Search

Abstract Background Healthcare decisionmaking is a complex process relying on disparate types of evidence and value judgments. Our objectives for this study were to develop a practical framework to facilitate decisionmaking in terms of supporting the deliberative process, providing access to evidence, and enhancing the communication of decisions. Methods Extensive analyses of the literature and of documented decisionmaking processes around the globe were performed to explore what steps are currently used to make decisions with respect to context (from evidence generation to communication of decision) and thought process (conceptual components of decisions). Needs and methodologies available to support decisionmaking were identified to lay the groundwork for the EVIDEM framework. Results A framework was developed consisting of seven modules that can evolve over the life cycle of a healthcare intervention. Components of decision that could be quantified, i.e., intrinsic value of a healthcare intervention and quality of evidence available, were organized into matrices. A multicriteria decision analysis (MCDA) Value Matrix (VM) was developed to include the 15 quantifiable components that are currently considered in decisionmaking. A methodology to synthesize the evidence needed for each component of the VM was developed including electronic access to full text source documents. A Quality Matrix was designed to quantify three criteria of quality for the 12 types of evidence usually required by decisionmakers. An integrated system was developed to optimize data analysis, synthesis and validation by experts, compatible with a collaborative structure. Conclusion The EVIDEM framework promotes transparent and efficient healthcare decisionmaking through systematic assessment and dissemination of the evidence and values on which decisions are based. It provides a collaborative framework that could connect all stakeholders and serve the healthcare community at local, national and international levels by allowing sharing of data, resources and values. Validation and further development is needed to explore the full potential of this approach.

Background: This study compared the incidence of loss of reduction (LOR) between metacarpal fractures fixed with screws alone and those fixed with plates and screws. Secondary aims included identifying patient or fracture characteristics associated with increased risk of LOR., Methods: We retrospectively reviewed 138 metacarpal fractures in 106 patients treated with open reduction internal fixation with screws (60 fractures) or plates and screws (78 fractures) with a mean radiographic follow-up of 50 days for evidence of LOR. We compared the incidence of LOR between the screw and plate groups using a χ 2 test. We performed logistic regression analysis to determine whether patient age, sex, metacarpal location (index, long, ring, small), the presence of multiple metacarpal fractures, or fracture pattern were associated with increased incidence of LOR., Results: Loss of reduction occurred in 19 (13.8%) of 138 fractures, with no statistically significant difference between lag screw (7 of 60, 11.6%) and plate fixation (12 of 78, 15.4%). Neither fracture pattern nor the presence of multiple metacarpal fractures was associated with an increased incidence of LOR, but patients experienced a 7% increase in the risk of LOR for each additional year of age. Loss of reduction occurred most frequently in index metacarpal fractures (4 of 12, 33%), although this did not reach statistical significance., Conclusions: We found no difference in LOR incidence between lag screw fixation and plate fixation. The overall incidence of LOR was higher in this study than previously reported and increased with increasing patient age.

Objective: Longitudinal assessment of cognitive and emotional functioning in patients with Parkinson's disease (PD) is helpful in tracking progression of the disease, developing treatment plans, evaluating outcomes, and educating patients and families. Determining whether change over time is meaningful in neurodegenerative conditions, such as PD, can be difficult as repeat assessment of neuropsychological functioning is impacted by factors outside of cognitive change. Regression-based prediction formulas are one method by which clinicians and researchers can determine whether an observed change is meaningful. The purpose of the current study was to develop and validate regression-based prediction models of cognitive and emotional test scores for participants with early-stage idiopathic PD and healthy controls (HC) enrolled in the Parkinson's Progression Markers Initiative (PPMI)., Methods: Participants with de novo PD and HC were identified retrospectively from the PPMI archival database. Data from baseline testing and 12-month follow-up were utilized in this study. In total, 688 total participants were included in the present study (NPD = 508; NHC = 185). Subjects from both groups were randomly divided into development (70%) and validation (30%) subsets., Results: Early-stage idiopathic PD patients and healthy controls were similar at baseline. Regression-based models were developed for all cognitive and self-report mood measures within both populations. Within the validation subset, the predicted and observed cognitive test scores did not significantly differ, except for semantic fluency., Conclusions: The prediction models can serve as useful tools for researchers and clinicians to study clinically meaningful cognitive and mood change over time in PD., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Background: No consensus exists about whether a volar approach (VA) or dorsal approach (DA) for proximal interphalangeal (PIP) arthroplasty yields better results. Previously reported range of motion (ROM) and complications vary from study to study. This retrospective review compared the ROM and complication rates of VA and DA approaches to PIP arthroplasty. Methods: The study included 66 adults (88 digits) who underwent PIP arthroplasty from 2000 to 2015, with minimum 30-day follow-up. Demographic data, surgical approach, pre- and post-operative ROM, duration of immobilization, timing and duration of hand therapy (occupational therapy [OT]), and major and minor complications were recorded. We compared mean change in ROM, postoperative ROM, and complication rates, and examined the association of duration of immobilization and time to OT initiation with postoperative ROM. Results: While there was no difference in postoperative ROM between volar and dorsal groups (56° and 54°, respectively, P > .05), there was a greater gain in ROM in the DA group (25° vs 2.7°, P = .017). There was no statistically significant difference in overall incidence of complications (VA: 37.8%, DA: 30.3%; P > .05) or revision surgery (VA: 15.6%, DA: 17.1%; P > .05). There were no differences in duration of immobilization, time to OT initiation, or number of OT sessions between the two groups, and none of these correlated with postoperative ROM. Conclusions: We identified no statistical difference in mean postoperative ROM, incidence of complications or revision surgery between volar and dorsal approaches for PIP arthroplasty.

Objective: Evaluate neuropsychological test performance in depressed patients with early-stage Parkinson's disease., Method: Data from 422 participants from the Parkinson's Progression Marker Initiative were examined. The Geriatric Depression Scale-15 was used to categorize depressed and non-depressed participants. Neuropsychological tests measured verbal learning/memory, processing speed, visuospatial ability, verbal fluency, and working memory. Demographic and clinical variables were compared using independent samples t tests and chi-square analyses.Linear regression models were fit to adjust for age, years of education, and symptom duration., Results: The non-depressed group (n = 280) was significantly older; t(246.08) = 2.25, p = .026 and had higher education; t(420) = 2.35, p = .019; and longer duration of PD symptoms; t(170.58) = -2.13, p = .035 than the depressed group (n = 142). The non-depressed group performed better on a working memory task than the depressed group, t(420) = 2.05, p = .041, but the results did not appear to be of clinical significance. There was no significant difference between other cognitive domains. The results were not influenced by age, education, or disease duration., Conclusions: Among patients with early-stage, untreated Parkinson's disease, depression does not appear to affect neuropsychological test performance. Clinicians should demonstrate caution in over-interpreting the influence of depression on cognition in this population., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Study Objective: In the initial period of the coronavirus disease 2019 (COVID-19) pandemic, there has been a substantial decrease in the number of patients seeking care in the emergency department. A first step in estimating the impact of these changes is to characterize the patients, visits, and diagnoses for whom care is being delayed or deferred., Methods: We conducted an observational study, examining demographics, visit characteristics, and diagnoses for all ED patient visits to an urban level 1 trauma center before and after a state emergency declaration and comparing them with a similar period in 2019. We estimated percent change on the basis of the ratios of before and after periods with respect to 2019 and the decline per week using Poisson regression. Finally, we evaluated whether each factor modified the change in overall ED visits., Results: After the state declaration, there was a 49.3% decline in ED visits overall, 35.2% (95% confidence interval -38.4 to -31.9) as compared with 2019. Disproportionate declines were seen in visits by pediatric and older patients, women, and Medicare recipients, as well as for presentations of syncope, cerebrovascular accidents, urolithiasis, and abdominal and back pain. Significant proportional increases were seen in ED visits for upper respiratory infections, shortness of breath, and chest pain., Conclusion: There have been significant changes in patterns of care seeking during the COVID-19 pandemic. Declines in ED visits, especially for certain demographic groups and disease processes, should prompt efforts to understand these phenomena, encourage appropriate care seeking, and monitor for the morbidity and mortality that may result from delayed or deferred care., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Patients hospitalized with Parkinson's disease (PD) require timely delivery of carbidopa-levodopa (C/L) medication. Ill-timed administration of C/L doses is associated with greater morbidity and longer lengths of stay., Objective: To understand the barriers to timely C/L administration, and implement strategies to improve the administration of the drug to hospitalized PD patients., Methods: Several key strategies were employed in 2015 to improve the timely delivery of C/L doses: 1. three kinds of nursing alert in the electronic medical record (EMR); 2. staff in-service education; 3. stocking immediate-release C/L into automated medication dispensing machines on key hospital units; 4. reports to nurse unit managers on timeliness of C/L administration; and 5. reconciliation of inpatient and outpatient levodopa orders by the hospital pharmacist upon admission. The primary outcome was the percent of C/L doses administered within 60, 30, and 15 minutes of scheduled time., Results: Our urban hospital, affiliated with a Parkinson's Foundation Center of Excellence, had 5,939 C/L administrations in 2018. There was sustained improvement in timely delivery of doses, from 89.3% in 2012 to 96.5% in 2018 (within 60 minutes of the scheduled time), 65.5% to 86.4% (30 minutes), and 42.3% to 71.1% (15 minutes) (all p < 0.001)., Conclusions: With multifaceted but relatively simple measures, we were able to "change the culture" so that hospitalized patients with Parkinson's disease receive levodopa on time.

Background: This study assessed the feasibility of implementing a yoga intervention adapted for participants diagnosed with chronic pain in a large Midwest neuroscience pain clinic. Although conducted using a small convenience sample, this was a novel program in that it was led by an advanced practice nurse certified in pain management and to teach yoga. She was therefore uniquely qualified to tailor the yoga practice to suit individual needs of study participants., Design: The intervention consisted of a weekly 1-hour class for 10 weeks. Feasibility measures included patient recruitment, program adherence, patient satisfaction, global impression of change, and likelihood of continuing yoga practice. In addition, it was hypothesized that the program would positively affect participants' pain interference, physical function, pain intensity, pain behavior, mood, sleep, and pain medication usage., Methods: Survey measurements were conducted 10 weeks before class start, immediately before the first class, and immediately after the last class., Conclusions: Although there is a strong body of research supporting the benefits of yoga for chronic pain conditions, our experience highlights some of the challenges of implementing an adaptive yoga program. Our study found that recruitment of patient through physician referral was highly feasible; however, retention rates for participants were very low. Program adherence is a barrier for research on yoga in chronic pain, as well as for clinical practice. A slight reduction in pain interference and physical function over time and trend toward improvement in all exploratory outcomes was identified. None of these trends were statistically significant, likely because of small sample size., (Copyright © 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Background: Alzheimer's disease, the most common cause of dementia, goes unrecognized in half of patients presenting to healthcare providers and is associated with increased acute care utilization. Routine cognitive screening of older adults in healthcare settings could improve rates of dementia diagnosis and patterns of healthcare utilization., Objective: To evaluate the impact of screening positive for cognitive impairment on provider action in primary and specialty care practices and patient healthcare utilization., Design: Individuals asymptomatic for cognitive impairment completed cognitive screening with the Mini-Cog (MC). Outcomes included MC screen-positive rates, provider follow-up actions, and healthcare utilization for all participants over a period of 36 months (18 months prior to and following MC screening). Data were extracted from the electronic medical record (EMR). Healthcare provider interventions and healthcare utilization for screen-positive and -negative groups, before and after screening, were compared., Participants: Primary and specialty care patients (n = 787) aged ≥ 65 without history of cognitive impairment seen in HealthPartners, an integrated healthcare system in Minnesota and Western Wisconsin., Key Results: In primary care and neurology practices combined, over the entire 36-month study window, individuals screening positive showed 32% higher rates of ED visits (p < 0.05) pre and post-screening compared to those screening negative. Screen positive also showed 39% higher rates of hospitalizations pre-screening (p < 0.05) and 58% higher rates post-screening (p < 0.01). While screen-detected cognitive impairment was associated with some relevant provider follow-up action in 32% of individuals, subsequent healthcare utilization did not change between the 18-month pre- and post-screening periods., Conclusion: Despite being associated with higher rates of healthcare utilization, screening positive on the MC led to a change in provider action in a minority of cases and did not reduce post-screening healthcare utilization. Screening for cognitive impairment alone is not sufficient to alter patterns of provider practice or patient healthcare utilization.

Objectives: To examine neuropsychological test performance among individuals clinically diagnosed with Parkinson's disease (PD) without evidence of dopaminergic deficiency on [123]I-CIT single photon emission computed tomography imaging., Methods: Data were obtained from the Parkinson's Progression Marker Initiative. The sample included 59 participants with scans without evidence of dopaminergic deficiency (SWEDD), 412 with PD, and 114 healthy controls (HC). Tests included Judgment of Line Orientation, Letter-Number Sequencing, Symbol Digit Modalities, Hopkins Verbal Learning Test-Revised, and Letter and Category Fluency. Multivariate analysis of variance was used to compare standardized scores between the groups., Results: There was a statistically significant difference in performances between the groups, F(14,1155)=5.04; p<.001; partial η2=.058. Pairwise comparisons revealed significant differences in Category Fluency between SWEDD (M=0.22; SD=1.08) and HC (M=0.86; SD=1.15) and in Symbol Digit Modalities Test performance between SWEDD (M=45.09; SD=11.54) and HC (M=51.75; SD=9.79). No significant differences between SWEDD and PD were found. Using established criteria, approximately one in four participants in the SWEDD and PD groups met criteria for mild cognitive impairment (MCI)., Conclusions: Individuals with SWEDD demonstrate significantly worse mental processing speed and semantic fluency than HC. The neuropsychological test performances and rates of MCI were similar between the SWEDD group and PD groups, which may reflect a common pathology outside of the nigrostriatal pathway. (JINS, 2018, 24, 646-651).

Objective: The objective of this study was to examine the impact of different methods of standardizing cognitive data in the Parkinson's Progression Marker Initiative., Methods: Cognitive data from 423 participants with Parkinson's disease were included (age = 61.7 [9.7], education = 15.6 [3.0]). Internal norms were calculated using the group mean and standard deviation of the healthy control group. Published norms were compared to the overall group mean of and to age-stratified norms from healthy controls for each neuropsychological test over 4 visits. Rates of mild cognitive impairment were calculated using established criteria., Results: The use of internal norms resulted in lower standardized scores than published norms on all tests with the exception of memory and processing speed (P ≤ .001). Individuals were 1.5 to 2.1 times more likely to be diagnosed with mild cognitive impairment using internal norms than published norms., Conclusions: Standardization approaches with cognitive data are not interchangeable. Selection of a normative comparison group impacts research and clinical interpretations of cognitive data. © 2018 International Parkinson and Movement Disorder Society., (© 2018 International Parkinson and Movement Disorder Society.)

Purpose: To determine whether there is a difference in the incidence of infection between exposed and buried K-wires when used to treat phalangeal, metacarpal, and distal radius fractures., Methods: We conducted a retrospective review identifying all patients aged greater than 16 years who underwent fixation of phalangeal, metacarpal, or distal radius fractures with K-wires between 2007 and 2015. We recorded patient demographic data, fracture location, number of K-wires used, whether K-wires were buried or left exposed, and duration of K-wire placement., Results: A total of 695 patients met inclusion criteria. Surgeons buried K-wires in 207 patients and left K-wires exposed in 488. Infections occurred more frequently in exposed K-wire cases than in buried K-wire ones. Subgroup analysis based on fracture location revealed a significantly increased risk of being treated for infection when exposed K-wires were used for metacarpal fractures., Conclusions: Patients with exposed K-wires for fixation of phalangeal, metacarpal, or distal radius fractures were more likely to be treated for a pin-site infection than those with K-wires buried beneath the skin. Metacarpal fractures treated with exposed K-wires were 2 times more likely to be treated for a pin-site infection (17.6% of exposed K wire cases vs 8.7% of buried K wire cases)., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate acceptability and clinical outcomes of acupuncture on patient-reported pain and anxiety in an emergency department (ED)., Design: Observational, retrospective pilot study., Setting: Abbott Northwestern Hospital ED, Minneapolis, MN., Methods: Retrospective data was used to identify patients receiving acupuncture in addition to standard medical care in the ED between 11/1/13 and 12/31/14. Feasibility was measured by quantifying the utilization of acupuncture in a novel setting and performing limited tests of its efficacy. Patient-reported pain and anxiety scores were collected by the acupuncturist using an 11-point (0-10) numeric rating scale before (pre) and immediately after (post) acupuncture. Efficacy outcomes were change in pain and anxiety scores., Results: During the study period, 436 patients were referred for acupuncture, 279 of whom were approached by the acupuncturist during their ED visit. Consent for acupuncture was obtained from 89% (248/279). A total of 182 patients, who had a pre-pain score >0 and non-missing anxiety scores, were included in analyses. Of the 52% (94/182) who did not have analgesics before or during the acupuncture session, the average decrease of 2.37 points (95% CI: 1.92, 2.83) was not different (p > 0.05) than the mean decrease of 2.68 points for those receiving analgesics (95% CI 2.21, 3.15). The average pre-anxiety score was 4.73 points (SD = 3.43) and the mean decrease was 2.27 points (95% CI: 1.89, 2.66)., Conclusions: Results from this observational trial indicate that acupuncture was acceptable and effective for pain and anxiety reduction, in conjunction with standard medical care. These results will inform future randomized trials., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)