Value Institute Publications
- Evaluation of a Systems-Based Tobacco Cessation Program Using Bedside Volunteers
Taylor D, Medaglio D, Jurkovitz C, Patterson F, Zhang Z, Gbadebo A, Bradley E, Wessells R, Goldenberg E
Nicotine Tob. Res. 2018 Nov;
Introduction: Hospitalization and post-discharge provides an opportune time for tobacco cessation. This study tested the feasibility, uptake, and cessation outcomes of a hospital-based tobacco cessation program, delivered by volunteers to the bedside with post-discharge referral to Quitline services. Patient characteristics associated with Quitline uptake and cessation were assessed.
Methods: Between February and November 2016, trained hospital volunteers approached inpatient tobacco users on six pilot units. Volunteers shared a cessation brochure and used the ASK-ADVISE-CONNECT model to connect ready-to-quit patients to the Delaware Quitline via fax-referral. Volunteers administered a follow-up survey to all admitted tobacco users via telephone or email at 3-months post-discharge.
Results: Of the 743 admitted tobacco users, 531 (72%) were visited by a volunteer, and 97% (531/547) of those approached, accepted the visit. Over one third (201/531; 38%) were ready-to-quit and fax-referred to the Quitline, and 36% of those referred accepted Quitline services. At 3-months post discharge, 37% (135/368) reported not using tobacco in the last 30 days; intent-to-treat cessation rate was 18% (135/743). In a multivariable regression model of Quitline fax-referral completion, receiving NRT during hospitalization was the strongest predictor (OR: 1.97; 95% CI: 1.34-2.90). In a model of 3-month cessation, receiving Quitline services (OR: 3.21, 95%CI: 1.35-7.68) and having coronary artery disease (OR: 2.28; 95% CI: 1.11-4.68) were associated with tobacco cessation, but a volunteer visit was not.
Conclusions: An "opt-out" tobacco cessation service using trained volunteers is feasible for connecting patients to Quitline services.
- Choosing Wisely in Delaware: Rationale for Evidence-Based Diagnosis & Evaluation of Low Back Pain
Tanaka L, Khan OA, Jackson EV, Miller KE, Chiam TC
Del Med J 2016 Jan;88(1):14-8
- Patient-Centered Handovers: Ethnographic Observations of Attending and Resident Physicians: Ethnographic Observations of Attending and Resident Physicians
Patient-Centered Handovers: Ethnographic Observations of Attending and Resident Physicians: Ethnographic Observations of Attending and Resident Physicians
Mount-Campbell AF, Rayo MF, OʼBrien JJ, Allen TT, Patterson ES
Qual Manag Health Care 2016 Oct/Dec;25(4):225-230
Handover communication improvement initiatives typically employ a "one size fits all" approach. A human factors perspective has the potential to guide how to tailor interventions to roles, levels of experience, settings, and types of patients. We conducted ethnographic observations of sign-outs by attending and resident physicians in 2 medical intensive care units at one institution. Digitally audiotaped data were manually analyzed for content using codes and time spent using box plots for emergent categories. A total of 34 attending and 58 resident physician handovers were observed. Resident physicians spent more time for "soon to be discharged" and "higher concern" patients than attending physicians. Resident physicians spent less time discussing patients which they had provided care for within the last 3 days ("handbacks"). The study suggested differences for how handovers were conducted for attending and resident physicians for 3 categories of patients; handovers differ on the basis of role or level of expertise, patient type, and amount of prior knowledge of the patient. The findings have implications for new directions for subsequent research and for how to tailor quality improvement interventions based upon the role, level of experience, level of prior knowledge, and patient categories.
- Patient Satisfaction with Care After Coronary Revascularization
Mosby DL, Manierre MJ, Martin SS, Kolm P, Abuzaid AS, Jurkovitz CT, Elliott DJ, Weintraub WS
Patient 2018 04;11(2):217-223
OBJECTIVE: Bridging the Divides (Bridges), a Centers for Medicare and Medicaid Services-funded program, developed a post-hospitalization care management infrastructure integrating information technology-enabled informatics with patient care for ischemic heart disease patients. The objective of this study was to assess patient satisfaction with the Bridges program and determine the patient characteristics associated with higher satisfaction.
METHODS: All adult English-speaking patients who underwent a percutaneous coronary intervention, coronary artery bypass grafting, or catheterization plus acute myocardial infarction and agreed to participate in the Bridges program were eligible. A survey instrument was administered to address patient satisfaction of care received, aspects of care that patients appreciated, and challenges faced. Descriptive statistics were calculated, and primary analyses included comparisons of overall patient satisfaction after discharge between procedure type, and according to age, sex, race, Elixhauser comorbidity count, and length of stay.
RESULTS: Four hundred and sixty-seven (46%) had complete or partial response rates. There was a statistically significant difference in the overall satisfaction among patients undergoing percutaneous coronary intervention, coronary artery bypass grafting, or catheterization plus acute myocardial infarction (p = 0.023). There were significant procedure by sex (p = 0.052) and procedure by age (p = 0.039) interactions. There were no statistically significant differences in overall satisfaction according to age, sex, race, comorbidity count, or length of stay.
CONCLUSIONS: This study identified several important components related to patient satisfaction for patients with ischemic heart disease. Results found that patients who underwent coronary artery bypass grafting were reportedly "very satisfied" when compared with patients who underwent percutaneous coronary intervention and catheterization plus acute myocardial infarction, as well as significant age and sex interactions between procedures.
- Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit
Vest MT, Kolm P, Bowen J, Trabulsi J, Lennon SL, Shapero M, McGraw P, Halbert J, Jurkovitz C
Am. J. Crit. Care 2018 Mar;27(2):136-143
BACKGROUND: Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting.
OBJECTIVES: To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship.
METHODS: A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index.
RESULTS: Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission.
CONCLUSION: The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.
- Co-occurrence of medical conditions: Exposing patterns through probabilistic topic modeling of snomed codes
Co-occurrence of medical conditions: Exposing patterns through probabilistic topic modeling of snomed codesBhattacharya M, Jurkovitz C, Shatkay H J Biomed Inform 2018 Jun;82:31-40 PMID: 29655947
AbstractPatients associated with multiple co-occurring health conditions often face aggravated complications and less favorable outcomes. Co-occurring conditions are especially prevalent among individuals suffering from kidney disease, an increasingly widespread condition affecting 13% of the general population in the US. This study aims to identify and characterize patterns of co-occurring medical conditions in patients employing a probabilistic framework. Specifically, we apply topic modeling in a non-traditional way to find associations across SNOMED-CT codes assigned and recorded in the EHRs of >13,000 patients diagnosed with kidney disease. Unlike most prior work on topic modeling, we apply the method to codes rather than to natural language. Moreover, we quantitatively evaluate the topics, assessing their tightness and distinctiveness, and also assess the medical validity of our results. Our experiments show that each topic is succinctly characterized by a few highly probable and unique disease codes, indicating that the topics are tight. Furthermore, inter-topic distance between each pair of topics is typically high, illustrating distinctiveness. Last, most coded conditions grouped together within a topic, are indeed reported to co-occur in the medical literature. Notably, our results uncover a few indirect associations among conditions that have hitherto not been reported as correlated in the medical literature.
- Impact of tart cherry juice on systolic blood pressure and low-density lipoprotein cholesterol in older adults: a randomized controlled trial
Impact of tart cherry juice on systolic blood pressure and low-density lipoprotein cholesterol in older adults: a randomized controlled trial
Chai SC, Davis K, Wright RS, Kuczmarski MF, Zhang Z
Food Funct 2018 Jun;9(6):3185-3194
Hypertension and dyslipidemia are major risk factors for cardiovascular disease (CVD). Common treatments for high blood pressure (BP) and dyslipidemia include medications, but there is question as to whether natural sources may be adequate to reduce CVD risk factors. We examined the effects of tart cherry juice on lipid profiles, BP, glucose, insulin, and homeostatic model assessment-insulin resistance (HOMA-IR) in older adults. In this randomized-controlled clinical trial, 17 men and 20 women between the ages of 65-80 years were randomly assigned to consume 480 ml of tart cherry juice or control drink daily for 12 weeks. Control beverages were matched for energy and sugar content. Outcome variables were assessed at baseline and after 12 weeks of tart cherry juice or control drink. Systolic BP and low-density lipoprotein cholesterol (LDL) exhibited treatment × time interaction effects. At the end of the study, participants in the tart cherry group had lower levels of LDL cholesterol (difference of -20.6 with P = 0.001) and total cholesterol (difference of -19.11 with P = 0.01), and higher levels of glucose (difference of 7.94 with P = 0.001), triglycerides (difference of 6.66 with P = 0.01) and BMI (difference of 1.06 with P = 0.02) than in the control group. Neither tart cherry juice nor control significantly altered body weight, high-density lipoprotein cholesterol, diastolic BP, insulin and HOMA-IR. Our findings show that tart cherry juice can lower the levels of systolic BP and LDL cholesterol. However, larger and longer follow-up studies are needed to further assess cardio-protective effects of tart cherry juice.
- The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study
The Unmet Need for Postacute Rehabilitation Among Medicare Observation Patients: A Single-Center Study
Goldstein JN, Schwartz JS, McGraw P, Banks TL, Hicks LS
J Hosp Med 2017 03;12(3):168-172
BACKGROUND: Medicare beneficiaries admitted under observation status must pay for postacute inpatient rehabilitation (PAIR) services, out of pocket, at potentially prohibitive costs.
OBJECTIVE: To determine if there is an unmet need for PAIR among Medicare observation patients and if this care is associated with longer hospital stay and increased rehospitalization.
DESIGN/SETTING: Observational study using electronic medical record and administrative data from a regional health system.
PATIENTS: 1323 community-dwelling Medicare patients admitted under observation status.
MEASUREMENTS: Summary statistics were calculated for demographic and administrative variables. Physical therapy (PT) and case management recommendations for a representative sample of 386 medical records were reviewed regarding need for PAIR services. Linear regression was used to measure the association between PT recommendation and hospital length of stay, adjusting for ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis, age, sex, and provider. Chi-square test was used to determine the association between PT recommendation and 30-day hospital revisit.
RESULTS: Of the 1323 study patients, 11 (0.83%) were discharged to PAIR facilities. However, 17 (4.4%) of the 386 patients whose charts were reviewed received a recommendation for this care. Adjusted mean hospital stay was longer (P ⟨ 0.001) for patients recommended for rehabilitation (75.9 h) than for patients with no PT needs (46.8 h). In addition, the 30-day hospital revisit rate was higher (P = 0.037) for the patients who had been recommended for rehabilitation (52.9%, 9/17) than for those who had not (25.4%, 30/118).
CONCLUSIONS: Medicare observation patients' potential need for PAIR services is 5- to 6-fold higher than their use of these services. Observation patients recommended for this care may have worse outcomes. Journal of Hospital Medicine 2017;12:168-172.
- Social constraints and fear of recurrence in couples coping with early stage breast cancer
Soriano EC, Pasipanodya EC, LoSavio ST, Otto AK, Perndorfer C, Siegel SD, Laurenceau JP
Health Psychol 2018 Sep;37(9):874-884
OBJECTIVE: Fear of cancer recurrence (FCR) is a top concern of breast cancer (BC) survivors and their spouses. FCR often occurs within an interpersonal context, yet there has been little research on relationship processes that may influence FCR in patients and spouses. It was hypothesized that the inhibition of disclosure of cancer-related concerns, thoughts, and feelings because of perceived partner disinterest or avoidance (termed social constraints) would predict greater FCR in BC patients and their spouses both globally and in the context of everyday life.
METHOD: Two studies, 1 cross-sectional (N = 46 couples) and 1 daily diary (21 days; N = 72 couples), were conducted to examine the between-person and within-person associations between social constraints and FCR in early stage BC patients and their spouses. Assessments were conducted about 6 months after BC surgery.
RESULTS: Global social constraints predicted greater global FCR in patients and spouses at the cross-sectional level, controlling for anxiety symptoms, relationship quality, and patient age, physical impairment, and BC stage. At the within-person level, results indicated that on days when more social constraints were reported, both partners were more likely to report greater FCR, controlling for momentary negative affect and relationship quality.
CONCLUSIONS: This study is the first to examine the within-person association between social constraints and FCR. These findings suggest relationship processes, particularly inhibition of disclosure, can uniquely influence the experience of FCR for both BC patients and their spouses, pointing to an important consideration for future research and possible intervention development. (PsycINFO Database Record
- Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors
Assessing the relationship between fear of cancer recurrence and health care utilization in early-stage breast cancer survivors
Otto AK, Soriano EC, Siegel SD, LoSavio ST, Laurenceau JP
J Cancer Surviv 2018 Oct;
PURPOSE: The purpose of this study was to determine whether fear of cancer recurrence (FCR) is associated with greater health care utilization (HCU) in early-stage breast cancer survivors.
METHODS: Three hundred early-stage breast cancer survivors diagnosed within the past 7 years reported on FCR as well as calls and visits to oncology providers and primary care providers during the preceding 3 months. Participants also reported on use of mental health services and psychotropic medications since diagnosis. Structural equation modeling was used to create a latent FCR factor and evaluate this factor as a predictor of various HCU outcomes controlling for age at diagnosis, years since diagnosis, generalized anxiety, objective risk of recurrence, and number of comorbidities.
RESULTS: FCR predicted more visits to both oncology providers (RR = 1.53, p = .002) and primary care providers (RR = 1.31, p = .013), as well as more phone calls to oncology providers (RR = 2.08, p = .007). FCR was not a significant predictor of phone calls to primary care providers (RR = 1.39, p = .054), utilization of mental health treatment (OR = 1.27, p = .362), or use of psychotropic medications (OR = 1.37, p = .178).
CONCLUSIONS: FCR was associated with increases in some types of HCU, which may reflect excessive medical reassurance-seeking and lead to unnecessary medical costs.
IMPLICATIONS FOR CANCER SURVIVORS: FCR is a serious concern that warrants greater attention to reduce distress-related health care utilization. Utilization of mental health services to address FCR may represent higher-value health care.
- Investigation of age-adjusted D-dimer using an uncommon assay
Parks C, Bounds R, Davis B, Caplan R, Laughery T, Zeserson E
Am J Emerg Med 2018 Sep;
BACKGROUND: Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED.
METHODS: This was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age × 5) - 20 and Age × 5 if >50, respectively. Estimates with their exact 95% threshold were performed.
RESULTS: 4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6-100), specificity of 16.7% (95% CI 15.6-17.8) and NPV of 99.9% (95% CI 99.3-100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8-98.4), specificity of 27.9% (95% CI 26.6-29.2) and NPV of 99.0% (95% CI 98.3-99.5) with the ACEP-endorsed formula demonstrating similar test characteristics.
CONCLUSION: Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.
- Data-driven approach to Early Warning Score-based alert management
Capan M, Hoover S, Miller KE, Pal C, Glasgow JM, Jackson EV, Arnold RC
BMJ Open Qual 2018;7(3):e000088
Background: Increasing adoption of electronic health records (EHRs) with integrated alerting systems is a key initiative for improving patient safety. Considering the variety of dynamically changing clinical information, it remains a challenge to design EHR-driven alerting systems that notify the right providers for the right patient at the right time while managing alert burden. The objective of this study is to proactively develop and evaluate a systematic alert-generating approach as part of the implementation of an Early Warning Score (EWS) at the study hospitals.
Methods: We quantified the impact of an EWS-based clinical alert system on quantity and frequency of alerts using three different alert algorithms consisting of a set of criteria for triggering and muting alerts when certain criteria are satisfied. We used retrospectively collected EHRs data from December 2015 to July 2016 in three units at the study hospitals including general medical, acute care for the elderly and patients with heart failure.
Results: We compared the alert-generating algorithms by opportunity of early recognition of clinical deterioration while proactively estimating alert burden at a unit and patient level. Results highlighted the dependency of the number and frequency of alerts generated on the care location severity and patient characteristics.
Conclusion: EWS-based alert algorithms have the potential to facilitate appropriate alert management prior to integration into clinical practice. By comparing different algorithms with regard to the alert frequency and potential early detection of physiological deterioration as key patient safety opportunities, findings from this study highlight the need for alert systems tailored to patient and care location needs, and inform alternative EWS-based alert deployment strategies to enhance patient safety.
- Factors Associated with Continued Food Insecurity among Households Recovering from Hurricane Katrina
Factors Associated with Continued Food Insecurity among Households Recovering from Hurricane Katrina
Clay LA, Papas MA, Gill KB, Abramson DM
Int J Environ Res Public Health 2018 Aug;15(8)
In 2010, 14.5% of US households experienced food insecurity, which adversely impacts health. Some groups are at increased risk for food insecurity, such as female-headed households, and those same groups are often also at increased risk for disaster exposure and the negative consequences that come with exposure. Little research has been done on food insecurity post-disaster. The present study investigates long-term food insecurity among households heavily impacted by Hurricane Katrina. A sample of 683 households participating in the Gulf Coast Child and Family Health Study were examined using a generalized estimation model to determine protective and risk factors for food insecurity during long-term recovery. Higher income (Odds Ratio (OR) 0.84, 95% Confidence Interval (CI) 0.77, 0.91), having a partner (OR 0.93; 95% CI 0.89, 0.97), or "other" race were found to be protective against food insecurity over a five-year period following disaster exposure. Low social support (OR 1.14; 95% CI 1.08, 1.20), poor physical health (OR 1.08; 95% CI 1.03, 1.13) or mental health (OR 1.13; 95% CI 1.09, 1.18), and female sex (OR 1.05; 95% CI 1.01, 1.10) were risk factors. Policies and programs that increase access to food supplies among high-risk groups are needed to reduce the negative health impacts of disasters.
- Cost-effectiveness of Daratumumab-based Triplet Therapies in Patients With Relapsed or Refractory Multiple Myeloma
Cost-effectiveness of Daratumumab-based Triplet Therapies in Patients With Relapsed or Refractory Multiple Myeloma
Zhang TT, Wang S, Wan N, Zhang L, Zhang Z, Jiang J
Clin Ther 2018 Jul;40(7):1122-1139
PURPOSE: The prominent efficacy of the addition of daratumumab to lenalidomide and dexamethasone (DRd) or the addition to bortezomib and dexamethasone (DVd) was proven previously for patients with relapsed or refractory multiple myeloma (RRMM). However, the cost-effectiveness of adding daratumumab to traditional doublet regimens versus doublet regimens alone (DRd vs Rd; DVd vs Vd) was unknown.
METHODS: We developed a semi-Markov model by using a US payer perspective and 10-year time horizon to estimate the cost and quality-adjusted life years (QALYs) for treatments. Clinical data were obtained from the POLLUX (Phase 3 Study Comparing DRd Versus Rd in Subjects with Relapsed or Refractory Multiple Myeloma [RRMM]) and CASTOR (Phase 3 Study Comparing DVd Versus Vd in Subjects with RRMM) trials. Deterministic and probabilistic sensitivity analyses were conducted to evaluate model uncertainty.
FINDINGS: The incremental cost-effectiveness ratio (ICER) for DVd compared with Vd was $284,180 per QALY; the ICER for DRd compared with Rd was $1,369,062 per QALY. Only when the price of daratumumab was reduced to 37% (US $702/vial) of the current price could the addition of daratumumab to Vd be cost-effective under the US willingness-to-pay (WTP) of $50,000/QALY. However, under no discount level of the daratumumab price is the addition of daratumumab to Rd acceptable. When the WTP increased to $300,000/QALY, the addition of DVd had a 56.7% probability of being cost-effective compared with the Vd regimen.
IMPLICATIONS: Due to the high price of daratumumab, neither the addition of daratumumab to Rd nor Vd proved to be cost-effective under US WTP. However, if the daratumumab price fell to a certain discount level, the DVd regimen might be cost-effective.
- Acculturation, diet, and psychological health among Asian students
Chai SC, Jiang H, Papas MA, Fang CS, Setiloane KT
J Am Coll Health 2018 Jul;:1-8
OBJECTIVE: The study examined the association between acculturation level, dietary nutrient intake, and psychological health of Asian students at the University of Delaware.
PARTICIPANTS: A total of 172 students completed the study.
METHODS: Data were collected, using questionnaires, through Qualtrics®. Linear regression models were used to examine the association between normally distributed diet and acculturation and demographic data.
RESULTS: As length of residence in the United States increased, acculturation level and maintenance of original culture both increased. There was no significant association between acculturation and nutrient intake. Chinese students were more likely than other Asian students to have nonspecific psychological distress.
CONCLUSION: There was no significant association between diet and acculturation level. A larger sample population with longer US residence is needed to further investigate this association. In an effort to improve psychological health of Asian students, challenges specific to this population, such as the language barrier, should be addressed.
- HOW NURSES IDENTIFY HOSPITALIZED PATIENTS ON THEIR PERSONAL NOTES: FINDINGS FROM ANALYZING 'BRAINS' HEADERS WITH MULTIPLE RATERS
HOW NURSES IDENTIFY HOSPITALIZED PATIENTS ON THEIR PERSONAL NOTES: FINDINGS FROM ANALYZING 'BRAINS' HEADERS WITH MULTIPLE RATERS
Sarkhel R, Socha JJ, Mount-Campbell A, Moffatt-Bruce S, Fernandez S, Patel K, Nandi A, Patterson ES
Proc Int Symp Hum Factors Ergon Healthc 2018 Jun;7(1):205-209
The overarching objective of this research is to reduce the burden of documentation in electronic health records by registered nurses in hospitals. Registered nurses have consistently reported that e-documentation is a concern with the introduction of electronic health records. As a result, many nurses use handwritten notes in order to avoid using electronic health records to access information about patients. At the top of these notes are patient identifiers. By identifying aspects of good and suboptimal headers, we can begin to form a model of how to effectively support identifying patients during assessments and care activities. The primary finding is that nurses use room number as the primary patient identifier in the hospital setting, not the patient's last name. In addition, the last name, gender, and age are sufficiently important identifiers that they are frequently recorded at the top of handwritten notes. Clearly distinguishable field labels and values are helpful in quickly scanning the identifier for identifying information. A web based annotator was designed as a first step towards machine learning approaches to recognize handwritten or printed data on paper sheets in future research.
- Does sharing good news buffer fear of bad news? A daily diary study of fear of cancer recurrence in couples approaching the first mammogram post-diagnosis
Does sharing good news buffer fear of bad news? A daily diary study of fear of cancer recurrence in couples approaching the first mammogram post-diagnosis
Soriano EC, Perndorfer C, Otto AK, Siegel SD, Laurenceau JP
Psychooncology 2018 Jun;
OBJECTIVE: The core of fear of cancer recurrence (FCR)-a top concern of couples after successful breast cancer (BC) treatment-is fear of death. Daily relationship processes may be instrumental in regulating FCR as triggers of existential distress are encountered. We tested the hypothesis that daily capitalization, the process of sharing good news (capitalization attempts) to a partner perceived as responsive (responsiveness), buffers patient and spouse FCR as they confront the first mammogram post-diagnosis.
METHODS: Fifty-seven early-stage BC survivors and their spouses reported daily FCR, capitalization, and positivity of the disclosed event during a 3-week diary period beginning 2 weeks before the first annual mammogram post-diagnosis. Dyadic multilevel path models estimated within-person effects of patient and spouse capitalization on same-day FCR, controlling for event positivity.
RESULTS: Before the mammogram, capitalization attempts were unrelated to FCR, but for patients, responsiveness was predictive of greater same-day FCR. After the mammogram, for both partners, attempts were predictive of greater same-day FCR, yet responsiveness was predictive of lower FCR.
CONCLUSIONS: Findings were largely inconsistent with the hypothesis that capitalization buffers existential distress. However, results revealed novel insights about daily dyadic processes that may characterize within-person adaptation to existential threat. Potential explanations for the differential links between capitalization and FCR based on timing (before versus after threat) and capitalization component (attempts versus responsiveness) are discussed.
- Checking Behavior, Fear of Recurrence, and Daily Triggers in Breast Cancer Survivors
Soriano EC, Valera R, Pasipanodya EC, Otto AK, Siegel SD, Laurenceau JP
Ann Behav Med 2018 May;
Background: Fear of cancer recurrence (FCR) is a top ongoing concern of breast cancer (BC) survivors and thus the focus of recent intervention development. The Self-Regulation Model of FCR (Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence-a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psychooncology. 1997;6:95-105.) states that everyday cancer-related events trigger FCR, which, in turn, leads to specific behavioral responses, including checking the body for signs or symptoms of cancer. Links between triggering events, FCR, and checking behavior have not yet been studied in the context of daily life or at the within-person level.
Purpose: The goal of this study was to examine whether FCR has a within-person link with daily checking behavior and whether FCR mediates the link between triggering events and checking behavior.
Methods: Seventy-two early-stage BC survivors completed daily diaries over a 21-day period approximately 5 months after BC surgery. FCR, checking behavior, and triggering events were assessed each evening.
Results: Multilevel modeling results indicated that FCR predicted greater odds of same-day, but not next-day, checking behavior. We found that daily FCR significantly mediated the same-day effect of triggering events on checking behavior. These average within-person effects varied substantially between patients and were not explained by momentary negative affect.
Conclusions: Findings support the within-person relationship between triggering events, FCR, and checking behavior posited by guiding theory, and can inform FCR intervention development.
- Characteristics and Outcomes of Adult Inpatients With Malnutrition
Vest MT, Papas MA, Shapero M, McGraw P, Capizzi A, Jurkovitz C
JPEN J Parenter Enteral Nutr 2018 Aug;42(6):1009-1016
BACKGROUND: The diagnosis of malnutrition remains controversial. Furthermore, it is unknown if physician diagnosis of malnutrition impacts outcomes. We sought to compare outcomes of patients with physician diagnosed malnutrition to patients recognized as malnourished by registered dietitians (RDs), but not physicians, and to describe the impact of each of 6 criteria on the diagnosis of malnutrition.
METHODS: We conducted a retrospective cohort study of adult patients identified as meeting criteria for malnutrition. Pediatric, psychiatric, maternity, and rehabilitation patients were excluded. Patient demographics, clinical data, malnutrition type and criteria, nutrition interventions, and outcomes were abstracted from the electronic medical record.
RESULTS: RDs identified malnutrition for 291 admissions during our study period. This represents 4.1% of hospital discharges. Physicians only diagnosed malnutrition on 93 (32%) of these cases. Physicians diagnosed malnutrition in 43% of patients with a body mass index <18.5 but only 26% of patients with body mass index higher than 18.5. Patients with a physician diagnosis had a longer length of stay (mean 14.9 days vs 7.1 days) and were more likely to receive parenteral nutrition (PN) (20.4% vs 4.6%). Of the patients, 62% had malnutrition due to chronic illness. Of the 6 criteria used to identify malnourished patients, weight loss and reduced energy intake were the most common.
CONCLUSIONS: Malnutrition is underrecognized by physicians. However, further research is needed to determine if physician recognition and treatment of malnutrition can improve outcomes. The most important criteria for identifying malnourished patients in our cohort were weight loss and reduced energy intake.
- Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study
Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study
Jasani G, Papas M, Patel AJ, Jasani N, Levine B, Zhang Y, Marshall ES
J Emerg Med 2018 Feb;54(2):156-164
BACKGROUND: Evaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays.
OBJECTIVE: Our aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP.
METHODS: Low-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0-1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6 months.
RESULTS: We enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6 months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; p = 0.89). Median time from triage to discharge was significantly shorter with IESE (572.6 min vs. 1466.0 min), resulting in significantly lower cost ($4380.50 vs. $6191.70). There were no adverse events related to IESE or early discharge.
CONCLUSIONS: In our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.
- We all make choices: A decision analysis framework for disposition decision in the ED
Capan M, Pigeon J, Marco D, Powell J, Groner K
Am J Emerg Med 2018 Mar;36(3):450-454
BACKGROUND: Emergency Department (ED) providers' disposition decision impacts patient care and safety. The objective of this brief report is to gain a better understanding of ED providers' disposition decision and risk tolerance of associated outcomes.
METHODS: We synthesized qualitative and quantitative methods including decision mapping, survey research, statistical analysis, and word clouds. Between July 2017 and August 2017, a 10-item survey was developed and conducted at the study hospital. Descriptive and statistical analyses were used to assess the relationship between the participant characteristics (age, gender, years of experience in the ED, and level of expertise) and risk tolerance of outcomes (72-h return and negative outcome) associated with disposition decision. Word clouds facilitated prioritization of qualitative responses regarding information impacting and supporting the disposition decision.
RESULTS: Total of 46 participants completed the survey. The mean age was 39.5 (standard deviation (SD) 10years), and mean years of experience was 9.6years (SD 8.7years). Decision map highlighted the connections between patient-, provider-, and system-related factors. Survey results showed that negative outcome resulted in less risk tolerance compared to 72-h return. Chi-square tests did not provide sufficient evidence to indicate that the responses are independent of participants characteristics - except age and the risk of 72-h return (p=0.046).
CONCLUSION: Discharge decision making in the ED is complex as it involves interconnected patient, provider, and system factors. Synthesizing qualitative and quantitative methods promise enhanced understanding of how providers arrive to disposition decision, as well as safety and quality of care in the ED.
- Application of a Theoretical Model Toward Understanding Continued Food Insecurity Post Hurricane Katrina
Application of a Theoretical Model Toward Understanding Continued Food Insecurity Post Hurricane Katrina
Clay LA, Papas MA, Gill K, Abramson DM
Disaster Med Public Health Prep 2018 Feb;12(1):47-56
OBJECTIVE: Disaster recovery efforts focus on restoring basic needs to survivors, such as food, water, and shelter. However, long after the immediate recovery phase is over, some individuals will continue to experience unmet needs. Ongoing food insecurity has been identified as a post-disaster problem. There is a paucity of information regarding the factors that might place an individual at risk for continued food insecurity post disaster.
METHODS: Using data from a sample (n=737) of households severely impacted by Hurricane Katrina, we estimated the associations between food insecurity and structural, physical and mental health, and psychosocial factors 5 years after Hurricane Katrina. Logistic regression models were fit and odds ratios (OR) and 95% CI estimated.
RESULTS: Nearly one-quarter of respondents (23%) reported food insecurity 5 years post Katrina. Marital/partner status (OR: 0.7, CI: 0.42, 0.99), self-efficacy (OR: 0.56, CI: 0.37, 0.84), sense of community (OR: 0.7, CI: 0.44, 0.98), and social support (OR: 0.59, CI: 0.39, 0.89) lowered the odds of food insecurity and explained most of the effects of mental health distress on food insecurity. Social support, self-efficacy, and being partnered were protective against food insecurity.
CONCLUSIONS: Recovery efforts should focus on fostering social-support networks and increased self-efficacy to improve food insecurity post disaster. (Disaster Med Public Health Preparedness. 2018;12:47-56).
- Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries
Goldstein JN, Zhang Z, Schwartz JS, Hicks LS
Am. J. Med. 2018 Jan;131(1):101.e9-101.e15
BACKGROUND: Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries.
METHODS: We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated.
RESULTS: After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24).
CONCLUSIONS: Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.
- The Importance of Inclusion for Cardiovascular Health Promotion Programs in Delaware
Papas MA, Stolz N, Orsega-Smith E, Sparling E, Freedman B
Health Promot Pract 2018 Mar;19(2):256-266
Individuals with disabilities experience greater rates of cardiovascular disease than individuals without disabilities. This increase can be attributed to decreased levels of physical activity, poor eating habits, and increased levels of diabetes, smoking, and obesity. Individuals with disabilities are often excluded from surveillance, treatment, and prevention efforts. Consequently, there is little known about their participation rates in health promotion and disease prevention programs. The aims of this investigation are (1) to examine time trends in cardiovascular disease and risk factors over a 10-year period by disability status and (2) to assess the inclusiveness of health promotion programs in Delaware. The percentage of individuals with disabilities increased from 18% in 2001 to 28% in 2011. Individuals with disabilities had higher rates of cardiovascular disease (t = 80.45; degrees of freedom [df] = 198; p 30 kg/m2) than individuals without disabilities (t = 33.0; df = 198; p < .0001). They also reported less physical activity (t = 44.21; df = 198; p < .0001) and worse diet quality (t = 4.70; df = 198; p < .0001). There was a consistent lack of information about inclusion and participation of individuals with disabilities in health promotion programs. Making adaptations within cardiovascular disease prevention programs in Delaware is imperative to improving the health of individuals with disabilities. Ensuring cardiovascular disease programs are accessible and provide disability-specific trained staff will reduce barriers to participation so that all individuals can benefit.
- APPLYING HUMAN FACTORS ENGINEERING TO IMPROVE USABILITY AND WORKFLOW IN PATHOLOGY INFORMATICS
Mount-Campbell AF, Hosseinzadeh D, Gurcan M, Patterson ES
Proc Int Symp Hum Factors Ergon Healthc 2017 Jun;6(1):23-27
Human factors engineering is an underutilized approach in the design, evaluation, and implementation of health information technology. Heuristic evaluation of the usability of an interface is a 'low-hanging fruit' for identifying a set of relatively simple modifications to a software program that can make software easier to use. In this paper, we describe recommendations to improve the usability of a software package used to view digitized images of tissues by pathologists. Several recommendations were immediately implemented, and others are planned for future releases. The changes are anticipated to be more compatible with user expectations from interacting with similar elements in other packages, and thus easier to learn and use.