Search

Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery.This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis.Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up.While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.

This study's purpose was to ascertain the prevalence of adverse childhood experiences (ACEs) in a pediatric population and their connection to other health history information.Using health history data, a retrospective, descriptive study was undertaken with 1,028 children seen at a school-based, interprofessional clinic over 1 academic year.Nearly 58% of children had at least one ACE, and 9.5% had four or more, similar to the prevalence of ACEs in adults reported in the original study by Felitti et al. (1998). With increasing ACEs, children had higher rates of intrauterine drug exposure, intensive care on delivery, homelessness, substance abuse, behavioral problems, mental illness, learning difficulties, and weight issues.Because ACEs are prevalent among children, pediatric providers should use trauma-informed care principles and teach and model a loving and supportive adult presence in children's lives.

Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness.The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals.A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results.Eight primary care clinics that were engaged in PCMH reform.We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years.In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03).The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.

BACKGROUND: Well-defined, systematic, and transparent processes to identify health research gaps, needs, and priorities are vital to ensuring that available funds target areas with the greatest potential for impact. OBJECTIVE: The purpose of this review is to characterize methods conducted or supported by research funding organizations to identify health research gaps, needs, or priorities. METHOD: We searched MEDLINE, PsycINFO, and the Web of Science up to September 2019. Eligible studies reported on methods to identify health research gaps, needs, and priorities that had been conducted or supported by research funding organizations. Using a published protocol, we extracted data on the method, criteria, involvement of stakeholders, evaluations, and whether the method had been replicated (i.e., used in other studies). RESULTS: Among 10,832 citations, 167 studies were eligible for full data extraction. More than half of the studies employed methods to identify both needs and priorities, whereas about a quarter of studies focused singularly on identifying gaps (7%), needs (6%), or priorities (14%) only. The most frequently used methods were the convening of workshops or meetings (37%), quantitative methods (32%), and the James Lind Alliance approach, a multi-stakeholder research needs and priority setting process (28%). The most widely applied criteria were importance to stakeholders (72%), potential value (29%), and feasibility (18%). Stakeholder involvement was most prominent among clinicians (69%), researchers (66%), and patients and the public (59%). Stakeholders were identified through stakeholder organizations (51%) and purposive (26%) and convenience sampling (11%). Only 4% of studies evaluated the effectiveness of the methods and 37% employed methods that were reproducible and used in other studies. DISCUSSION: To ensure optimal targeting of funds to meet the greatest areas of need and maximize outcomes, a much more robust evidence base is needed to ascertain the effectiveness of methods used to identify research gaps, needs, and priorities. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-07064-1.

Background Patient-reported outcomes (PRO) obtained from follow-up survey data are essential to understanding the longitudinal effects of bariatric surgery. However, capturing data among patients who are well beyond the recovery period of surgery remains a challenge, and little is known about what factors may influence follow-up rates for PRO. Objectives To assess the effect of hospital practices and surgical outcomes on patient survey completion rates at 1 year after bariatric surgery. Setting Prospective, statewide, bariatric-specific clinical registry. Methods Patients at hospitals participating in the Michigan Bariatric Surgery Collaborative are surveyed annually to obtain information on weight loss, medication use, satisfaction, body image, and quality of life following bariatric surgery. Hospital program coordinators were surveyed in June 2017 about their practices for ensuring survey completion among their patients. Hospitals were ranked based on 1-year patient survey completion rates between 2011 and 2015. Multivariable regression analyses were used to identify associations between hospital practices, as well as 30-day outcomes, on hospital survey completion rankings. Results Overall, patient survey completion rates at 1 year improved from 2011 (33.9% ± 14.5%) to 2015 (51.0% ± 13.0%), although there was wide variability between hospitals (21.1% versus 77.3% in 2015). Hospitals in the bottom quartile for survey completion rates had higher adjusted rates of 30-day severe complications (2.6% versus 1.7%, respectively; P = .0481), readmissions (5.0% versus 3.9%, respectively; P = .0157), and reoperations (1.5% versus .7%, respectively; P = .0216) than those in the top quartile. While most hospital practices did not significantly impact survey completion at 1 year, physically handing out surveys during clinic visits was independently associated with higher completion rates (odds ratio, 13.60; 95% confidence interval, 1.99−93.03; P =.0078). Conclusions Hospitals vary considerably in completion rates of patient surveys at 1 year after bariatric surgery, and lower rates were associated with hospitals that had higher complication rates. Hospitals with the highest completion rates were more likely to physically hand surveys to patients during clinic visits. Given the value of PRO on longitudinal outcomes of bariatric surgery, improving data collection across multiple hospital systems is imperative.

Well-defined, systematic, and transparent processes to identify health research gaps, needs, and priorities are vital to ensuring that available funds target areas with the greatest potential for impact. This study documents a scoping review of published methods used for identifying health research gaps, establishing research needs, and determining research priorities and provides relevant information on 362 studies. Of the 362 studies, 167 were linked to funding decisionmaking and underwent a more detailed data abstraction process. The authors noted that most studies focused on physical health conditions, but few addressed psychological health conditions. The most frequent method for identifying research gaps, needs, and priorities was to convene workshops or conferences. One-third of studies employed quantitative methods, and nearly as many used the James Lind Alliance Priority Setting Partnerships approach. Other methods included literature reviews, qualitative methods, consensus methods, and reviews of source materials. The criterion most widely applied to determine health research gaps, needs, and priorities was the importance to stakeholders, followed by the potential value and feasibility of carrying out the research. The two largest stakeholder groups were researchers and clinicians. More than one-half the studies involved patients and the public as stakeholders. Very few studies have evaluated the impact of methods used to identify research gaps, needs, and priorities. This study provides a roadmap of methods used for identifying health research gaps, needs, and priorities, which may help accelerate progress toward validating methods that ensure the effective targeting of funds to meet the greatest areas of need and to maximize impact.

Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices.We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis.At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery.Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.

OBJECTIVES Young children enrolled in Medicaid make few dental visits and have high rates of tooth decay. To improve access to care, state Medicaid programs have enacted policies encouraging nondental providers to deliver preventive oral health services (POHS) in medical offices. Policies vary by state, with some states requiring medical providers to obtain training prior to delivering POHS. Our objective was to test whether these training requirements were associated with higher rates of POHS for Medicaid-enrolled children

Think tank grey literature can be used for teaching and research in policy-oriented courses, but because much of this content is scattered throughout the far reaches of cyberspace, students and man...

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data. We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records. There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively). Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

Enhanced Recovery After Surgery (ERAS) Protocols are well-established in fields such as colorectal surgery but within bariatric surgery have not been uniformly adopted by all programs.Qualitative study with focus groups at five hospitals participating in a statewide bariatric surgery quality improvement collaborative. Members of the clinical care team at each pilot site participated. Participants described barriers to implementation, and strategies to address these.Participants expressed satisfaction with the implementation process. Barriers included a lack of buy-in from team members, availability of specific resources, staffing turnover, and interruption to implementation. Increased communication at all phases and a specific point-person to guide implementation would improve success.These findings will be integrated into our work as we continue to implement this protocol at all hospitals participating within the collaborative. Future work will focus on the impact of the protocol on clinical outcomes and patient satisfaction following surgery.

Strategies to capitalize on enolate intermediates generated from stereoselective conjugate borylation to α,β-unsaturated carbonyl systems are surprisingly rare despite the ubiquity of Michael acceptors, and the potential to generate valuable scaffolds bearing multiple stereocenters. Herein, we report a mild and stereoselective copper-catalyzed conjugate borylation/Mannich cyclization reaction. This strategy is feasible with a broad range of Michael acceptors, and can be leveraged to generate versatile borylated tetrahydroquinoline scaffolds bearing three contiguous stereocenters. The synthetic potential of these complex heterocycles has been explored through a series of derivatization studies., Copper-catalyzed enantio- and diastereoselective conjugate borylation across Michael acceptors, with subsequent Mannich-type cyclization, was utilized to construct tetrahydroquinoline scaffolds containing three contiguous stereocenters.

OBJECTIVE To examine effects of a financial incentives program on follow-up and weight loss after bariatric surgery. SUMMARY BACKGROUND DATA Consistent follow-up may improve weight loss and other health outcomes after bariatric surgery. Yet, rates of follow-up after surgery are often low. METHODS Patients from 3 practices within a statewide collaborative were invited to participate in a 6-month financial incentives program. Participants received incentives for attending post-operative appointments at 1, 3, and 6 months which doubled when participants weighed less than their prior visit. Participants were matched with contemporary patients from control practices by demographics, starting BMI and weight, surgery date, and procedure. Pre-intervention estimates used matched historic patients from the same program and control practices with the criteria listed above. Patients between the two historic groups were additionally matched on surgery date to ensure balance on matched variables. We conducted difference-in-differences analyses to examine incentives program effects. Follow-up attendance and percent excess weight loss were measured post-operative months 1, 3, 6 and 12. RESULTS 110 program participants from January 1, 2018 to July 31, 2019 were matched to 203 historic program practice patients (November 20 to December 27, 2017). The control group had 273 pre-intervention patients and 327 post-intervention patients. In difference-in-differences analyses, the intervention increased follow-up rates at 1 month (+14.8%, P

To determine the accuracy of postoperative patient-reported comorbidity assessment, as it may be an important mechanism for long-term follow-up in surgical patients.Less than 1% of patients who qualify actually undergo bariatric surgery which may be due to concerns surrounding long-term efficacy. Longitudinal follow-up of patients' comorbidities remains a challenge.Retrospective, cross-sectional study of bariatric surgery patients from 38 sites within a state-wide collaborative from 2017 to 2018. A minimum of 10 and maximum of 20 responses to a 1-year postoperative questionnaire from each site were randomly sampled. We examined percent agreement between patient-reported and medical chart audit comorbidity assessment and further evaluated agreement by intraclass correlation or κ statistic. Postoperative comorbidities assessed include weight, hyperlipidemia, hypertension, diabetes, depression, obstructive sleep apnea, gastroesophageal reflux disease (GERD), anxiety, and pain.Five hundred eighty-five patients completed postoperative questionnaires after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass. The response rate was 64% during the study period. Patients reported weight with a mean difference of 2.7 lbs from chart weight (intraclass correlation = 0.964). Agreement between patient report and audit for all comorbidities was above 80% except for GERD (71%). κ statistics were greater than 0.6 (good agreement) for hyperlipidemia, hypertension, diabetes, and depression. Anxiety ( κ = 0.45) and obstructive sleep apnea ( κ = 0.53) had moderate agreement. Concordance for GERD and pain were fair (both κ = 0.38).Patient-reported comorbidity assessment has high levels of agreement with medical chart audit for many comorbidities and can improve understanding of long-term outcomes. This will better inform patients and providers with hopes of 1 day moving beyond the 1%.

Introduction Relative motion splinting has been used successfully in the treatment of extensor tendon repairs and has recently been applied in flexor tendon rehabilitation. The purpose of this systematic review was to identify articles reporting use of relative motion flexion (RMF) splinting following flexor tendon repair and to examine indications for use and clinical outcomes. Methods Seven medical databases, four trials registries and three grey literature sources were systematically searched and screened against pre-specified eligibility criteria. Screening, data extraction and quality appraisal were independently performed by two reviewers. Results A total of 12 studies were identified, of which three met the review eligibility criteria: one retrospective case series; one cadaveric proof of concept study; and one ongoing prospective case series. The type of splint (including metacarpophalangeal joint position and available movement), exercise programme, and zone of tendon injury varied between studies. Both case series presented acceptable range of movement and grip strength outcomes. The prospective series reported one tendon rupture and two tenolysis procedures; the retrospective series reported no tendon ruptures or secondary surgeries. Discussion We found limited evidence supporting the use of RMF splinting in the rehabilitation of zones I-III flexor tendon repairs. Further prospective research with larger patient cohorts is required to assess the clinical outcomes, patient reported outcomes and safety of RMF splinting in comparison to other regimes. Application of the relative motion principles to flexor tendon splinting varied across the included studies, and we suggest an operational definition of relative motion in this context.

Individual weight loss outcomes after bariatric surgery can vary considerably. As a result, identifying and assisting patients who are not on track to reach their weight loss goals can be challenging.Using a bariatric surgery outcomes calculator, which was formulated using a state-wide bariatric-specific data registry, predicted weight loss at 1 year after surgery was calculated on 658 patients who underwent bariatric surgery at 35 different bariatric surgery programs between 2015 and 2017. Patient characteristics, postoperative complications, and weight loss trajectories were compared between patients who met or exceeded their predicted weight loss calculation to those who did not based on observed to expected weight loss ratio (O:E) at 1 year after surgery.Patients who did not meet their predicted weight loss at 1 year (n = 237, 36%) had a mean O:E of 0.71, while patients who met or exceeded their prediction (n = 421, 63%) had a mean O:E = 1.14. At 6 months, there was a significant difference in the percent of the total amount of predicted weight loss between the groups (88% of total predicted weight loss for those that met their 1-year prediction vs 66% for those who did not, p0.0001). Age, gender, procedure type, and risk-adjusted complication rates were similar between groups.Using a bariatric outcomes calculator can help set appropriate weight-loss expectations after surgery and also identify patients who may benefit from additional therapy prior to reaching their weight loss nadir.

Objective This study sought to explore the relationship of bariatric surgeon age and patient outcomes. Background Regulators, policy makers, and patient advocacy groups have recently been pushing to establish clear guidelines for physician retirement in the United States. Although it is often assumed that increasing physician age leads to worse patient outcomes, the relationship is lacking robust evidence, and is still unclear. Methods We conducted a study analyzing all bariatric surgeons in Michigan who participated in a statewide collaborative quality improvement program (n = 71) who performed primary laparoscopic Roux-en-Y Gastric Bypass, or sleeve gastrectomy operations, and data on their patients (n = 60430) over the past 10 years. Our primary outcomes were 30-day postoperative complications. Odds ratios for overall complications and serious complications were calculated for each age group, and surgery type. Results Late career surgeons had more bariatric surgery experience and had a higher average annual case volume than early career surgeons. Considering all cases in the past 10 years, older surgeons performed more Roux-en-Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons (34.7% and 51.5%). When adjusting for patient and surgeon characteristics, there were no statistically significant differences in overall or serious complication rates for either procedure among surgeon age groups. Conclusions When evaluating bariatric surgeons in the State of Michigan, we found no statistically significant association between surgeon age and patient outcomes. Our findings do not provide evidence for age-specific retirement cut-offs, but support the development of guidelines which are holistic, and focus on evaluating and improving physician outcomes at all career levels.

OBJECTIVE The aim of this study was to explore the efficacy of current bariatric perioperative measures at reducing emergency department (ED) visits following bariatric surgery in the state of Michigan. SUMMARY OF BACKGROUND DATA Many ED visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits. METHODS We studied 48,035 eligible bariatric surgery patients across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk- and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery, and hospital summary characteristics were compared. We then studied whether a hospital's compliance with specific perioperative measures was significantly associated with reduced ED visit rates. RESULTS Only 3 of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital's ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of venous thromboembolism complications (P = 0.04, P = 0.0065, and P = 0.0047, respectively). Also, a hospital's compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (P = 0.12). CONCLUSIONS Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful.

We present an audit of public awareness, freedom of choice and health behavior change relating to high heel wear subsequent to a major public awareness campaign in the summer of 2017. Substantial reductions in workplace high heel wear were found, whereby increasingly those who wear high heels regularly at work have freely chosen to do so, although certain issues of social expectations remain in certain sectors. Largely, freedom of choice has greatly increased in workplaces in line with increased public and employer awareness. However, high heel wear has not substantially reduced in social settings, and progress has not been made with social expectation and explicit requirement to wear high heels at social events.

Physician-nurse communication skills are critical for incoming residents; however, standardized training and feedback targeting these skills are not well-described. We used a qualitative approach to determine types of feedback standardized registered nurses (SRN) can provide to students pre-residency. Senior medical students enrolled in an elective one-month specialty-specific Residency Preparation Course in 2018 participated in a simulated paging curriculum where they responded to urgent pages from SRNs about mock patients. The SRNs followed a script and assessed students using a rubric, then provided immediate verbal feedback on the students’ clinical management and communication skills. We recorded, de-identified, transcribed, and coded feedback, then determined themes. Seventy-six students participated and 162 encounters were recorded. We developed nine codes and identified two themes: positive reinforcement and authentic clinical feedback. The SRNs connected the cases to real-life experiences, reflecting upon mistakes or interactions they have made, to emphasize learning points for the student. This non-scripted, authentic clinical feedback reinforced the feedback provided on specific domains including information gathering, communication, and clinical management. This study highlights the value of utilizing SRNs to provide interprofessional feedback to medical students just prior to residency.

This content area module (CAM) for workplace stress prevention and reduction in the Air Force is a companion volume to the Getting To Outcomes Operations Guide for U.S. Air Force Community Action Teams. It includes guidance, resources, and examples of completed tools for Community Action Teams that have an interest in planning, implementing, and evaluating workplace stress prevention and reduction initiatives as part of a Community Action Plan.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from Recovery Month.

More than 2.7 million service members have deployed since 2001, and many who return report mental health challenges. This report describes a cross-agency evaluation of four public awareness campaigns that aim to overcome negative perceptions and promote awareness of mental health disorders and their treatment: the Real Warriors Campaign, Make the Connection, National Recovery Month, and awareness materials related to the Veterans Crisis Line.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from the Veterans Crisis Line.

This brief describes the results of an interim evaluation that examined the scope, content, and dissemination of mental health public awareness campaigns. RAND researchers conducted a comprehensive evaluation of four such efforts.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from the Make the Connection.

This brief is one in a series examining mental health public awareness campaigns' messages, consistency of messaging in their materials, and tools used to deliver content to audiences. This brief discusses materials from the Real Warrior Campaign.

Burnout is becoming increasingly prevalent among primary care physicians. Recent studies have attributed electronic health record (EHR) related tasks as a potential source of physician burnout. In this cross-sectional study, EHR use was compared to self-reported burnout for 107 faculty physicians at 10 university-affiliated primary care clinics. Physicians who self-reported burnout spent more time managing their inbox and in the EHR after hours. Burnout was associated with lower rates of same day chart closure, longer completion time for inbox messages, and more incomplete messages. Burnout, while related to overall workload, had a complex relationship with EHR use, which was influenced by but could not wholly explained by clinical workload. Our results suggest that burnout is less prevalent with less allocated clinical time, however, more research is necessary to identify the optimal balance between clinical duties and academic pursuits. Segmenting providers based on relative workload to determine variation within similar groups may help optimize EHR use.