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BACKGROUND:Approximately half of hospitalized patients suffer functional decline due to spending the vast majority of their time in bed. Previous studies of early mobilization have demonstrated improvement in outcomes, but the interventions studied have been resource-intensive. We aimed to decrease the time hospital inpatients spend in bed through a pragmatic mobilization protocol. METHODS:This prospective, non-blinded, controlled clinical trial assigned inpatients to the study wards per routine clinical care in an urban teaching hospital. All subjects on intervention wards were provided with a behavioral intervention, consisting of educational handouts, by the nursing staff. Half of the intervention wards were supplied with recliner chairs in which subjects could sit. The primary outcome was hospital length of stay. The secondary outcome was the '6-Clicks' functional score. RESULTS:During a 6-month study period, 6082 patient encounters were included. The median length of stay was 84 hours (IQR 44-175 hours) in the control group, 80 hours (IQR 44-155 hours) in the group who received the behavioral intervention alone, and 88 hours (IQR 44-185 hours) in the group that received both the behavioral intervention and the recliner chair. In the multivariate analysis, neither the behavioral intervention nor the provision of a recliner chair was associated with a significant decrease in length of stay or increase in functional status as measured by the '6-Clicks' functional score. CONCLUSION:The program of educational handouts and provision of recliner chairs to discourage bed rest did not increase functional status or decrease length of stay for inpatients in a major urban academic center. Education and physical resources must be supplemented by other active interventions to reduce time spent in bed, functional decline, and length of stay. TRIAL REGISTRATION:ClinicalTrials.gov, HS-16-00804.

Objectives: Clinical trials are complicated, expensive, time-consuming, and frequently do not lead to discoveries that improve the health of patients with disease. Adaptive clinical trials have emerged as a methodology to provide more flexibility in design elements to better answer scientific questions regarding whether new treatments are efficacious. Limited observational data exist that describe the complex process of designing adaptive clinical trials. To address these issues, the Adaptive Designs Accelerating Promising Treatments Into Trials project developed six, tailored, flexible, adaptive, phase-III clinical trials for neurological emergencies, and investigators prospectively monitored and observed the processes. The objective of this work is to describe the adaptive design development process, the final design, and the current status of the adaptive trial designs that were developed. Methods: To observe and reflect upon the trial development process, we employed a rich, mixed methods evaluation that combined quantitative data from visual analog scale to assess attitudes about adaptive trials, along with in-depth qualitative data about the development process gathered from observations. Results: The Adaptive Designs Accelerating Promising Treatments Into Trials team developed six adaptive clinical trial designs. Across the six designs, 53 attitude surveys were completed at baseline and after the trial planning process completed. Compared to baseline, the participants believed significantly more strongly that the adaptive designs would be accepted by National Institutes of Health review panels and non-researcher clinicians. In addition, after the trial planning process, the participants more strongly believed that the adaptive design would meet the scientific and medical goals of the studies. Conclusion: Introducing the adaptive design at early conceptualization proved critical to successful adoption and implementation of that trial. Involving key stakeholders from several scientific domains early in the process appears to be associated with improved attitudes towards adaptive designs over the life cycle of clinical trial development.

Objective: We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP). Materials and Methods: We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of >10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters. Results: A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center. Conclusion: This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care.

BACKGROUND: The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents. METHODS: Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5:1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3:1 and 2:1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared. RESULTS: Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams. CONCLUSIONS: Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes.

Background The US President's Emergency Plan for AIDS Relief (PEPFAR) was reauthorized in June 2008 with a three‐fold increase in funds, and a broader, more explicit mandate to improve health in the low‐ and middle‐income countries that it funded. However, the ability of a disease‐specific, or vertical, programme to have a spill‐over effect and improve health outcomes has been questioned. In this study, we sought to examine associations between being designated as a PEPFAR focus country (and receiving increased PEPFAR funding) and non‐HIV‐specific health outcomes in the World Health Organization (WHO) Africa Region, the area most affected by the HIV/AIDS epidemic. Methods A retrospective analysis of publicly available health outcomes data published by the World Health Organization was performed for all countries in the WHO Africa Region. Fractional changes in health indicators between 2000 and 2006 were calculated, and PEPFAR focus and non‐focus countries were then compared. Results Overall, countries in the WHO Africa Region showed a small worsening in health outcomes status when all indicators were analyzed together and weighted equally. However, more health indicators improved than worsened over this six‐year period. A comparison of PEPFAR focus and non‐focus countries found no significant difference in the fractional change among 13 of 14 health indicators during the study period. Conclusions This study suggests that vertical programmes, even one that is the scale of PEPFAR, may have little or no impact on health outcomes not explicitly targeted.