Beyond the gender binary: a survey of gender marginalization and social boundaries in Australian jazz and improvisation.

Jazz and improvisation have typically been associated with ideals of freedom and liberty; however, in practice these genres are known to be constrained by entrenched patterns of male domination and gender discrimination. Despite a large number of qualitative accounts evidencing persistent sexism and gender exclusion in the field, there exists a lack of empirical data to assess the scale of this phenomenon and substantiate smaller-scale research on gender inequality. In this paper, we employ boundary theory to report on a quantitative investigation of gender marginalization in jazz and improvisation in the Australian context, positioning gender as a symbolic boundary resulting in the social exclusion and marginalization of gender diverse individuals and women. An anonymous survey (n=124) was run over a period of five months, to explore the beliefs, attitudes, and experiences concerning gender, of people participating in Australian jazz and improvisation. A means comparison found that gender was a statistically significant indicator (p ≤0.05) on almost all measures, with gender diverse respondents significantly more likely to report the effects of marginalization than their (cisgender) counterparts. Additionally, the results indicated contrasting forms of musical engagement and marginalization across gender groups, with women perceiving exclusion to a lesser extent than gender diverse practitioners, and differing in their opinions regarding work opportunities. Lastly, a widespread but historically unspoken awareness of sexual harassment in the Australian jazz and improvisation industry was reported by all genders. This paper concludes with three recommendations for future research, policy and practice: 1. Specific targeted strategies are needed to address the manifold and complex forms of marginalization experienced by gender diverse people; 2. Heightened institutional visibility for marginalized groups is needed to change gendered narratives and highlight awareness of inequities; and 3. Enhanced safety measures are critically needed to address sexual harassment throughout the industry.

Comprehensive Shielding System Enhances Radiation Protection for Structural Heart Procedures.

Background: This study of radiation exposure (RE) to physicians performing structural heart procedures evaluated the efficacy of a novel comprehensive radiation shield compared to those of traditional shielding methods. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been documented to provide superior RE protection during coronary procedures compared to that provided by a standard "drop down" shield. The purpose of this study was to assess the efficacy of this shield in transcatheter aortic valve replacement (TAVR) procedures, which are associated with disproportionate RE to operators. Methods: This single-center, 2-group cohort, observational analysis compared RE to the primary physician operator performing TAVR using the Protego shield (n = 25) with that using a standard drop-down shield with personal leaded apparel (n = 25). RE was measured at both thyroid and waist levels with a real-time dosimetry system (RaySafe i3, RaySafe) and was calculated on a mean per case basis. Data were collected on additional procedural parameters, including access site(s) for device implantation, per case fluoroscopy time, air kerma, and patient factors, including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites. Results: The Protego system reduced operator RE by 99% compared to that using standard protection. RE was significantly lower at both the thyroid level (0.08 ± 0.27 vs 79.2 ± 62.4 µSv; P < .001) and the waist level (0.70 ± 1.50 vs 162.0 ± 91.0 µSv, P < .001). "Zero" total RE was documented by RaySafe in 60% (n = 15) of TAVR cases using Protego. In contrast, standard protection did not achieve zero exposure in a single case. Conclusions: The Protego shield system provides superior operator RE protection during TAVR procedures. This shield allows operators to work without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Trends in Post-Acute Care use in Medicare Advantage Versus Traditional Medicare: A Retrospective Cohort Analysis.

OBJECTIVES: We sought to describe national trends in hospitalization and post-acute care utilization rates in skilled nursing facilities (SNFs) and home health (HH) for both Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries, reaching up to the COVID-19 pandemic (2015-2019). DESIGN: Retrospective, observational using 100% sample of Medicare Provider Analysis and Review file (MedPAR), the Medicare Beneficiary Summary File, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS). SETTING AND PARTICIPANTS: Medicare beneficiaries aged 66 and older enrolled in MA or TM who were hospitalized and discharged alive. METHODS: We first calculated the proportions of MA and TM beneficiaries who were hospitalized and who used any post-acute care, as well as the total number of days of post-acute care used. We also calculated the size of the post-acute care network used by TM and MA beneficiaries within each hospital in our sample and the measured quality (star ratings) of the post-acute care providers used. RESULTS: We found hospitalizations, SNF stays, and HH stays were all decreasing over time in both populations. Although similar proportions of MA and TM beneficiaries received SNF or HH care, MA beneficiaries received fewer days. The largest difference we found was in the number of post-acute care providers used in TM and MA, with MA using far fewer; however, quality ratings were similar among post-acute care providers used in each program. CONCLUSIONS AND IMPLICATIONS: Together, these results suggest MA beneficiaries have fewer days in post-acute care, receive care from fewer providers of similar measured quality to TM, but have a similar number of days outside the hospital or SNF in the first 100 days after hospital discharge.

Postdischarge needs identified by an automated text messaging program: A mixed-methods study.

BACKGROUND: Text messaging has emerged as a popular strategy to engage patients after hospital discharge. Little is known about how patients use these programs and what types of needs are addressed through this approach. OBJECTIVE: The goal of this study was to describe the types and timing of postdischarge needs identified during a 30-day automated texting program. METHODS: The program ran from January to August 2021 at a primary care practice in Philadelphia. In this mixed-methods study, two reviewers conducted a directed content analysis of patient needs expressed during the program, categorizing them along a well-known transitional care framework. We describe the frequency of need categories and their timing relative to discharge. RESULTS: A total of 405 individuals were enrolled; the mean (SD) age was 62.7 (16.2); 64.2% were female; 47.4% were Black; and 49.9% had Medicare insurance. Of this population, 178 (44.0%) expressed at least one need during the 30-day program. The most frequent needs addressed were related to symptoms (26.8%), coordinating follow-up care (20.4%), and medication issues (15.7%). The mean (SD) number of days from discharge to need was 10.8 (7.9); there were no significant differences in timing based on need category. CONCLUSIONS: The needs identified via an automated texting program were concentrated in three areas relevant to primary care practice and within nursing scope of practice. This program can serve as a model for health systems looking to support transitions through an operationally efficient approach, and the findings of this analysis can inform future iterations of this type of program.

Evaluating the relationship between facility Age-Friendly recognition and subsequent facility-free days in older Veterans.

BACKGROUND: Thousands of health systems have been recognized as "Age-Friendly" for implementing geriatric care practices aligned with the "4Ms" (What Matters, Medication, Mentation, and Mobility). However, the effect of Age-Friendly recognition on patient outcomes is largely unknown. We sought to identify this effect in the Veterans Health Administration (VHA)-one of the largest Age-Friendly integrated health systems in the United States. METHODS: There were 50 VA medical centers (VAMCs) recognized as Age-Friendly by December 2021. We used a time-event difference-in-difference analysis to identify the association of a VAMC's recognition as Age-Friendly on the change in facility-free days (days outside the hospital or nursing home) among Veterans treated at that facility. We also evaluated this association in three subgroups: Veterans at particularly high risk of nursing home entry, Veterans who lived within 10 miles of a medical center, and facilities that had reached Level 2 Age-Friendly recognition. We also evaluated individual components of the endpoint in terms of change in hospital and nursing home days separately. RESULTS: We found Age-Friendly recognition was associated with small statistically significant improvements in facility-free days (0.2% on a base of 97% facility-free days on average per year, or an additional 0.73 days per year on a base of 354 days). There were no differences in any subgroup, or any individual component of the endpoint across all groups. CONCLUSIONS: At the individual level, an increase of 0.2% in facility-free days is a weak effect. However, sites were early in implementation, and facility-free days may not be a responsive outcome measure. However, across an entire population, small changes in facility-free days may accrue large cost savings. Future evaluations should consider a broader variety of process and outcome measures.

Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers.

RATIONALE & OBJECTIVE: Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers. STUDY DESIGN: This is a convergent parallel mixed-methods study. SETTING & PARTICIPANTS: We convened a 7-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers-through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to (1) rank their top 3 major barriers (quantitative) and (2) describe barriers to home dialysis (qualitative). ANALYTICAL APPROACH: We compiled a list of the top 3 patient/care partner-perceived and top 3 provider-perceived barriers (quantitative). We also conducted a directed content analysis of open-ended survey responses (qualitative). RESULTS: There were 522 complete responses (233 providers; 289 patients/care partners). The top 3 patient/care partner-perceived barriers were fear of performing home dialysis; lack of space; and the need for home-based support. The top 3 provider-perceived barriers were poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified 9 themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favors in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency. LIMITATIONS: This was an online survey that is subject to nonresponse bias. CONCLUSIONS: The top 3 barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic. PLAIN-LANGUAGE SUMMARY: There are many barriers to home dialysis use in the United States. However, we know little about which barriers are the most important to patients and clinicians. This makes it challenging to develop strategies to increase home dialysis use. In this study, we surveyed patients, care partners, and clinicians across the country to identify the most important barriers to home dialysis, namely (1) patients/care partners identified fear of home dialysis, lack of space, and lack of home-based support; and (2) clinicians identified poor patient education, limited support for staff and patients, and lack of experienced staff. These findings suggest that patients and clinicians perceive different barriers and that both sets of barriers should be addressed to expand home dialysis use.

Automated Text Message-Based Program and Use of Acute Health Care Resources After Hospital Discharge: A Randomized Clinical Trial.

Importance: Postdischarge outreach from the primary care practice is an important component of transitional care support. The most common method of contact is via telephone call, but calls are labor intensive and therefore limited in scope. Objective: To test whether a 30-day automated texting program to support primary care patients after hospital discharge reduces acute care revisits. Design, Setting, and Participants: A 2-arm randomized clinical trial was conducted from March 29, 2022, through January 5, 2023, at 30 primary care practices within a single academic health system in Philadelphia, Pennsylvania. Patients were followed up for 60 days after discharge. Investigators were blinded to assignment, but patients and practice staff were not. Participants included established patients of the study practices who were aged 18 years or older, discharged from an acute care hospitalization, and considered medium to high risk for adverse health events by a health system risk score. All analyses were conducted using an intention-to-treat approach. Intervention: Patients in the intervention group received automated check-in text messages from their primary care practice on a tapering schedule for 30 days following discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. Patients in the control group received a standard transitional care management telephone call from their practice within 2 business days of discharge. Main Outcomes and Measures: The primary study outcome was any acute care revisit (readmission or emergency department visit) within 30 days of discharge. Results: Of the 4736 participants, 2824 (59.6%) were female; the mean (SD) age was 65.4 (16.5) years. The mean (SD) length of index hospital stay was 5.5 (7.9) days. A total of 2352 patients were randomized to the intervention arm and 2384 were randomized to the control arm. There were 557 (23.4%) acute care revisits in the control group and 561 (23.9%) in the intervention group within 30 days of discharge (risk ratio, 1.02; 95% CI, 0.92-1.13). Among the patients in the intervention arm, 79.5% answered at least 1 message and 41.9% had at least 1 need identified. Conclusions and Relevance: In this randomized clinical trial of a 30-day postdischarge automated texting program, there was no significant reduction in acute care revisits. Trial Registration: ClinicalTrials.gov Identifier: NCT05245773.

Comprehensive radiation shield minimizes operator radiation exposure in coronary and structural heart procedures.

OBJECTIVES: This study evaluated the efficacy of a novel comprehensive shield designed to minimize radiation exposure (RE) to Physicians performing coronary and structural heart procedures. BACKGROUND: The Protego™ radiation shielding system (Image Diagnostics Inc., Fitchburg, Ma) is designed to provide comprehensive protection from RE and has been State certified sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons. METHODS: This single center two-group cohort study assessed the efficacy of this shield in a large number of cardiac procedures (coronary and structural), comparing operator RE compared to standard protection methods (personal lead apparel and "drop down" shield). RESULTS: The Protego™ system reduced operator RE by 99 % compared to Standard Protection. RE was significantly lower at both "Head" level by thyroid median dose 0.0 (0.0, 0,0) vs 5.7 (2.9, 8.2) µSv (p < 0.001), as well as waist dose 0.0 (0.0, 0.0) vs 10.0 (5.0, 16.6) µSv (p < 0.001). "Zero" Total RE was documented by Raysafe™ in 64 % (n = 32) of TAVR cases and 73.2 % (n = 183) of the coronary cases utilizing Protego™. In contrast, standard protection did not achieve "Zero" exposure in a single case. These dramatic differences in RE were achieved despite higher fluoroscopy times in the Protego™ arm (11.9 ± 8.6 vs 14.3 ± 12.5 min, p = 0.015). Per case procedural exposure measured by Dose Area Product was higher in the Protego™ group compared to standard protection (115.4 ± 139.2 vs 74.9 ± 69.3, p < 0.001). CONCLUSION: The Protego™ shield provides total body RE protection for operators performing both coronary and structural heart procedures. This shield allows procedural performance without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up.

BACKGROUND: High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. METHODS: The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. RESULTS: The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. CONCLUSIONS: The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

Association between Timing of Clinical Evaluation by a Physician or Advanced Practitioner and Risk of Rehospitalization in Older Adults Admitted to a Skilled Nursing Facility Following Hospitalization: A Cohort Study.

OBJECTIVES: How transitional care services are provided to patients receiving post-acute care in skilled nursing facilities (SNFs) is not well understood. We aimed to determine the association of timing of physician or advanced practice provider (APP) visit after SNF admission with rehospitalization risk in a national cohort of older adults. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 2,482,616 Medicare fee-for-service beneficiaries aged ≥66 years who entered an SNF for post-acute care following hospitalization. METHODS: We measured the relative risk of being rehospitalized within 14 days of SNF admission as a function of time to the first PAP visit, using time to follow-up as a time-dependent covariate, adjusted for patient demographics and clinical characteristics. We also evaluated whether findings extended across groups with different SNF prognosis on admission. RESULTS: Patients seen sooner after admission to an SNF (0-1 days) were less likely to be rehospitalized compared to patients seen later (≥2 days). The relative difference was similar across different risk groups. CONCLUSIONS AND IMPLICATIONS: Timely evaluation by a physician or APP after SNF admission may protect against rehospitalization. Investment in the workforce such as training programs, practice innovations, and equitable reimbursement for SNF visits after hospital discharge may mitigate labor shortages that were exacerbated by the COVID pandemic.

Applying i-PARIHS to Identify Emerging Innovations in Hospital Discharge Decision Making in Response to System Stress: A Qualitative Study.

Background: The purpose of this qualitative study was to use a Learning Health System approach to identify factors influencing the emergence of innovation in rehabilitation hospital discharge decision-making during the Coronavirus 2019 (COVID-19) pandemic. Methods: Rehabilitation clinicians were recruited from the Veterans Affairs Health Care System and participated in individual semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Data were analyzed using a rapid qualitative, deductive team-based approach informed by directed content analysis. Results: Twenty-three rehabilitation clinicians representing physical (N = 11) and occupational therapy (N = 12) participated in the study. Three primary themes were generated: (1) Recipients: innovations emerged as approaches to communicating discharge recommendations changed (in-person to virtual) and strong patient/family preferences to discharge to the home challenged collaborative goal setting; (2) Context: the ability of rehabilitation clinicians to innovate and the form of innovations were influenced by the broader hospital system, interdisciplinary team dynamics, and policy fluctuations; (3) Innovation: emerging innovations in discharge processes included perceived increases in team collaboration, shifts in caseload prioritization, and alternative options for post-acute care. Conclusions: Our findings reinforce that rehabilitation clinicians developed innovative strategies to quickly adapt to multiple systems-level factors that were changing in the face of the COVID-19 pandemic. Future research is needed to assess the impact of innovations, remediate unintended consequences, and evaluate the implementation of promising innovations to respond to emerging healthcare delivery needs more rapidly.

Experimental validation of rotating detonation for rocket propulsion.

Space travel requires high-powered, efficient rocket propulsion systems for controllable launch vehicles and safe planetary entry. Interplanetary travel will rely on energy-dense propellants to produce thrust via combustion as the heat generation process to convert chemical to thermal energy. In propulsion devices, combustion can occur through deflagration or detonation, each having vastly different characteristics. Deflagration is subsonic burning at effectively constant pressure and is the main means of thermal energy generation in modern rockets. Alternatively, detonation is a supersonic combustion-driven shock offering several advantages. Detonations entail compact heat release zones at elevated local pressure and temperature. Specifically, rotating detonation rocket engines (RDREs) use detonation as the primary means of energy conversion, producing more useful available work compared to equivalent deflagration-based devices; detonation-based combustion is poised to radically improve rocket performance compared to today's constant pressure engines, producing up to 10[Formula: see text] increased thrust. This new propulsion cycle will also reduce thruster size and/or weight, lower injection pressures, and are less susceptible to engine-damaging acoustic instabilities. Here we present a collective effort to benchmark performance and standardize operability of rotating detonation rocket engines to develop the RDRE technology readiness level towards a flight demonstration. Key detonation physics unique to RDREs, driving consistency and control of chamber dynamics across the engine operating envelope, are identified and addressed to drive down the variability and stochasticity observed in previous studies. This effort demonstrates an RDRE operating consistently across multiple facilities, validating this technology's performance as the foundation of RDRE architecture for future aerospace applications.

Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations.

BACKGROUND: Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans. OBJECTIVE: We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D). DESIGN: Retrospective cohort study from 2015 to 2019. PARTICIPANTS: Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states). MAIN MEASURES: Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups. KEY RESULTS: The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions. CONCLUSIONS: The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.