Randomized Controlled Trial of a Cognitive Intervention to Improve Memory in Heart Failure.

BACKGROUND: The objective of this 3-arm randomized controlled trial was to evaluate the efficacy of computerized cognitive training (CCT) in improving primary outcomes of delayed-recall memory and serum brain-derived neurotrophic factor (BDNF) levels; and the secondary outcomes were working memory, instrumental activities of daily living (IADLs) and health-related quality of life (HRQL) in patients with heart failure (HF). METHODS AND RESULTS: Patients (n = 256) were randomly assigned to 8 weeks of CCT using BrainHQ, computerized crossword puzzles active control intervention, and usual care. All patients received weekly nurse-enhancement interventions. Data were collected at enrollment and baseline visits and at 10 weeks and 4 and 8 months. In mixed effects models, there were no statistically significant group or group-by-time differences in outcomes. There were statistically significant differences over time in all outcomes in all groups. Patients improved over time on measures of delayed-recall memory, working memory, IADLs, and HRQL and had decreased serum BDNF. CONCLUSIONS: CCT did not improve outcomes compared with the active control intervention and usual care. Nurse-enhancement interventions may have led to improved outcomes over time. Future studies are needed to test nurse-enhancement interventions in combination with other cognitive interventions to improve memory in persons with HF.

Hospital staffing patterns and safety culture perceptions: The mediating role of perceived teamwork and perceived handoffs.

BACKGROUND: As hospitals are under increasing pressure to improve quality and safety, safety culture has become a focal issue for high-risk organizations, including hospitals. Prior research has examined how structural characteristics directly impact safety culture. However, and based on Donabedian's structure-process-outcome quality model, there is a need to understand the processes that intermediate the relationship between structural characteristics and safety culture perceptions. PURPOSE: The processes by which registered nurse (RN) and hospitalist staffing may affect safety culture perceptions were examined in this study. Specifically, this study investigates the processes of perceived teamwork across units and perceived handoffs. METHODOLOGY: Data sources for this research included Hospital Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality, the American Hospital Association's Annual Survey Data, the American Hospital Association Information Technology supplement, and the Area Health Resource File. Two separate mediation models for each process were used. Propensity weights were assigned to each hospital in the sample ( N = 207) to adjust for potential nonresponse bias of hospitals that did not assess employee's safety culture perceptions. RESULTS: Results suggest that RN staffing influences safety culture perceptions, but hospitalist staffing does not. In addition, RN staffing has an indirect effect on safety culture perceptions through better processes. PRACTICE IMPLICATIONS: Our study sheds light on how staffing affects safety culture perceptions. Specifically, our findings suggest that positive perceptions of teamwork across units and handoffs are integral in the relationship between RN staffing and safety culture perceptions. Hospital managers should, therefore, invest resources in staff recruitment and retention. In addition, a targeted focus on perceived teamwork and handoffs may allow hospital managers to improve safety culture perceptions.

Preparing Students for a More Public Health-Aware Market in Response to COVID-19.

The COVID-19 pandemic has made the public more aware of public health and the role its professionals play in addressing the pandemic. Schools and programs in public health have a new opportunity to recruit, train, and sustain the public health workforce. Academic public health can further educate the public and prepare students for meaningful careers through interprofessional education and practice-based learning.

Resource-based view on safety culture's influence on hospital performance: The moderating role of electronic health record implementation.

BACKGROUND: Patient safety and safety culture have received increasing attention from agencies such as the Agency of Healthcare Research and Quality and the Institute of Medicine. Safety culture refers to the fundamental values, attitudes, and perceptions that provide a unique source of competitive advantage to improve performance. This study contributes to the literature and expands understanding of safety culture and hospital performance outcomes when considering electronic health record (EHR) usage. PURPOSE: Based on the resource-based view of the firm, this study examined the association between safety culture and hospital quality and financial performance in the presence of EHR. METHODOLOGY/APPROACH: Data consist of the 2016 Hospital Survey on Patient Safety, Hospital Compare, American Hospital Association's annual survey, and the American Hospital Association's Information Technology supplement. Our final analytic sample consisted of 154 hospitals. We used a two-part nested regression model approach. RESULTS/CONCLUSION: Safety culture has a direct positive relationship with financial performance (operating margin). Furthermore, having basic EHR as compared to not having EHR further enhances this positive relationship. On the other hand, safety culture does not have a direct association with quality performance (readmissions) in most cases. However, safety culture coupled with basic EHR functionalities, compared to not having EHR, is associated with lower readmissions. PRACTICE IMPLICATIONS: Hospitals should strive to improve patient safety culture as part of their strategic plan for quality improvement. In addition, hospital managers should consider implementing EHR as a resource that can support safety culture's effect on outcomes such as financial and quality performance indicators. Future studies can examine the differences between basic and advanced EHR presence in relation to safety culture.

Supporting Health System Transformation: The development of an integrated interprofessional curriculum inclusive of public health students.

Under pressures to support health system transformation, many health professional accreditation organizations have incorporated standards requiring interprofessional education. However, the inclusion of population health topics and public health or health administration students into IPE experiences is limited. With the belief that understanding and cooperation among the health professions will be important to support health system transformation, The Louisiana State University Health Sciences Center-New Orleans has created several IPE experiences focused on population health, programs that are examined in this article along with insights that could prove useful for other programs seeking to build IPE into their regular curricula.

Refusal to participate in heart failure studies: do age and gender matter?

AIMS AND OBJECTIVES: The objective of this retrospective study was to evaluate reasons heart failure patients decline study participation, to inform interventions to improve enrollment. BACKGROUND: Failure to enrol older heart failure patients (age > 65) and women in studies may lead to sampling bias, threatening study validity. DESIGN: This study was a retrospective analysis of refusal data from four heart failure studies that enrolled 788 patients in four states. METHODS: Chi-Square and a pooled t-test were computed to analyse refusal data (n = 300) obtained from heart failure patients who were invited to participate in one of the four studies but declined. RESULTS: Refusal reasons from 300 patients (66% men, mean age 65·33) included: not interested (n = 163), too busy (n = 64), travel burden (n = 50), too sick (n = 38), family problems (n = 14), too much commitment (n = 13) and privacy concerns (n = 4). Chi-Square analyses showed no differences in frequency of reasons (p > 0·05) between men and women. Patients who refused were older, on average, than study participants. CONCLUSIONS: Some reasons were patient-dependent; others were study-dependent. With 'not interested' as the most common reason, cited by over 50% of patients who declined, recruitment measures should be targeted at stimulating patients' interest. Additional efforts may be needed to recruit older participants. However, reasons for refusal were consistent regardless of gender. RELEVANCE TO CLINICAL PRACTICE: Heart failure researchers should proactively approach a greater proportion of women and patients over age 65. With no gender differences in type of reasons for refusal, similar recruitment strategies can be used for men and women. However, enrolment of a representative proportion of women in heart failure studies has proven elusive and may require significant effort from researchers. Employing strategies to stimulate interest in studies is essential for recruiting heart failure patients, who overwhelmingly cited lack of interest as the top reason for refusal.

Nurse-Enhanced Computerized Cognitive Training Increases Serum Brain-Derived Neurotropic Factor Levels and Improves Working Memory in Heart Failure.

BACKGROUND: Memory loss is common in heart failure (HF) patients, but few interventions have been tested to treat it. The objective of this study was to evaluate efficacy of a cognitive training intervention, Brain Fitness, to improve memory, serum brain-derived neurotropic factor (BDNF) levels, working memory, processing speed, executive function, instrumental activities of daily living, mobility, depressive symptoms, and health-related quality of life. METHODS AND RESULTS: Twenty-seven HF patients were randomly assigned to Brain Fitness and health education active control interventions. Data were collected at baseline and 8 and 12 weeks. Linear mixed models analyses were completed. Patients in the Brain Fitness group were older with lower ejection fraction. At 12 weeks, a group by time interaction effect was found for serum BDNF levels (P = .011): serum BDNF levels increased among patients who completed Brain Fitness and decreased among patients who completed health education. No differences were found in memory, but a group by time interaction (P = .046) effect was found for working memory. CONCLUSIONS: Findings support efficacy of Brain Fitness in improving working memory and serum BDNF levels as a biomarker of intervention response. A randomized controlled study is needed among a larger more diverse group of HF patients.

Finance theory and hospital cash balances.

Competing financial theories have been offered to understand hospitals' cash holding with scant recent evidence. Using data from a national sample of 608 not-for-profit hospitals, we find support for the trade-off theory which posits targeted cash balances. We do not find support for the financial hierarchy theory which posits a preference for use of cash to pay for capital investments. Findings apply to holdings of cash and marketable securities, but not board-designated funds where no model provided meaningful explanatory power.

Hospital philanthropy.

It remains an open question whether hospital spending on fundraising efforts to garner philanthropy is a good use of funds. Research and industry reports provide conflicting results. We describe the accounting and data challenges in analysis of hospital philanthropy, which include measurement of donations, measurement of fundraising expenses, and finding the relationships among organizations where these cash flows occur. With these challenges, finding conflicting results is not a surprise.

Healthcare Associated Infections, Nurse Staffing, and Financial Performance.

Healthcare associated infections (HAIs) are a concern to patients, hospital administrators and policymakers. For over than a decade, efforts have been made to hold hospitals accountable for the costs of HAIs. This study uses contingency theory as a framework to examine the association between HAIs and hospital financial performance. We use publicly available data on 2059 hospitals in 2014 to 2016 that include HAIs, staffing financial performance, and hospital and hospital market characteristics. The key independent variables are available infection rates and nurse staffing. The dependent variables are indicators of financial performance: operating margin, total margin, and days cash on hand. We find nearly identical negative direct associations between infections and operating margins and total margins (-0.07%), and positive associations between the interaction of infections and nurse staffing (0.05%). A 10% higher infection rate would be predicted to be associated with only a 0.2% lower profit margin. The associations between HAIs, nurse staffing and days cash on hand were insignificantly different from zero.

Evaluating depressive symptoms, BDNF Val66Met, and APOE-ε4 as moderators of response to computerized cognitive training in heart failure.

BACKGROUND: Depressive symptoms, brain-derived neurotrophic factor (BDNF) Val66Met, and apolipoprotein (APOE)-ε4 may moderate response to computerized cognitive training (CCT) interventions among patients with heart failure (HF). OBJECTIVES: The purpose of this study was to examine moderators of intervention response to CCT over 8 months among patients with HF enrolled in a 3-arm randomized controlled trial. Outcomes were memory, serum BDNF, working memory, instrumental activities of daily living (IADLs), and health-related quality of life (HRQL). METHODS: 256 patients with HF were randomized to CCT, computerized crossword puzzles active control, and usual care control groups for 8 weeks. Data were collected at enrollment, baseline, 10 weeks, and 4 and 8 months. Mixed effects models were computed to evaluate moderators. RESULTS: As previously reported, there were no statistically significant group by time effects in outcomes among the 3 groups over 8 months. Tests of moderation indicated that depressive symptoms and presence of BDNF Val66Met and APOE-ε4 were not statistically significant moderators of intervention response in outcomes of delayed recall memory, serum BDNF, working memory, IADLs, and HRQL. In post hoc analysis evaluating baseline global cognitive function, gender, age, and HF severity as moderators, no significant effects were found. HF severity was imbalanced among groups (P = .049) which may have influenced results. CONCLUSIONS: Studies are needed to elucidate biological mechanisms of cognitive dysfunction in HF and test novel interventions to improve memory, serum BDNF, working memory, IADLs and HRQL. Patients may need to be stratified or randomized by HF severity within intervention trials.

Nurse-Enhanced Memory Intervention in Heart Failure: the MEMOIR study.

BACKGROUND: Many patients with heart failure (HF) have cognitive deficits, including memory loss. OBJECTIVES: The aim of this study was to evaluate the efficacy of a cognitive training intervention on memory (primary outcome), working memory, psychomotor speed, executive function, and performance of cognitive activities and instrumental activities of daily living (IADLs). METHODS AND RESULTS: Forty patients with HF were randomly assigned to the computerized plasticity-based cognitive training intervention called Brain Fitness or to the health education active control intervention. Advanced practice nurses made weekly home visits to assess symptoms and monitor intervention adherence. Patients completed demographic and clinical data (baseline), neuropsychologic tests (baseline and 8 and 12 weeks), and measures of cognitive and IADLs performance (baseline and 12 weeks) and satisfaction (12 weeks). Linear mixed models analyses indicated a significant group by time interaction for delayed recall memory (P = .032) and a significant time effect for total (list learning) (P < .001) and delayed (P = .015) recall memory, psychomotor speed (P = .029), and performance of IADLs (P = .006). Intervention adherence and patient satisfaction were high. CONCLUSIONS: To our knowledge, this was the first test of Brain Fitness in HF. Although it was a preliminary study with limitations, results support the need for a larger randomized controlled trial to determine whether the memory loss of HF is amenable to plasticity-based interventions.

Cash holdings of not-for-profit hospitals.

Many not-for-profit (NFP) hospitals hold substantial cash reserves. Using a national sample of 608 NFP hospitals over the period 1996-1999, we related theories of cash holdings to NFP hospitals to develop a conceptual framework for understanding cash holdings. We tested whether these hospitals differentially managed operating and strategic cash with respect to establishing target balances and investigated motivations for holding cash. NFP hospitals actively targeted levels of operating cash, but did not target strategic cash balances. Strategic cash balances were positively related to profitability and growth in assets, but negatively associated with the use of debt.

Costs of Biopsy and Complications in Patients with Lung Cancer.

PURPOSE: To describe the distribution of diagnostic procedures, rates of complications, and total cost of biopsies for patients with lung cancer. PATIENTS AND METHODS: Observational study using data from IBM Marketscan® Databases for continuously insured adult patients with a primary lung cancer diagnosis and treatment between July 2013 and June 2017. Costs of lung cancer diagnosis covered 6 months prior to index biopsy through treatment. Costs of chest CT scans, biopsy, and post-procedural complications were estimated from total payments. Costs of biopsies incidental to inpatient admissions were estimated by comparable outpatient biopsies. RESULTS: The database included 22,870 patients who had a total of 37,160 biopsies, of which 16,009 (43.1%) were percutaneous, 14,997 (40.4%) bronchoscopic, 4072 (11.0%) surgical and 2082 (5.6%) mediastinoscopic. Multiple biopsies were performed on 41.9% of patients. The most common complications among patients receiving only one type of biopsy were pneumothorax (1304 patients, 8.4%), bleeding (744 patients, 4.8%) and intubation (400 patients, 2.6%). However, most complications did not require interventions that would add to costs. Median total costs were highest for inpatient surgical biopsies ($29,988) and lowest for outpatient percutaneous biopsies ($1028). Repeat biopsies of the same type increased costs by 40-80%. Complications account for 13% of total costs. CONCLUSION: Costs of biopsies to confirm lung cancer diagnosis vary substantially by type of biopsy and setting. Multiple biopsies, inpatient procedures and complications result in higher costs.

Term Limits in Academic Public Health Administration.

OBJECTIVES: Term limits might be appropriate for leadership positions in academic public health. This study assessed the appointment processes and terms for deans, directors, and chairs of schools and programs of public health and their views on term limits. METHODS: A 10-question survey was developed for the Association of Schools and Programs of Public Health and provided electronically to 127 deans and program directors in November and December 2019, of whom 58 (46%) responded. RESULTS: Of 54 respondents to the question on term limits, 45 deans and directors of schools and programs of public health served with no terms or limits and 9 served with terms of 3-5 years with no limits on the number of terms. Respondents largely agreed with most arguments for or against term limits. Of 51 respondents, most indicated completely or moderately valid support for 2 arguments for term limits: diversity (n = 40) and succession planning (n = 40). Of 51 respondents, most indicated completely or moderately valid support for 3 arguments against term limits: stable and continuous leadership (n = 40), time for leadership development (n = 37), and loss of institutional memory (n = 35). Twenty-seven of 53 responding deans and directors viewed the most appropriate terms and limits as being more restrictive than their current terms; the other 26 viewed the most appropriate terms as being the same as their current terms. No respondents preferred less restrictive limits than their current terms. CONCLUSION: Although term limits for deans, directors, and chairs are rare in schools and programs of public health, many deans and directors view term limits as appropriate. Schools and programs may reconsider their current policies for term limits.

Healthcare utilization in community-acquired pneumonia episodes of care: a comparison across the continuum of managed care.

OBJECTIVE: Compare healthcare utilization and total payments for community-acquired pneumonia (CAP) episodes-of-care among 5 health plan designs spanning the continuum of managed care. RESEARCH DESIGN: Medical and prescription claims analysis of CAP episodes among enrollees of employer-sponsored health plans. Episode characteristics, healthcare utilization, and payments were compared across fee-for-service, Preferred Provider Organizations (PPO), point of service, partial capitation, and Health Maintenance Organizations as defined by the employers. Medstat Episode of Care Grouper Version 2.1.5 was employed to create episodes of CAP care. Categorical and continuous measures of patient and care characteristics across plan designs were compared by chi tests and one-way analysis-of-variance as appropriate. Total per-episode payments for provided services across plan designs were compared using a general linear model with a log-link function and gamma distribution. RESULTS: Greater average patient age, episode severity, number of office visits, rate of hospitalization, length of stay, and inpatient mortality overall were found within PPO episodes compared with all other plan designs. Total episode payments controlling for age, sex, disease severity, and geography were greatest among PPO episodes and attributed largely to more office visits and longer lengths of hospital stays compared with other plan types. CONCLUSIONS: As previously shown among other patient populations and conditions, PPO episodes of CAP are associated with greater total payments due in large part to increased resource utilization among the episodes of lowest severity.

Readmission Rates and Their Impact on Hospital Financial Performance: A Study of Washington Hospitals.

This longitudinal study examines whether readmission rates, made transparent through Hospital Compare, affect hospital financial performance by examining 98 hospitals in the State of Washington from 2012 to 2014. Readmission rates for acute myocardial infarction (AMI), pneumonia (PN), and heart failure (HF) were examined against operating revenues per patient, operating expenses per patient, and operating margin. Using hospital-level fixed effects regression on 276 hospital year observations, the analysis indicated that a reduction in AMI readmission rates is related with increased operating revenues as expenses associated with costly treatments related with unnecessary readmissions are avoided. Additionally, reducing readmission rates is related with an increase in operating expenses. As a net effect, increased PN readmission rates may show marginal increase in operating margin because of the higher operating revenues due to readmissions. However, as readmissions continue to happen, a gradual increase in expenses due to greater use of resources may lead to decreased profitability.