-selected BC patients was higher than previous reported on randomized controlled trials that evaluated adjuvant TC regimen in the same dosing and schedule as used in our cohort. Primary prophylaxis with G-CSF was associated with a statistically significant lower risk of FN and should be considered in the management of patients who receive this chemotherapy combination.

One of the policy mechanisms aimed at improving population health through health care delivery is the Hospital Readmissions Reduction Program (HRRP) as outlined in the Affordable Care Act. Although numerous procedural and behavioral interventions have been implemented, the empirical evidence of the efficacy of these interventions is mixed and specific to certain patient segments. This review aimed to systematically assess studies of hospital interventions to reduce 30-day readmissions for specific diseases and populations. Following the PRISMA review checklist, searches were conducted from January 2000 to August 2018 in the MEDLINE and EMBASE databases using terms such as “patient readmission”, “readmit” and “re-hospitalization” in conjunction with disease terms such as “asthma”, “chronic obstructive pulmonary disease (COPD)” and “pneumonia”. Of 3,806 articles identified, 45 were included after a 3-step inclusion process. The age group most frequently considered among the studies was the 65 age cohort. Multidisciplinary collaborative interventions were most frequently effective for the subset of elderly, female, Caucasian, and heart failure patients. Interventions involving patient or family education delivered before and after care were most effective for racial minority, elderly, COPD, and heart failure patients. Telephone follow-up, tele-homecare, and medication reconciliation were largely found to be successful in reducing readmissions. Major gaps exist in identifying successful interventions for reducing 30-day readmissions among patients who sought treatment for sepsis, stroke, and replacement of the hip or knee. Our findings indicate an opportunity for researchers to further study, and for healthcare organizations to implement, more well-informed interventional strategies to reduce readmissions.

Only one quarter of U.S. hospitals demonstrated low enough levels of 30 day readmission rates to avoid penalties imposed by the Hospital Readmissions Reduction Program (HRRP) in 2016. Previous work describes interventions for reducing hospital readmission rates; however, without a comprehensive analysis of these interventions, healthcare leaders cannot prioritize strategies for implementation within their healthcare environment. This comparative study identifies the most effective interventions to reduce unplanned 30-day readmissions. The MEDLINE-PubMed database was used to conduct a systematic review of existing literature about interventions for 30-day readmission reduction published from 2006 through 2017. Data were extracted on hospital type, setting, disease type, intervention type, study sample, and impact level. Of 4,886 citations, 508 articles were reviewed in full-text, and 90 articles met the inclusion criteria. Based on the three analytic methodologies of means, weighted means, and pooled estimated impact level, the most effective interventions to reduce unplanned 30-day admissions were identified as collaboration with clinical teams and/or community providers, post-discharge home visits, telephone follow-up calls, patient/family education, and discharge planning. Commonly, all five interventions identify patient level engagement for success. The findings reveal the need for shared accountability towards desired outcomes among health systems, providers, and patients while providing hospital leaders with actionable strategies that can effectively reduce 30-day readmission rates.

Purpose: This study had two goals: (a) to assess the validity of the Online Survey Certification and Reporting (OSCAR) staffing data by comparing them to staffing measures from audited Medicaid Cost Reports and (b) to identify systematic differences between facilities that over-report or underreport staffing in the OSCAR. Design and Methods: We merged the 2002 Texas Nursing Facility Cost Report, the OSCAR for Texas facilities surveyed in 2002, and the 2003 Area Resource File. We eliminated outliers in the OSCAR using three decision rules, resulting in a final sample size of 941 of the total of 1,017 nonhospital-based facilities. We compared OSCAR and Medicaid Cost Report staffing measures for three staff types. We examined differences between facilities that over-reported or underreported staffing levels in the OSCAR by using logistic regression. Results: Average staffing levels were higher in the OSCAR than in the Medicaid Cost Report data. The two sets of measures exhibited correlations ranging between 0.5 and 0.6. For-profit and larger facilities consistently over-reported registered nurse staffing levels. Factors associated with increased odds of over-reporting licensed vocational nursing or certified nursing assistant staffing were lower Medicare or Medicaid censuses and less market competition. Facility characteristics associated with over-reporting were consistent across different levels of over-reporting. Underreporting was much less prevalent. Implications: Certain types of facilities consistently over-report staffing levels. These reporting errors will affect the validity of consumer information systems, regulatory activities, and health services research results, particularly research using OSCAR data to examine the relationship between staffing and quality. Results call for a more accurate reporting system.

Purpose: We examined the effects of facility and market-level characteristics on staffing levels and turnover rates for direct care staff, and we examined the effect of staff turnover on staffing levels. Design and Methods: We analyzed cross-sectional data from 1,014 Texas nursing homes. Data were from the 2002 Texas Nursing Facility Medicaid Cost Report and the Area Resource File for 2003. After examining factors associated with staff turnover, we tested the significance and impact of staff turnover on staffing levels for registered nurses (RNs), licensed vocational nurses (LVNs) and certified nursing assistants (CNAs). Results: All three staff types showed strong dependency on resources, such as reimbursement rates and facility payor mix. The ratio of contracted to employed nursing staff as well as RN turnover increased LVN turnover rates. CNA turnover was reduced by higher administrative expenditures and higher CNA wages. Turnover rates significantly reduced staffing levels for RNs and CNAs. LVN staffing levels were not affected by LVN turnover but were influenced by market factors such as availability of LVNs in the county and women in the labor force. Implications: Staffing levels are not always associated with staff turnover. We conclude that staff turnover is a predictor of RN and CNA staffing levels but that LVN staffing levels are associated with market factors rather than turnover. Therefore, it is important to focus on management initiatives that help reduce CNA and RN turnover and ultimately result in higher nurse staffing levels in nursing homes.