Search

This document describes performance measures for heart failure that are appropriate for public reporting or pay-for-performance programs and is meant to serve as a focused update of the "2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures." The new performance measures are taken from the "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines" and are selected from the strongest recommendations (Class 1 or Class 3). In contrast, quality measures may not have as much evidence base and generally comprise metrics that might be useful for clinicians and health care organizations for quality improvement but are not yet appropriate for public reporting or pay-for-performance programs. New performance measures include optimal blood pressure control in patients with heart failure with preserved ejection fraction, the use of sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction, and the use of guideline-directed medical therapy in hospitalized patients. New quality measures include the use of sodium-glucose cotransporter-2 inhibitors in patients with heart failure with mildly reduced and preserved ejection fraction, the optimization of guideline-directed medical therapy prior to intervention for chronic secondary severe mitral regurgitation, continuation of guideline-directed medical therapy for patients with heart failure with improved ejection fraction, identifying both known risks for cardiovascular disease and social determinants of health, patient-centered counseling regarding contraception and pregnancy risks for individuals with cardiomyopathy, and the need for a monoclonal protein screen to exclude light chain amyloidosis when interpreting a bone scintigraphy scan assessing for transthyretin cardiac amyloidosis.

OBJECTIVES: To develop treat-to-target (T2T) recommendations in giant cell arteritis (GCA) and polymyalgia rheumatica (PMR). METHODS: A systematic literature review was conducted to retrieve data on treatment targets and outcomes in GCA/PMR as well as to identify the evidence for the effectiveness of a T2T-based management approach in these diseases. Based on evidence and expert opinion, the task force (29 participants from 10 countries consisting of physicians, a healthcare professional and a patient) developed recommendations, with consensus obtained through voting. The final level of agreement was provided anonymously. RESULTS: Five overarching principles and six-specific recommendations were formulated. Management of GCA and PMR should be based on shared decisions between patient and physician recognising the need for urgent treatment of GCA to avoid ischaemic complications, and it should aim at maximising health-related quality of life in both diseases. The treatment targets are achievement and maintenance of remission, as well as prevention of tissue ischaemia and vascular damage. Comorbidities need to be considered when assessing disease activity and selecting treatment. CONCLUSION: These are the first T2T recommendations for GCA and PMR. Treatment targets, as well as strategies to assess, achieve and maintain these targets have been defined. The research agenda highlights the gaps in evidence and the need for future research.

Background: To address the societal burden of low back pain (LBP), several health systems have adopted Models of Care (MoCs). These evidence-informed models aim for consistent care and outcomes. However, real-world applications vary, with each setting presenting unique challenges and nuances in the primary healthcare landscape. This scoping review aims to synthesize the available evidence regarding the use of implementation theories, models or frameworks, context-specific factors, implementation strategies and outcomes reported in MoCs targeting LBP in primary healthcare. Methods: MEDLINE(Pubmed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were searched. Eligible records included MoCs for adults with LBP in primary healthcare. Two reviewers independently extracted data concerning patient-related, system-related and implementation-related outcomes. The implementation processes, including guiding theories, models or frameworks, barriers and facilitators to implementation and implementation strategies were also extracted. The data were analysed through a descriptive qualitative content analysis and synthesized via both quantitative and qualitative approaches. Results: Eleven MoCs (n = 29 studies) were included. Implementation outcomes were assessed in 6 MoCs through quantitative, qualitative, and mixed methods approaches. Acceptability and appropriateness were the most reported outcomes. Only 5 MoCs reported underlying theories, models, or frameworks. Context-specific factors influencing implementation were identified in 3 MoCs. Common strategies included training providers, developing educational materials, and changing record systems. Notably, only one MoC included a structured multifaceted implementation strategy aligned with the evaluation of patient, organizational and implementation outcomes. Conclusions: The implementation processes and outcomes of the MoCs were not adequately reported and lacked sufficient theoretical support. As a result, conclusions about the success of implementation cannot be drawn, as the strategies employed were not aligned with the outcomes. This study highlights the need for theoretical guidance in the development and implementation of MoCs for the management of LBP in primary healthcare. Registration: Open Science Framework Registries (). [ABSTRACT FROM AUTHOR]

Abstract Background To address the societal burden of low back pain (LBP), several health systems have adopted Models of Care (MoCs). These evidence-informed models aim for consistent care and outcomes. However, real-world applications vary, with each setting presenting unique challenges and nuances in the primary healthcare landscape. This scoping review aims to synthesize the available evidence regarding the use of implementation theories, models or frameworks, context-specific factors, implementation strategies and outcomes reported in MoCs targeting LBP in primary healthcare. Methods MEDLINE(Pubmed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were searched. Eligible records included MoCs for adults with LBP in primary healthcare. Two reviewers independently extracted data concerning patient-related, system-related and implementation-related outcomes. The implementation processes, including guiding theories, models or frameworks, barriers and facilitators to implementation and implementation strategies were also extracted. The data were analysed through a descriptive qualitative content analysis and synthesized via both quantitative and qualitative approaches. Results Eleven MoCs (n = 29 studies) were included. Implementation outcomes were assessed in 6 MoCs through quantitative, qualitative, and mixed methods approaches. Acceptability and appropriateness were the most reported outcomes. Only 5 MoCs reported underlying theories, models, or frameworks. Context-specific factors influencing implementation were identified in 3 MoCs. Common strategies included training providers, developing educational materials, and changing record systems. Notably, only one MoC included a structured multifaceted implementation strategy aligned with the evaluation of patient, organizational and implementation outcomes. Conclusions The implementation processes and outcomes of the MoCs were not adequately reported and lacked sufficient theoretical support. As a result, conclusions about the success of implementation cannot be drawn, as the strategies employed were not aligned with the outcomes. This study highlights the need for theoretical guidance in the development and implementation of MoCs for the management of LBP in primary healthcare. Registration Open Science Framework Registries ( https://osf.io/rsd8x ).

Loss to follow-up (LTFU) distorts results of randomized controlled trials (RCTs). Understanding trial characteristics that contribute to LTFU may enable investigators to anticipate the extent of LTFU and plan retention strategies. The objective of this systematic review and meta-analysis was to investigate the extent of LTFU in surgical RCTs and evaluate associations between trial characteristics and LTFU. MEDLINE, Embase, and PubMed Central were searched for surgical RCTs published between January 2002 and December 2021 in the 30 highest impact factor surgical journals. Two-hundred eligible RCTs were randomly selected. The pooled LTFU rate was estimated using random intercept Poisson regression. Associations between trial characteristics and LTFU were assessed using metaregression. The 200 RCTs included 37,914 participants and 1307 LTFU events. The pooled LTFU rate was 3.10 participants per 100 patient-years (95% confidence interval [CI] 1.85-5.17). Trial characteristics associated with reduced LTFU were standard-of-care outcome assessments (rate ratio [RR] 0.17; 95% CI 0.06-0.48), surgery for transplantation (RR 0.08; 95% CI 0.01-0.43), and surgery for cancer (RR 0.10; 95% CI 0.02-0.53). Increased LTFU was associated with patient-reported outcomes (RR 14.21; 95% CI 4.82-41.91) and follow-up duration ≥ three months (odds ratio 10.09; 95% CI 4.79-21.28). LTFU in surgical RCTs is uncommon. Participants may be at increased risk of LTFU in trials with outcomes assessed beyond the standard of care, surgical indications other than cancer or transplant, patient-reported outcomes, and longer follow-up. Investigators should consider the impact of design on LTFU and plan retention strategies accordingly. [ABSTRACT FROM AUTHOR]

BACKGROUND: Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS: The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS: Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS: KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed. [ABSTRACT FROM AUTHOR]

Objective: To analyze the supply of input and procedures, non-invasive and micro-invasive, for dental caries lesions in Primary Care in Brazil, comparing the Brazilian geographic regions in three different periods. Material and Methods: Historical series study based on secondary data extracted from the 1st Cycle (2012), 2nd (2014), and 3rd cycle (2018) of the External Evaluation of the National Program for Access and Quality of Primary Care. The proportions of Oral Health Teams offering non-invasive (fluor) and micro-invasive (sealants) supplies and procedures between Brazilian geographic regions were compared using the Chi-square test, using the Z Test adjusted by the Bonferroni method, and between the years (2012, 2014, and 2018) using the Cochran Q test (p

Objective: To analyze the supply of input and procedures, non-invasive and micro-invasive, for dental caries lesions in Primary Care in Brazil, comparing the Brazilian geographic regions in three different periods. Material and Methods: Historical series study based on secondary data extracted from the 1st Cycle (2012), 2nd (2014), and 3rd cycle (2018) of the External Evaluation of the National Program for Access and Quality of Primary Care. The proportions of Oral Health Teams offering non-invasive (fluor) and micro-invasive (sealants) supplies and procedures between Brazilian geographic regions were compared using the Chi-square test, using the Z Test adjusted by the Bonferroni method, and between the years (2012, 2014, and 2018) using the Cochran Q test (p<0.05). The percentage variation between the proportions per cycle was calculated. Results: The availability of inputs of fluor gel in Brazil increased between 2014 (91.6%) and 2018 (94.1%) (p<0.001), but statistically only in the Northeast and North (p<0.001). The offer of the topical fluorine procedure increased between 2012 (78.8%) and 2018 (87.4%) (p<0.001) in Brazil, with the most significant increase in the North (+7.5%) and Northeast (+22.0%). There was greater availability of inputs of sealants in Brazil between 2012 (56.8%) and 2018 (69.5%) (p<0.001) in Brazil, and more significant expansion in the Northeast (+43.4%). There was a greater offer of the sealing procedure in Brazil between 2014 (98.6%) and 2018 (98.5%), compared to 2012 (94.7%) (p<0.001), with more significant expansion in the North (+5.8%). Conclusion: There was an increase in the supply of input and procedures, non-invasive and micro-invasive, in Primary Care in Brazil. Despite maintaining regional inequalities, they were reduced, with greater expansion in the North and Northeast regions between the years evaluated. [ABSTRACT FROM AUTHOR]

The Sup-ER protocol involves a repositioning program for infants with brachial plexus birth injury to position the shoulder in external rotation (ER) to address progressive loss in passive range of motion (PROM). The British Columbia Children's Hospital (BCCH) eligibility criteria for this protocol are infants aged 4-8 weeks with decreased shoulder ER PROM and/or Active Movement Scale (AMS) shoulder ER and/or supination scores ≤2. The resources needed to implement this protocol in large clinics have not been studied. This study aims to evaluate the BCCH criteria that are used to identify appropriate candidates for the Sup-ER protocol. A retrospective cohort study was conducted to identify the percentage of infants who would have been recommended the Sup-ER protocol based on their PROM and AMS scores between 4 and 8 weeks of age. A sensitivity and specificity evaluation was used to describe the BCCH criteria's ability to identify infants in this historical cohort who went on to have incomplete shoulder function (ie, true positive) vs infants who had functional shoulder outcome at 9 months of age (ie, false positive). At a mean of 5.8 weeks (95% confidence interval [CI] 5.3, 6.3), 46 of the 87 (53%) infants satisfied the BCCH Sup-ER protocol criteria. Forty-four (51%) were female, half (n = 45) were left side affected, and 88% had upper plexus injury. The BCCH Sup-ER protocol criteria had sensitivity of 100% and specificity of 71% to identify infants with incomplete shoulder function. Removing the AMS supination ≤2 score criterion from the criteria improves the specificity to 84%, while sensitivity remains high (97%). Modifying the BCCH criteria to all infants aged 4-8 weeks with AMS shoulder ER ≤2 and/or decreased shoulder ER PROM improves the precision of identifying infants who would benefit from the Sup-ER protocol. • Using the British Columbia Children's Hospital (BCCH) criteria, 53% of infants at a high volume brachial plexus clinic would be recommended the Sup-ER protocol. • Modifying the BCCH criteria by removing the supination criterion reduces the number of qualifying infants by 10% while maintaining high sensitivity (97%). • These modified BCCH criteria improve the precision of identifying infants who would benefit from the Sup-ER protocol. [ABSTRACT FROM AUTHOR]

BackgroundRespiratory complications are associated with significant morbidity and mortality in trauma patients. The care transition from the intensive care unit (ICU) to the acute care ward is a vulnerable time for injured patients. There is a lack of knowledge about the epidemiology of respiratory events and their outcomes during this transition.MethodsRetrospective cohort study in a single Level I trauma center of injured patients 18 years and older initially admitted to the ICU from 2015 to 2019 who survived initial transfer to the acute care ward. The primary outcome was occurrence of a respiratory event, defined as escalation in oxygen therapy beyond nasal cannula or facemask for three or more consecutive hours. Secondary outcomes included unplanned intubation for a primary pulmonary cause, adjudicated via manual chart review, as well as in-hospital mortality and length of stay. Multivariable logistic regression was used to examine patient characteristics associated with posttransfer respiratory events.ResultsThere were 6,561 patients that met the inclusion criteria with a mean age of 52.3 years and median Injury Severity Score of 18 (interquartile range, 13-26). Two hundred and sixty-two patients (4.0%) experienced a respiratory event. Respiratory events occurred early after transfer (median, 2 days, interquartile range, 1-5 days), and were associated with high mortality (16% vs. 1.8%, p < 0.001), and ICU readmission rates (52.6% vs. 4.7%, p < 0.001). Increasing age, male sex, severe chest injury, and comorbidities, including preexisting alcohol use disorder, congestive heart failure, and chronic obstructive pulmonary disease, were associated with increased odds of a respiratory event. Fifty-eight patients experienced an unplanned intubation for a primary pulmonary cause, which was associated with an in-hospital mortality of 39.7%.ConclusionRespiratory events after transfer to the acute care ward occur close to the time of transfer and are associated with high mortality. Interventions targeted at this critical time are warranted to improve patient outcomes.Level of evidencePrognostic and Epidemiological study, level III.

BackgroundThe United States Chronic Thromboembolic Pulmonary Hypertension Registry (US-CTEPH-R) was designed to characterize the demographic characteristics, evaluation, clinical course, and outcomes of surgical and nonsurgical therapies for patients with chronic thromboembolic pulmonary hypertension.Research questionWhat are the differences in baseline characteristics and 1-year outcomes between operated and nonoperated subjects?Study design and methodsThis study describes a multicenter, prospective, longitudinal, observational registry of patients newly diagnosed (< 6 months) with CTEPH. Inclusion criteria required a mean pulmonary artery pressure ≥ 25 mm Hg documented by right heart catheterization and radiologic confirmation of CTEPH. Between 2015 and 2018, a total of 750 patients were enrolled and followed up biannually until 2019.ResultsMost patients with CTEPH (87.9%) reported a history of acute pulmonary embolism. CTEPH diagnosis delays were frequent (median, 10 months), and most patients reported World Health Organization functional class 3 status at enrollment with a median mean pulmonary artery pressure of 44 mm Hg. The registry cohort was subdivided into Operable patients undergoing pulmonary thromboendarterectomy (PTE) surgery (n = 566), Operable patients who did not undergo surgery (n = 88), and those who were Inoperable (n = 96). Inoperable patients were older than Operated patients; less likely to be obese; have a DVT history, non-type O blood group, or thrombophilia; and more likely to have COPD or a history of cancer. PTE resulted in a median pulmonary vascular resistance decline from 6.9 to 2.6 Wood units (P < .001) with a 3.9% in-hospital mortality. At 1-year follow-up, Operated patients were less likely treated with oxygen, diuretics, or pulmonary hypertension-targeted therapy compared with Inoperable patients. A larger percentage of Operated patients were World Health Organization functional class 1 or 2 at 1 year (82.9%) compared with the Inoperable (48.2%) and Operable/No Surgery (56%) groups (P < .001).InterpretationDifferences exist in the clinical characteristics between patients who exhibited operable CTEPH and those who were inoperable, with the most favorable 1-year outcomes in those who underwent PTE surgery.Clinical trial registrationClinicalTrials.gov; No.: NCT02429284; URL: www.clinicaltrials.gov.

OBJECTIVES: We propose a preventive and therapeutic assessment program for mucositis in patients with cancer based on a comprehensive review of scientific evidence. MATERIAL AND METHODS: This methodological study, designed as a non-systematic review, entails a thorough review of the scientific evidence on the management of mucositis in patients with cancer. The PICO method was used, allowing for a structured approach to explore and synthesize relevant evidence. RESULTS: Effective mucositis management requires regular assessments, dental exams, preventive strategies, and consideration of modifiable risk factors. Pharmacological therapies may be considered for severe cases, while oral antimicrobials, prophylactic antiviral and antifungal therapy can prevent infections. Topical anesthetics o?er pain relief but require careful administration. A gradual management plan, from gentle rinses to analgesics, is recommended. CONCLUSION: The suggested program may improve the identification, prevention, and management of this complication to achieve optimal management outcomes.

Background: Primary health care systems have a key role in meeting health needs of community, including function. The aim of this paper is to describe the population involved in the Community Physiotherapist project and their health outcomes over a one-year period. Methods: The Community Physiotherapist is an on-call service which requires a request by general practitioners or medical specialists. Reason for prescription, waiting time for service delivery, diagnostic categories, provided intervention, number of interventions and outcomes were recorded for everyone included in the project. Possible differences in characteristics between individuals referred by medical specialists and general practitioners were also investigated. Results: From January to December 2022, 409 individuals were referred to the Community Physiotherapist pathway. Functional goals were achieved in 79.5% of interventions, without reported adverse events. In most cases physiotherapists provided counselling or caregiver training and 3.3% of individuals needed a full rehabilitation program. The groups of individuals referred by the two types of prescribers showed no significant differences, apart, as expected, from their median age. Conclusions: The introduction of the Community Physiotherapist model within the primary care setting allows to provide appropriate, effective and safe interventions. Sharing the project among all the health professionals helped to support its appropriateness and effectiveness. Results also indicate that a new organizational model, such as the Community Physiotherapist, will take a long time to be implemented. [ABSTRACT FROM AUTHOR]

To validate Sections GG (Self-Care and Mobility Assessment), B (Hearing, Speech, and Vision), and C (Cognitive Patterns) of the Centers for Medicare and Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument (CMS-IRF PAI) Version 1.4 in comparison with Functional Independence Measure (FIM) motor subscale (FIMm) and cognitive subscale (FIMc). Retrospective cohort. Single inpatient rehabilitation facility. Cohort of 1296 patients admitted for rehabilitation after stroke, between October 1, 2016, and October 1, 2019. Not applicable. Sections GG, B, and C scores were compared with FIMm and FIMc using Spearman's and Bland-Altman Analyses. Sections GG and FIMm were highly correlated on admission (ρ=0.919, P <.001) and discharge (ρ=0.929, P <.001). Ceiling effects at discharge were more pronounced for Section GG (8.6%). Bland-Altman analyses revealed a bias toward higher scores on Section GG vs FIMm on admission (Bias=2.3%, P <.001), and discharge (Bias=6.2%, P <.001). Section GG showed bias toward greater gains in function (Bias=3.9%, P <.001), particularly in walking and stairs (bias=3.71%, P <.001). Comparable self-care items accounted for a smaller percentage of the Section GG gains compared with FIMm (bias=-7.5%, P <.001). The internal validity of a scale consisting of Section B and C (B+C scale) was good, (Cronbach's alpha=0.868) and was highly correlated with FIMc (ρ=0.745), but rated patients at a higher level of cognition (bias=20.0%, P <.001) and had a greater ceiling effect (20.4%) on admission compared with the FIMc (0.6%). The B+C scale and Section GG were correlated with FIMc and FIMm subscales but biased toward higher ratings of ability. Ceiling effects may limit discrimination at higher level of cognition/functional independence. The clinical acceptability of Section GG total scores as an outcome measure and predictor of long-term outcomes requires further study. [ABSTRACT FROM AUTHOR]

Target: BP™ is a national initiative launched by the American Heart Association and the American Medical Association in 2017 in response to the high prevalence of uncontrolled blood pressure (BP) in the United States. Target: BP™ provides support to health care organizations and health care teams, with no user fees, to improve the quality of care for adults with hypertension by providing education and resources and recognizing organizations committed to prioritizing and reporting their rate of BP control. Through Target: BP™, the American Heart Association and the American Medical Association also collaborate to align policy with evidence through federal, state, and institutional policy advocacy and raise public awareness through media campaigns. In 2022, Target: BP™ recognized 1309 health care organizations serving 8.4 million patients with hypertension for prioritizing BP control, 675 of which affirmed performance of evidence-based BP measurement activities and 551 of which reported BP control rates =70%. With the proportion of US adults with controlled BP falling to 48.2% from 2017 to 2020, Target: BP™ remains focused on regaining lost ground in national BP control rates by emphasizing accurate BP measurement, rapid treatment intensification, healthful lifestyle changes, and evidence-based use of self-measured BP monitoring. Target: BP™ also emphasizes adoption of team-based care models and prioritizing equitable health outcomes. [ABSTRACT FROM AUTHOR]

Quality improvement (QI) in medicine is reliant on a team-based approach and an understanding of core QI principles. Part 2 of this continuing medical education series outlines the steps of performing a QI project, from identifying QI opportunities, to carrying out successive Plan-Do-Study-Act cycles, to hard-wiring improvements into the system. QI frameworks will be explored and readers will understand how to interpret basic QI data. [ABSTRACT FROM AUTHOR]

Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Psychosocial interventions for adolescent mental health problems are effective, but evidence on their longer-term outcomes is scarce, especially in low-resource settings. We report on the 12-month sustained effectiveness and costs of scaling up a lay counselor-delivered, transdiagnostic problem-solving intervention for common adolescent mental health problems in low-income schools in New Delhi, India. METHODS AND FINDINGS: Participants in the original trial were 250 school-going adolescents (mean [M] age = 15.61 years, standard deviation [SD] = 1.68), including 174 (69.6%) who identified as male. Participants were recruited from 6 government schools over a period of 4 months (August 20 to December 14, 2018) and were selected on the basis of elevated mental health symptoms and distress/functional impairment. A 2-arm, randomized controlled trial design was used to examine the effectiveness of a lay counselor-delivered, problem-solving intervention (4 to 5 sessions over 3 weeks) with supporting printed booklets (intervention arm) in comparison with problem solving delivered via printed booklets alone (control arm), at the original endpoints of 6 and 12 weeks. The protocol was modified, as per the recommendation of the Trial Steering Committee, to include a post hoc extension of the follow-up period to 12 months. Primary outcomes were adolescent-reported psychosocial problems (Youth Top Problems [YTP]) and mental health symptoms (Strengths and Difficulties Questionnaire [SDQ] Total Difficulties scale). Other self-reported outcomes included SDQ subscales, perceived stress, well-being, and remission. The sustained effects of the intervention were estimated at the 12-month endpoint and over 12 months (the latter assumed a constant effect across 3 follow-up points) using a linear mixed model for repeated measures and involving complete case analysis. Sensitivity analyses examined the effect of missing data using multiple imputations. Costs were estimated for delivering the intervention during the trial and from modeling a scale-up scenario, using a retrospective ingredients approach. Out of the 250 original trial participants, 176 (70.4%) adolescents participated in the 12-month follow-up assessment. One adverse event was identified during follow-up and deemed unrelated to the intervention. Evidence was found for intervention effects on both SDQ Total Difficulties and YTP at 12 months (YTP: adjusted mean difference [AMD] = -0.75, 95% confidence interval [CI] = -1.47, -0.03, p = 0.04; SDQ Total Difficulties: AMD = -1.73, 95% CI = -3.47, 0.02, p = 0.05), with stronger effects over 12 months (YTP: AMD = -0.98, 95% CI = -1.51, -0.45, p < 0.001; SDQ Total Difficulties: AMD = -1.23, 95% CI = -2.37, -0.09; p = 0.03). There was also evidence for intervention effects on internalizing symptoms, impairment, perceived stress, and well-being over 12 months. The intervention effect was stable for most outcomes on sensitivity analyses adjusting for missing data; however, for SDQ Total Difficulties and impairment, the effect was slightly attenuated. The per-student cost of delivering the intervention during the trial was $3 United States dollars (USD; or $158 USD per case) and for scaling up the intervention in the modeled scenario was $4 USD (or $23 USD per case). The scaling up cost accounted for 0.4% of the per-student school budget in New Delhi. The main limitations of the studys methodology were the lack of sample size calculations powered for 12-month follow-up and the absence of cost-effectiveness analyses using the primary outcomes. CONCLUSIONS: In this study, we observed that a lay counselor-delivered, brief transdiagnostic problem-solving intervention had sustained effects on psychosocial problems and mental health symptoms over the 12-month follow-up period. Scaling up this resource-efficient intervention is an affordable policy goal for improving adolescents access to mental health care in low-resource settings. The findings need to be interpreted with caution, as this study was a post hoc extension, and thus, the sample size calculations did not take into account the relatively high attrition rate observed during the long-term follow-up. TRIAL REGISTRATION: ClinicalTrials.gov NCT03630471.

BACKGROUND: Delirium is a deleterious condition affecting up to 60% of patients in the surgical ICU (SICU). Few SICU-focused delirium interventions have been implemented, including those addressing sleep-wake disruption, a modifiable delirium risk factor common in critically ill patients. RESEARCH QUESTION: What is the effect on delirium and sleep quality of a multicomponent nonpharmacologic intervention aimed at improving sleep-wake disruption in patients in the SICU setting? STUDY DESIGN AND METHODS: Using a staggered pre-post design, we implemented a quality improvement intervention in two SICUs (general surgery or trauma and cardiovascular) in an academic medical center. After a preintervention (baseline) period, a multicomponent unit-wide nighttime (ie, efforts to minimize unnecessary sound and light, provision of earplugs and eye masks) and daytime (ie, raising blinds, promotion of physical activity) intervention bundle was implemented. A daily checklist was used to prompt staff to complete intervention bundle elements. Delirium was evaluated twice daily using the Confusion Assessment Method for the Intensive Care Unit. Patient sleep quality ratings were evaluated daily using the Richards-Campbell Sleep Questionnaire (RCSQ). RESULTS: Six hundred forty-six SICU admissions (332 baseline, 314 intervention) were analyzed. Median age was 61 years (interquartile range, 49-70 years); 35% of the cohort were women and 83% were White. During the intervention period, patients experienced fewer days of delirium (proportion ± SD of ICU days, 15 ± 27%) as compared with the preintervention period (20 ± 31%; P = .022), with an adjusted pre-post decrease of 4.9% (95% CI, 0.5%-9.2%; P = .03). Overall RCSQ-perceived sleep quality ratings did not change, but the RCSQ noise subscore increased (9.5% [95% CI, 1.1%-17.5%; P = .02). INTERPRETATION: Our multicomponent intervention was associated with a significant reduction in the proportion of days patients experienced delirium, reinforcing the feasibility and effectiveness of a nonpharmacologic sleep-wake bundle to reduce delirium in critically ill patients in the SICU. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03313115; URL: www.clinicaltrials.gov.

Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95-1.00). Lower odds of IRF versus home discharge were observed in people aged

BackgroundThere has recently been considerable interest in better understanding how blood pressure should be managed after an episode of hospitalized AKI, but there are scant data regarding the associations between blood pressure measured after AKI and subsequent adverse outcomes. We hypothesized that among AKI survivors, higher blood pressure measured three months after hospital discharge would be associated with worse outcomes. We also hypothesized these associations between blood pressure and outcomes would be similar among those who survived non-AKI hospitalizations.MethodsWe quantified how systolic blood pressure (SBP) observed three months after hospital discharge was associated with risks of subsequent hospitalized AKI, loss of kidney function, mortality, and heart failure events among 769 patients in the prospective ASSESS-AKI cohort study who had hospitalized AKI. We repeated this analysis among the 769 matched non-AKI ASSESS-AKI enrollees. We then formally tested for AKI interaction in the full cohort of 1538 patients to determine if these associations differed among those who did and did not experience AKI during the index hospitalization.ResultsAmong 769 patients with AKI, 42 % had subsequent AKI, 13 % had loss of kidney function, 27 % died, and 18 % had heart failure events. SBP 3 months post-hospitalization did not have a stepwise association with the risk of subsequent AKI, loss of kidney function, mortality, or heart failure events. Among the 769 without AKI, there was also no stepwise association with these risks. In formal interaction testing using the full cohort of 1538 patients, hospitalized AKI did not modify the association between post-discharge SBP and subsequent risks of adverse clinical outcomes.ConclusionsContrary to our first hypothesis, we did not observe that higher stepwise blood pressure measured three months after hospital discharge with AKI was associated with worse outcomes. Our data were consistent with our second hypothesis that the association between blood pressure measured three months after hospital discharge and outcomes among AKI survivors is similar to that observed among those who survived non-AKI hospitalizations.

Background/objectivesCOVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide.DesignCross-sectional qualitative design using semi-structured interviews.SettingHBPC practices in the NYC metro area during spring 2020.ParticipantsHBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices.MeasurementsSemi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach.ResultsParticipants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients.ConclusionNYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.

OBJECTIVE: Common data elements (CDEs) are standardized questions and answer choices that allow aggregation, analysis, and comparison of observations from multiple sources. Clinical CDEs are foundational for learning health care systems, a data-driven approach to health care focused on continuous improvement of outcomes. We aimed to create clinical CDEs for pediatric epilepsy. METHODS: A multiple stakeholder group (clinicians, researchers, parents, caregivers, advocates, and electronic health record [EHR] vendors) developed clinical CDEs for routine care of children with epilepsy. Initial drafts drew from clinical epilepsy note templates, CDEs created for clinical research, items in existing registries, consensus documents and guidelines, quality metrics, and outcomes needed for demonstration projects. The CDEs were refined through discussion and field testing. We describe the development process, rationale for CDE selection, findings from piloting, and the CDEs themselves. We also describe early implementation, including experience with EHR systems and compatibility with the International League Against Epilepsy classification of seizure types. RESULTS: Common data elements were drafted in August 2017 and finalized in January 2020. Prioritized outcomes included seizure control, seizure freedom, American Academy of Neurology quality measures, presence of common comorbidities, and quality of life. The CDEs were piloted at 224 visits at 10 centers. The final CDEs included 36 questions in nine sections (number of questions): diagnosis (1), seizure frequency (9), quality of life (2), epilepsy history (6), etiology (8), comorbidities (2), treatment (2), process measures (5), and longitudinal history notes (1). Seizures are categorized as generalized tonic-clonic (regardless of onset), motor, nonmotor, and epileptic spasms. Focality is collected as epilepsy type rather than seizure type. Seizure frequency is measured in nine levels (all used during piloting). The CDEs were implemented in three vendor systems. Early clinical adoption included 1294 encounters at one center. SIGNIFICANCE: We created, piloted, refined, finalized, and implemented a novel set of clinical CDEs for pediatric epilepsy.

Rationale & objectiveObservational studies have reported a U-shaped association between blood pressure (BP) before a hemodialysis session and death. In contrast, because a linear association between out-of-dialysis-unit BP and death has been reported, home BP may be a better target for treatment. To test the feasibility of this approach, we conducted a pilot trial of treating home versus predialysis BP in hemodialysis patients.Study designA 4-month, parallel, randomized, controlled trial.Settings & participants50 prevalent hemodialysis patients in San Francisco and Seattle. Participants were randomly assigned using 1:1 block randomization, stratified by site.InterventionsTo target home systolic BP (SBP) of 100-200mm Hg; 0.2% vs 0%) or low (defined as

Background: The post-acute patient standardized functional items (Section GG) include non-response options such as refuse, not attempt and not applicable. We examined non-response patterns and compared four methods to address non-response functional data in Section GG at nation-wide inpatient rehabilitation facilities (IRF). Methods: We characterized non-response patterns using 100% Medicare 2018 data. We applied four methods to generate imputed values for each non-response functional item of each patient: Monte Carlo Markov Chains multiple imputations (MCMC), Fully Conditional Specification multiple imputations (FCS), Pattern-mixture model (PMM) multiple imputations and the Centers for Medicare and Medicaid Services (CMS) approach. We compared changes of Spearman correlations and weighted kappa between Section GG and the site-specific functional items across impairments before and after applying four methods. Results: One hundred fifty-nine thousand six hundred ninety-one Medicare fee-for-services beneficiaries admitted to IRFs with stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. At discharge, 3.9% (self-care) and 61.6% (mobility) of IRF patients had at least one non-response answer in Section GG. Patients tended to have non-response data due to refused at discharge than at admission. Patients with non-response data tended to have worse function, especially in mobility; also improved less functionally compared to patients without non-response data. Overall, patients coded as 'refused' were more functionally independent in self-care and patients coded as 'not applicable' were more functionally independent in transfer and mobility, compared to other non-response answers. Four methods showed similar changes in correlations and agreements between Section GG and the site-specific functional items, but variations exist across impairments between multiple imputations and the CMS approach. Conclusions: The different reasons for non-response answers are correlated with varied functional status. The high proportion of patients with non-response data for mobility items raised a concern of biased IRF quality reporting. Our findings have potential implications for improving patient care, outcomes, quality reporting, and payment across post-acute settings. [ABSTRACT FROM AUTHOR]

Quality indicators (QIs) are tools for improving and maintaining the standard of care. Although burn injuries are a major global health threat, requiring standardized management, there is a lack of worldwide accepted quality indicators for burn care. This study aims to identify the best burn care-specific QIs as perceived by worldwide burn practitioners. The ISBI Burn Care Committee developed a survey to analyze which burn care- specific QIs were relevant to international burn care professionals. The questionnaire was based on the three dimensions of the Donabedian model (i.e., Structure, Process, and Outcome) to evaluate the quality of care. The study was conducted from April to September 2021 and analyzed and reported following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). According to the 124 worldwide respondents, the most relevant QIs were: access to intensive care, burn surgeons, and dedicated burn care nurses (Structure category), 24-hours access to burn services, local protocols based on documented guidelines (Process category), and in-hospital mortality and incidence of severe infections (Outcome category). Specific QIs related to structures, clinical processes, and outcomes are needed to monitor the treatment of burn patients globally, assess the efficiency of the provided treatment, and harmonize the worldwide standard of burn care. • Burn-specific QIs are essential for maintaining and improving Burn Care locally and internationally. • The ISBI Burn Care Committee conducted a specific survey among international burn care professionals. • The integration of specific structural, process and outcome QIs outlines a model for quality improvement in burn care. [ABSTRACT FROM AUTHOR]

Background: Clinical quality registries provide rich and useful data for clinical quality monitoring and research purposes but are susceptible to data quality issues that can impact their usage. Objective : This study assessed the concordance between comorbidities recorded in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and those in state-based hospital admission datasets. Method: All patients in New South Wales, South Australia, Tasmania, Victoria and Western Australia recorded in ANZDATA as requiring chronic kidney replacement therapy (KRT) between 01/07/2000 and 31/12/2015 were linked with state-based hospital admission datasets. Coronary artery disease, diabetes mellitus, cerebrovascular disease, chronic lung disease and peripheral vascular disease recorded in ANZDATA at each annual census date were compared overall, over time and between different KRT modalities to comorbidities recorded in hospital admission datasets, as defined by the International Classification of Diseases (ICD-10-AM), using both the kappa statistic and logistic regression analysis. Results: 29, 334 patients with 207,369 hospital admissions were identified. Comparison was made at census date for every patient comparison. Overall agreement was "very good" for diabetes mellitus (92%, k = 0.84) and "poor" to "fair" (21–61%, k = 0.02–0.22) for others. Diabetes mellitus recording had the highest accuracy (sensitivity 93% (±SE 0.2) and specificity 93% (±SE 0.2)), and cerebrovascular disease had the lowest (sensitivity 54% (±SE 0.2) and specificity 21% (±SE 0.3)). The false positive rates for cerebrovascular disease, peripheral vascular disease and chronic airway disease ranged between 18 and 33%. The probability of a false positive was lowest for kidney transplant patients for all comorbidities and highest for patients on haemodialysis. Conclusions and Implications: Agreement between the clinical quality registry and hospital admission datasets was variable, with the prevalence of comorbidities being higher in ANZDATA. [ABSTRACT FROM AUTHOR]

Introduction: This article is an important contribution to the application of Callista Roy's Adaptation Model to groups. Objective: To promote adaptive behaviors through primary health care strategies for a group of chronically ill older adults living in a municipality in the department of Cundinamarca, Colombia. Materials and methods: A qualitative participatory action research approach was used. A nurse used participant observation and characterized the community; besides, with exploratory questions, the nurse enabled them to identify their problems and suggest strategies for improvement, including for their own health. Subsequently, the nursing care process was applied. Results: Group behavior was assessed through the following modes of adaptation: physiologic adaptation, selfconcept or group identity, role-function adaptation or unit of social functioning and social integrity, and interdependence adaptation or social context in which the group functions. Discussion: Applying Roy's model in practice makes it possible to identify negative situations in groups, promote innovative coping processes, and control environmental stimuli in a community. Assessment skills must be sharp, as they are key to applying Roy's model to community practice. Conclusions: The stimuli that trigger the main adaptation problems were identified, and a nursing care plan was implemented developing adaptation strategies, such as home visits, intergenerational meetings, community participation with support groups created by the municipality, and health education, to promote group adaptation. [ABSTRACT FROM AUTHOR]

ObjectiveTo examine the use of benzodiazepines and the association between low benzodiazepine dose, breakthrough seizures, and respiratory support in patients with status epilepticus.MethodsIn this cross-sectional analysis of adult patients with status epilepticus treated by an emergency medical services agency from 2013 to 2018, the primary outcome was treatment with a second benzodiazepine dose, an indicator for breakthrough seizure. The secondary outcome was receiving respiratory support. Midazolam was the only benzodiazepine administered.ResultsAmong 2,494 patients with status epilepticus, mean age was 54.0 years and 1,146 (46%) were female. There were 1,537 patients given midazolam at any dose, yielding an administration rate of 62%. No patients received a dose and route consistent with national guidelines. Rescue therapy with a second midazolam dose was required in 282 (18%) patients. Higher midazolam doses were associated with lower odds of rescue therapy (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9) and were not associated with increased respiratory support. If anything, higher doses of midazolam were associated with decreased need for respiratory support after adjustment (OR, 0.9; 95% CI, 0.8-1.0).ConclusionsAn overwhelming majority of patients with status epilepticus did not receive evidence-based benzodiazepine treatment. Higher midazolam doses were associated with reduced use of rescue therapy and there was no evidence of respiratory harm, suggesting that benzodiazepines are withheld without clinical benefit.Classification of evidenceThis study provides Class III evidence that for patients with status epilepticus, higher doses of midazolam led to a reduced use of rescue therapy without an increased need for ventilatory support.

ObjectiveTo compare the outcomes of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients with pure aortic insufficiency (PAI).BackgroundThe treatment of choice for patients with severe symptomatic PAI is SAVR. However, not all patients are candidates for surgery because of comorbidities or are deemed high risk for surgery. As a result, TAVR is being used as an off-label procedure in some patients with PAI.Patients and methodsWe analyzed the National Inpatient Sample database from January 1, 2016, to December 31, 2017, using the International Classification of Diseases, 10th Revision. Inclusion criteria were patients with aortic valve insufficiency undergoing either TAVR or SAVR. Patients with concomitant aortic stenosis, or history of infective endocarditis, and those below the age of 18 years were excluded.ResultsA total of 14,720 patients with PAI underwent valve replacement. Of those, 6.2% underwent TAVR. The TAVR group was significantly older (median age 78 years vs 64 years; P

ObjectiveTo assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.Data sourcesMultiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.Study designCross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.Data collection/extraction methods1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions).Principal findingsFinancial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).ConclusionsHigher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

BackgroundThe emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran.MethodsThis study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model.ResultsDuring the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p

BACKGROUND:Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom. METHODS/DESIGN:A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim. DISCUSSION:The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.

We aimed to develop and validate an instrument to detect hospital medication prescribing errors using repurposed clinical decision support system data. Despite significant efforts to eliminate medication prescribing errors, these events remain common in hospitals. Data from clinical decision support systems have not been used to identify prescribing errors as an instrument for physician-level performance. We evaluated medication order alerts generated by a knowledge-based electronic prescribing system occurring in one large academic medical center's acute care facilities for patient encounters between 2009 and 2012. We developed and validated an instrument to detect medication prescribing errors through a clinical expert panel consensus process to assess physician quality of care. Six medication prescribing alert categories were evaluated for inclusion, one of which - dose - was included in the algorithm to detect prescribing errors. The instrument was 93% sensitive (recall), 51% specific, 40% precise, 62% accurate, with an F1 score of 55%, positive predictive value of 96%, and a negative predictive value of 32%. Using repurposed electronic prescribing system data, dose alert overrides can be used to systematically detect medication prescribing errors occurring in an inpatient setting with high sensitivity.

Community mental health services are increasingly embracing evidence-based interventions (EBIs), and the professional workforce is diversifying to meet the needs of historically underserved groups. As such, it is increasingly important to understand how psychotherapist cultural factors may be associated with attitudes toward EBIs. The use of standardized assessments within routine progress monitoring is a cornerstone of EBIs, yet therapist attitudes remain an obstacle to implementation. The current study examines the associations between therapist cultural identity and attitudes toward and use of routine progress monitoring. An online survey was used to gather data from 229 ethnic minority community therapists delivering EBIs in a large public mental health system serving children and families. Therapists had an average age of 35.2 years (SD = 7.7), 86.5% were female, 69.9% were Hispanic/Latinx and 30.2% were other ethnic minority, 36.2% were licensed, 90.8% held a masters degree, and 76.4% reported ability to deliver services in a non-English language. Hierarchical multiple regression analyses revealed that stronger heritage cultural identity was related to perceptions of potential harm with routine progress monitoring. In addition, more favorable views of standardized assessment instructions were associated with positive attitudes toward routine progress monitoring. We discuss how findings point to the need for additional user-centered research with diverse community therapists to learn how assessment and progress monitoring can be better designed to address their cultural and racial-based concerns. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

We developed and tested Passport to Wellness (PtW), a client-centered intervention to improve engagement in HIV/STI prevention and services to improve social determinants of health among Black men who have sex with men (BMSM) using incentives and peer support. We assessed PtW's impact on HIV/STI screening and pre/post-exposure prophylaxis (PrEP/PEP) knowledge/uptake using a randomized trial that compared the full intervention to one lacking peer support. We compared changes within groups surveyed at baseline and 6 months. We enrolled 80 eligible BMSM, among 399 screened. Among retained participants (34 peer-supported; 27 comparison), overall increases were observed in HIV (30% to 87%; p < .001) and STI (28% to 80%; p < .001) testing within the prior 6 months, as well as in PrEP and PEP awareness, and PrEP use. Statistically significant between group differences were not observed. Tailored prevention planning, incentives, and addressing social determinants may help move Black MSM along the HIV prevention continuum.

BackgroundNo trials have compared cabozantinib and regorafenib for the second-line treatment of advanced hepatocellular carcinoma (HCC).ObjectivesConduct a matching-adjusted indirect comparison (MAIC) of the efficacy and safety of second-line cabozantinib and regorafenib in patients with advanced HCC and disease progression after prior sorafenib.MethodsThe CELESTIAL and RESORCE trials were used for indirect comparison of second-line cabozantinib and regorafenib in advanced HCC. Population-level data were available for RESORCE, individual patient data (IPD) for CELESTIAL. To align with RESORCE, the CELESTIAL population was limited to patients who received first-line sorafenib only. To minimize potential effect-modifying population differences, the CELESTIAL IPD were weighted to balance the distribution of clinically relevant baseline characteristics with those of RESORCE. Overall survival (OS) and progression-free survival (PFS) were evaluated for the matching-adjusted second-line CELESTIAL population and compared with those for RESORCE using weighted Kaplan-Meier curves and parametric modeling. Rates of grade 3/4 treatment-emergent adverse events (TEAEs) affecting > 5% of patients in any study arm were compared.ResultsIn the matching-adjusted second-line populations (CELESTIAL, effective sample size = 266; RESORCE, n = 573), median (95% confidence interval) OS was similar for cabozantinib and regorafenib (11.4 [8.9-17.0] versus 10.6 [9.1-12.1] months; p = 0.3474, log-rank test). Median PFS was longer for cabozantinib than regorafenib (5.6 [4.9-7.3] versus 3.1 [2.8-4.2] months; p = 0.0005, log-rank test). There was a trend for lower rates of some grade 3/4 TEAEs with regorafenib than with cabozantinib, which may reflect the exclusion of sorafenib-intolerant patients from RESORCE but not from CELESTIAL, a difference that the MAIC methods could not remove. Only diarrhea rates were statistically significantly lower for regorafenib (p  ≤ 0.001).ConclusionsCabozantinib may achieve similar OS and prolonged PFS compared with regorafenib in patients with progressive advanced HCC after prior sorafenib.

ObjectivesDischarge of hospitalized pediatric patients may be delayed for various "nonmedical" reasons. Such delays impact hospital flow and contribute to hospital crowding. We aimed to improve discharge efficiency for our hospitalized pediatric patients by using an iterative quality improvement (QI) process.MethodsOpportunities for improved efficiency were identified using value stream mapping, root cause, and benefit-effort analyses. QI interventions were focused on altered physician workflow, standardized discharge checklists, and physician workshops by using multiple plan-do-study-act cycles. The primary outcome of percentage of discharges before noon, process measure of percentage of discharges with orders before 10 am, and balancing measures of readmission rate, emergency department revisit rate, and parent experience survey scores were analyzed by using statistical process control. The secondary outcome of mean length of stay was analyzed using t tests and linear regression.ResultsImplementation of our interventions was associated with special cause variation, with an upward shift in mean percentage of discharges before noon from 13.2% to 18.5%. Mean percentage of patients with discharge orders before 10 am also increased from 13.6% to 23.6% and met rules for special cause. No change was detected in a control group. Adjusted mean length of stay index, 30-day readmissions, and parent experience survey scores remained unchanged. Special cause variation indicated a decreased 48-hour emergency department revisit rate associated with our interventions.ConclusionsAn iterative QI process improved discharge efficiency without negatively affecting subsequent hospital use or parent experience. With this study, we support investment of resources into improving pediatric discharge efficiency through value stream mapping and rapid cycle QI.

This study examined the relationship between caregivers' and youths' treatment expectations and characteristics of exposure tasks (quantity, mastery, compliance) in cognitive-behavioral therapy (CBT) for childhood anxiety. Additionally, compliance with exposure tasks was tested as a mediator of the relationship between treatment expectations and symptom improvement. Data were from youth (N = 279; 7-17 years old) enrolled in the Child/Adolescent Anxiety Multimodal Study (CAMS) and randomized to cognitive-behavioral therapy (CBT) or the combination of CBT and sertraline for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. Caregivers and youth independently reported treatment expectations prior to randomization, anxiety was assessed pre- and post-treatment by independent evaluators blind to treatment condition, and exposure characteristics were recorded by the cognitive-behavioral therapists following each session. For both caregivers and youths, more positive expectations that anxiety would improve with treatment were associated with greater compliance with exposure tasks, and compliance mediated the relationship between treatment expectations and change in anxiety symptoms following treatment. Additionally, more positive parent treatment expectations were related to a greater number and percentage of sessions with exposure. More positive youth treatment expectations were associated with greater mastery during sessions focused on exposure. Findings underscore the importance of addressing parents' and youths' treatment expectations at the outset of therapy to facilitate engagement in exposure and maximize therapeutic gains.

The UCLA Immunogenetics Center is an Immunogenetics and Histocompatibility laboratory that performs testing for multiple transplant programmes within and outside of UCLA. The single antigen bead (SAB) test is a high complexity luminex bead test used to assess pretransplant and post-transplant patients for the presence of pathogenic human leucocyte antigen donor-specific antibody associated with allograft rejection. Efficient reporting of the SAB test has been difficult as data analysis and reports are generated in the laboratory information system (LIS) and uploaded to the electronic medical record (EMR) as PDFs. To solve this, we recently developed a state of the art reporting workflow allowing discrete reporting of SAB data (antibody specificity, mean fluorescent intensity and interpretative comments) from the LIS HistoTrac to UCLA Health System's EMR EPIC:CareConnect. However, a proportion of tests did not report to the EMR appropriately. Baseline system performance data evaluated over a 10-week period showed that ~4.5/100 tests resulted in EPIC as 'preliminary result' or 'in process' instead of 'final result' with only common cause variation. Quality improvement methods were employed to improve the process with the SMART Aim of reporting 100% of tests as 'final result'. Pareto analysis identified two errors accounting for 79% of common system-level failures-status errors and interface errors. We hypothesised that addressing the status error would reduce or eliminate the interface errors. We used the Model For Improvement to test a reprogramming intervention. Status and interface errors were completely resolved through the process improvement. Continuous monitoring revealed a system-level shift with only ~1.9/100 tests resulting inappropriately. Through the audit process, the remaining common system-level failures were identified and resolved. Therefore, 100% of tests result to EPIC as 'final result'. The study demonstrates that high complexity SAB bead data can be efficiently reported EPIC:CareConnect from HistoTrac as discrete data.

Abstract Background Management delays imply worse outcomes in rheumatoid arthritis (RA) and, therefore, should be minimized. We evaluated changes in diagnostic and treatment delays regarding RA in the last decades in Brazil. Methods Adults fulfilling the ACR/EULAR (2010) criteria for RA were assessed. Delays in diagnosis and treatment, and the frequencies of early management initiation within thresholds (windows of opportunity) of 3, 6, and 12 months from symptoms onset were evaluated. The Mann–Kendall trend test, chi-squared tests with Cramer’s V effect sizes and analysis of variance were conducted. Results We included 1116 patients: 89.4% female, 56.8% white, mean (SD) age 57.1 (11.5) years. A downward trend was found in diagnostic (tau = − 0.677, p

Abstract Background The Chronic Care Model (CCM) is a longstanding and widely adopted model guiding chronic illness management. Little is known about how CCM elements are implemented in rare disease care or how patients’ care experiences relate to health-related quality of life (HRQoL). We engaged patients living with systemic sclerosis (SSc) to assess current care according to the CCM from the patient perspective and their HRQoL. Methods We employed an explanatory sequential mixed methods design. First, we conducted a cross-sectional quantitative survey (n = 101) using the Patient Assessment of Chronic Illness Care (PACIC) and Systemic Sclerosis Quality of Life (SScQoL) questionnaires. Next, we used data from individual patient interviews (n = 4) and one patient focus group (n = 4) to further explore care experiences of people living with SSc with a focus on the PACIC dimensions. Results The mean overall PACIC score was 3.0/5.0 (95% CI 2.8–3.2, n = 100), indicating care was ‘never’ to ‘generally not’ aligned with the CCM. Lowest PACIC subscale scores related to ‘goal setting/tailoring’ (mean = 2.5, 95% CI 2.2–2.7) and ‘problem solving/contextual counselling’ (mean = 2.9, 95% CI 2.7–3.2). No significant correlations were identified between the mean PACIC and SScQoL scores. Interviews revealed patients frequently encounter major shortcomings in care including ‘experiencing organized care with limited participation’, ‘not knowing which strategies are effective or harmful’ and ‘feeling left alone with disease and psychosocial consequences’. Patients often responded to challenges by ‘dealing with the illness in tailored measure’, ‘taking over complex coordination of care’ and ‘relying on an accessible and trustworthy team’. Conclusions The low PACIC mean overall score is comparable to findings in patients with common chronic diseases. Key elements of the CCM have yet to be systematically implemented in Swiss SSc management. Identified gaps in care related to lack of shared decision-making, goal-setting and individual counselling-aspects that are essential for supporting patient self-management skills. Furthermore, there appears to be a lack of complex care coordination tailored to individual patient needs.

Cardiac rehabilitation – programs comprehensively delivering outpatient secondary prevention – is under-available and under-studied in the resource-poor settings where it is needed most. This report summarizes the governance, participating sites, patient characteristics and outcomes, as well as knowledge translation activities during first year of operation of ICCPR's registry, namely the International Cardiac Rehab Registry. A pilot study was undertaken with five centers, demonstrating feasibility, satisfaction with the on-boarding processes, as well as data quality. Fourteen centers have been engaged from all regions but Europe; Data have been entered on >1000 patients (18.1% female; mean age = 57.6), of whom 62.4% completed their programs and 19.9% dropped out for work or clinical reasons. Post-program, completers had significantly better work status, functional capacity, medication adherence, physical activity levels, diet, as well as lower tobacco use than non-completers (all p < 0.05). A site Certification program was developed and piloted, with five centers now recognized for their quality, given they met over 70% of the 13 internationally agreed standards based on Registry data and a virtual site assessment. Annual assessments have started. Quality improvement activities will soon be underway. We continue to invite new programs, supporting development in resource-poor settings to the benefit of patients served. [ABSTRACT FROM AUTHOR]

ObjectivesThis study sought to describe clinical and procedural characteristics of veterans undergoing transcatheter aortic valve replacement (TAVR) within U.S. Department of Veterans Affairs (VA) centers and to examine their association with short- and long-term mortality, length of stay (LOS), and rehospitalization within 30 days.BackgroundVeterans with severe aortic stenosis frequently undergo TAVR at VA medical centers.MethodsConsecutive veterans undergoing TAVR between 2012 and 2017 were included. Patient and procedural characteristics were obtained from the VA Clinical Assessment, Reporting, and Tracking system. The primary outcomes were 30-day and 1-year survival, LOS >6 days, and rehospitalization within 30 days. Logistic regression and Cox proportional hazards analyses were performed to evaluate the associations between pre-procedural characteristics and LOS and rehospitalization.ResultsNine hundred fifty-nine veterans underwent TAVR at 8 VA centers during the study period, 860 (90%) by transfemoral access, 50 (5%) transapical, 36 (3.8%) transaxillary, and 3 (0.3%) transaortic. Men predominated (939 of 959 [98%]), with an average age of 78.1 years. There were 28 deaths within 30 days (2.9%) and 134 at 1 year (14.0%). Median LOS was 5 days, and 141 veterans were rehospitalized within 30 days (14.7%). Nonfemoral access (odds ratio: 1.74; 95% confidence interval [CI]: 1.10 to 2.74), heart failure (odds ratio: 2.51; 95% CI: 1.83 to 3.44), and atrial fibrillation (odds ratio: 1.40; 95% CI: 1.01 to 1.95) were associated with increased LOS. Atrial fibrillation was associated with 30-day rehospitalization (hazard ratio: 1.79; 95% CI: 1.22 to 2.63).ConclusionsVeterans undergoing TAVR at VA centers are predominantly elderly men with significant comorbidities. Clinical outcomes of mortality and rehospitalization at 30 days and 1-year mortality compare favorably with benchmark outcome data outside the VA.

ObjectiveDysfunction in positive affect is a defining symptom of bipolar I disorder (BD), both during and between mood episodes. We hypothesize that helping people with BD learn skills to create balance in their affective experiences by engaging in strategies that increase low activation positive emotion (LAP; e.g., relaxation) could help to improve well-being during periods of symptom remission. We discuss the development and preliminary outcomes of a positive emotion regulation (PER) group treatment for people with BD, designed as a supplement to pharmacological treatment.MethodThe Learning Affective Understanding for a Rich Emotional Life (LAUREL) intervention is a group-based intervention covering 10 empirically supported skills designed to increase LAP. Sixteen people with BD enrolled in the LAUREL intervention and twelve completed baseline and post-intervention assessments.ResultsParticipants who completed the study (n = 12) attended the majority of groups (87.96%) and reported practicing skills, on average, 16 times a week. We were unable to detect significant differences in mania symptoms following engagement in this PER intervention. Finally, participants reported increases in several areas associated with well-being post-intervention, including mindfulness, reappraisal, and self-compassion.ConclusionThis study provides a theoretical framework and preliminary support for a PER intervention for BD.