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BACKGROUND: Respectful maternity care includes shared decision-making (SDM). However, research on SDM is lacking from the intrapartum period and instruments to measure it have only recently been developed. TeamBirth is a quality improvement initiative that uses team huddles to improve SDM during labor and birth. Team huddles are structured meetings including the patient and full care team when the patient's preferences, care plans, and expectations for when the next huddle will occur are reviewed. METHODS: We used patient survey data (n = 1253) from a prospective observational study at four U.S. hospitals to examine the relationship between TeamBirth huddles and SDM. We measured SDM using the Mother's Autonomy in Decision-Making (MADM) scale. Linear regression models were used to assess the association between any exposure to huddles and the MADM score and between the number of huddles and the MADM score. RESULTS: In our multivariable model, experiencing a huddle was significantly associated with a 3.13-point higher MADM score. When compared with receiving one huddle, experiencing 6+ huddles yielded a 3.64-point higher MADM score. DISCUSSION: Patients reporting at least one TeamBirth huddle experienced significantly higher SDM, as measured by the MADM scale. Our findings align with prior research that found actively involving the patient in their care by creating structured opportunities to discuss preferences and choices enables SDM. We also demonstrated that MADM is sensitive to hospital-based quality improvement, suggesting that future labor and birth interventions might adopt MADM as a patient-reported experience measure.
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A private-academic partnership built the Vaccine Equity Planner (VEP) to help decision-makers improve geographic access to COVID-19 vaccinations across the United States by identifying vaccine deserts and facilities that could fill those deserts. The VEP presented complex, updated data in an intuitive form during a rapidly changing pandemic situation. The persistence of vaccine deserts in every state as COVID-19 booster recommendations develop suggests that vaccine delivery can be improved. Underresourced public health systems benefit from tools providing real-time, accurate, actionable data. (Am J Public Health. 2023;113(4):363-367. https://doi.org/10.2105/AJPH.2022.307198).
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Vacinas contra COVID-19 , COVID-19 , Humanos , Saúde Pública , COVID-19/prevenção & controle , Assistência Médica , PandemiasRESUMO
Vaccine development and implementation decisions need to be guided by accurate and robust burden of disease data. We developed an innovative systematic framework outlining the properties of such data that are needed to advance vaccine development and evaluation, and prioritize research and surveillance activities. We focus on 4 objectives-advocacy, regulatory oversight and licensure, policy and post-licensure evaluation, and post-licensure financing-and identify key stakeholders and specific requirements for burden of disease data aligned with each objective. We apply this framework to group A Streptococcus, a pathogen with an underrecognized global burden, and give specific examples pertinent to 8 clinical endpoints. This dynamic framework can be adapted for any disease with a vaccine in development and can be updated as vaccine candidates progress through clinical trials. This framework will also help with research and innovation priority setting of the Immunization Agenda 2030 (IA2030) and accelerate development of future vaccines.
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Infecções Estreptocócicas , Vacinas Estreptocócicas , Efeitos Psicossociais da Doença , Humanos , Infecções Estreptocócicas/epidemiologia , Infecções Estreptocócicas/prevenção & controle , Streptococcus pyogenes , Desenvolvimento de VacinasRESUMO
BACKGROUND: TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery. METHODS: We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth. RESULTS: A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures. CONCLUSIONS: Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.
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Comunicação , Trabalho de Parto , Recém-Nascido , Feminino , Humanos , Gravidez , Estudos de Viabilidade , Segurança do Paciente , FamíliaRESUMO
PURPOSE: We sought to determine whether smartphone GPS data uncovered differences in recovery after breast-conserving surgery (BCS) and mastectomy, and how these data aligned with self-reported quality of life (QoL). METHODS: In a prospective pilot study, adult smartphone-owners undergoing breast surgery downloaded an application that continuously collected smartphone GPS data for 1 week preoperatively and 6 months postoperatively. QoL was assessed with the Short-Form-36 (SF36) via smartphone delivery preoperatively and 4 and 12 weeks postoperatively. Endpoints were trends in daily GPS-derived distance traveled and home time, as well as SF36 Physical (PCS) and Mental Component Scores (MCS) comparing BCS and mastectomy patients. RESULTS: Thirty-one patients were included. Sixteen BCS and fifteen mastectomy patients were followed for a mean of 201 (SD 161) and 174 (107) days, respectively. There were no baseline differences in demographics, PCS/MCS, home time, or distance traveled. Through 12 weeks postoperatively, mastectomy patients spent more time at home [e.g., week 4: 16.7 h 95% CI (14.3, 19.6) vs. 11.0 h (9.4, 12.9), p < 0.001] and traveled shorter distances [e.g., week 4: 52.5 km 95% CI (36.1, 76.0) vs. 107.7 km (75.8-152.9), p = 0.009] compared with BCS patients. There were no significant QoL differences throughout the study as measured by the MCS [e.g., week 4 difference: 7.83 95% CI (- 9.02, 24.7), p = 0.362] or PCS [e.g., week 4 difference: 8.14 (- 6.67, 22.9), p = 0.281]. GPS and QoL trends were uncorrelated (ρ < ± 0.26, p > 0.05). CONCLUSIONS: Differences in BCS and mastectomy recovery were successfully captured using smartphone GPS data. These data may describe currently unmeasured aspects of physical and mental recovery, which could supplement traditional and QoL outcomes to inform shared decision-making.
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Neoplasias da Mama , Adulto , Neoplasias da Mama/cirurgia , Feminino , Sistemas de Informação Geográfica , Humanos , Mastectomia , Projetos Piloto , Estudos Prospectivos , Qualidade de Vida , SmartphoneRESUMO
OBJECTIVE: We merged direct, multisource, and systematic assessments of surgeon behavior with malpractice claims, to analyze the relationship between surgeon 360-degree reviews and malpractice history. BACKGROUND: Previous work suggests that malpractice claims are associated with a poor physician-patient relationship, which is likely related to behaviors captured by 360-degree review. We hypothesize that 360-degree review results are associated with malpractice claims. METHODS: Surgeons from 4 academic medical centers covered by a common malpractice carrier underwent 360-degree review in 2012 to 2013 (n = 385). Matched, de-identified reviews and malpractice claims data were available for 264 surgeons from 2000 to 2015. We analyzed 23 questions, highlighting positive and negative behaviors within the domains of education, excellence, humility, openness, respect, service, and teamwork. Regression analysis with robust standard error was used to assess the potential association between 360-degree review results and malpractice claims. RESULTS: The range of claims among the 264 surgeons was 0 to 8, with 48.1% of surgeons having at least 1 claim. Multiple positive and negative behaviors were significantly associated with the risk of having malpractice claims (P < 0.05). Surgeons in the bottom decile for several items had an increased likelihood of having at least 1 claim. CONCLUSION: Surgeon behavior, as assessed by 360-degree review, is associated with malpractice claims. These findings highlight the importance of teamwork and communication in exposure to malpractice. Although the nature of malpractice claims is complex and multifactorial, the identification and modification of negative physician behaviors may mitigate malpractice risk and ultimately result in the improved quality of patient care.
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Relações Interprofissionais , Imperícia/estatística & dados numéricos , Relações Médico-Paciente , Comportamento Social , Cirurgiões/legislação & jurisprudência , Cirurgiões/psicologia , Competência Clínica , Cirurgia Geral , Humanos , Massachusetts , Procedimentos Ortopédicos , Satisfação do Paciente , Revisão dos Cuidados de Saúde por Pares , Gestão de Riscos , Cirurgiões/éticaRESUMO
BACKGROUND: The management quality of healthcare facilities has consistently been linked to facility performance, but available tools to measure management are costly to implement, often hospital-specific, not designed for low- and middle-income countries (LMICs), nor widely deployed. We addressed this gap by developing the PRImary care facility Management Evaluation Tool (PRIME-Tool), a primary health care facility management survey for integration into routine national surveys in LMICs. We present an analysis of the tool's psychometric properties and suggest directions for future improvements. METHODS: The PRIME-Tool assesses performance in five core management domains: Target setting, Operations, Human resources, Monitoring, and Community engagement. We evaluated two versions of the PRIME-Tool. We surveyed 142 primary health care (PHC) facilities in Ghana in 2016 using the first version (27 items) and 148 facilities in 2017 using the second version (34 items). We calculated floor and ceiling effects for each item and conducted exploratory factor analyses to examine the factor structure for each year and version of the tool. We developed a revised management framework and PRIME-tool as informed by these exploratory results, further review of management theory literature, and co-author consensus. RESULTS: The majority (17 items in 2016, 23 items in 2017) of PRIME-Tool items exhibited ceiling effects, but only three (2 items in 2016, 3 items in 2017) showed floor effects. Solutions suggested by factor analyses did not fully fit our initial hypothesized management domains. We found five groupings of items that consistently loaded together across each analysis and named these revised domains as Supportive supervision and target setting, Active monitoring and review, Community engagement, Client feedback for improvement, and Operations and financing. CONCLUSION: The revised version of the PRIME-Tool captures a range of important and actionable information on the management of PHC facilities in LMIC contexts. We recommend its use by other investigators and practitioners to further validate its utility in PHC settings. We will continue to refine the PRIME-Tool to arrive at a parsimonious tool for tracking PHC facility management quality. Better understanding the functional components of PHC facility management can help policymakers and frontline managers drive evidence-based improvements in performance.
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Atenção Primária à Saúde/organização & administração , Inquéritos e Questionários , Análise Fatorial , Gana , Pesquisa sobre Serviços de Saúde , Humanos , Psicometria , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: Evaluate the impact of a World Health Organization Safe Childbirth Checklist coaching-based intervention (BetterBirth Program) on availability and procurement of essential childbirth-related supplies. DESIGN: Matched pair, cluster-randomized controlled trial. SETTING: Uttar Pradesh, India. PARTICIPANTS: 120 government-sector health facilities (60 interventions, 60 controls). Supply-availability surveys were conducted quarterly in all sites. Coaches collected supply procurement sources from intervention sites. INTERVENTIONS: Coaching targeting implementation of Checklist with data feedback and action planning. MAIN OUTCOME MEASURES: Mean supply availability by study arm; change in procurement sources for intervention sites. RESULTS: At baseline, 6 and 12 months, the intervention sites had a mean of 20.9 (95% confidence interval (CI): 20.2-21.5); 22.4 (95% CI: 21.8-22.9) and 22.1 (95% CI:21.4-22.8) items, respectively. Control sites had 20.8 (95% CI: 20.3-21.3); 20.9 (95% CI: 20.3-21.5) and 21.7 (95% CI: 20.8-22.6) items at the same time-points. There was a small but statistically significant higher availability in intervention sites at 6 months (difference-in-difference (DID) = 1.43, P < 0.001), which was not seen by 12 months (DID = 0.37, P = 0.53). Greater difference between intervention and control sites starting in the bottom quartile of supply availability was seen at 6 months (DID = 4.0, P = 0.0002), with no significant difference by 12 months (DID = 1.5, P = 0.154). No change was seen in procurement sources with ~5% procured by patients with some rates as high as 29% (oxytocin). CONCLUSIONS: Implementation of the BetterBirth Program, incorporating supply availability, resulted in modest improvements with catch-up by control facilities by 12 months. Supply-chain coaching may be most beneficial in sites starting with lower supply availability. Efforts are needed to reduce reliance on patient-funding for some critical medications. TRIAL REGISTRATION: ClinicalTrials.gov #NCT02148952; Universal Trial Number: U1111-1131-5647.
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Lista de Checagem , Parto Obstétrico , Equipamentos e Provisões/provisão & distribuição , Melhoria de Qualidade/organização & administração , Feminino , Instalações de Saúde , Humanos , Índia , Recém-Nascido , Tutoria , Gravidez , Setor Público , Organização Mundial da SaúdeRESUMO
PURPOSE: The Statin-Associated Muscle Symptom Clinical Index (SAMS-CI) is a method for assessing the likelihood that a patient's muscle symptoms (e.g., myalgia or myopathy) were caused or worsened by statin use. The objectives of this study were to prepare the SAMS-CI for clinical use, estimate its inter-rater reliability, and collect feedback from physicians on its practical application. METHODS: For content validity, we conducted structured in-depth interviews with its original authors as well as with a panel of independent physicians. Estimation of inter-rater reliability involved an analysis of 30 written clinical cases which were scored by a sample of physicians. A separate group of physicians provided feedback on the clinical use of the SAMS-CI and its potential utility in practice. RESULTS: Qualitative interviews with providers supported the content validity of the SAMS-CI. Feedback on the clinical use of the SAMS-CI included several perceived benefits (such as brevity, clear wording, and simple scoring process) and some possible concerns (workflow issues and applicability in primary care). The inter-rater reliability of the SAMS-CI was estimated to be 0.77 (confidence interval 0.66-0.85), indicating high concordance between raters. With additional provider feedback, a revised SAMS-CI instrument was created suitable for further testing, both in the clinical setting and in prospective validation studies. CONCLUSIONS: With standardized questions, vetted language, easily interpreted scores, and demonstrated reliability, the SAMS aims to estimate the likelihood that a patient's muscle symptoms were attributable to statins. The SAMS-CI may support better detection of statin-associated muscle symptoms in clinical practice, optimize treatment for patients experiencing muscle symptoms, and provide a useful tool for further clinical research.
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Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Músculo Esquelético/efeitos dos fármacos , Mialgia/induzido quimicamente , Inquéritos e Questionários , Retroalimentação Psicológica , Humanos , Entrevistas como Assunto , Idioma , Músculo Esquelético/patologia , Músculo Esquelético/fisiopatologia , Mialgia/diagnóstico , Mialgia/fisiopatologia , Variações Dependentes do Observador , Valor Preditivo dos Testes , Pesquisa Qualitativa , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Fluxo de TrabalhoRESUMO
OBJECTIVES: Intravenous (IV) cannulation is commonly performed in pediatric emergency departments (EDs). The busy ED environment is often not conducive to conventional nonpharmacological pain management. This study assessed the use of Ditto (Diversionary Therapy Technologies, Brisbane, Australia), a handheld electronic device which provides procedural preparation and distraction, as a means of managing pain and distress during IV cannulation performed in the pediatric ED. METHODS: A randomized controlled trial with 98 participants, aged 3 to 12 years, was conducted in a pediatric ED. Participants were recruited and randomized into 5 intervention groups as follows: (1) Standard Distraction, (2) PlayStation Portable Distraction, (3) Ditto Distraction, (4) Ditto Procedural Preparation, and (5) Ditto Preparation and Distraction. Children's pain and distress levels were assessed via self-reports and observational reports by caregivers and nursing staff across the following 3 time points: (1) before, (2) during, and (3) after IV cannulation. RESULTS: Caregivers and nursing staff reported significantly reduced pain and distress levels in children accessing the combined preparation and distraction Ditto protocol, as compared to standard distraction (P ≤ 0.01). This intervention also saw the greatest reduction in pain and distress as reported by the child. CONCLUSIONS: Caregiver reports indicate that using the combined Ditto protocol was most effective in reducing children's pain experiences while undergoing IV cannulation in the ED. The use of Ditto offers a promising opportunity to negotiate barriers to the provision of nonpharmacological approaches encountered in the busy ED environment, and provide nonpharmacological pain-management interventions in pediatric EDs.
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Adaptação Psicológica , Ansiedade/prevenção & controle , Cateterismo/efeitos adversos , Serviço Hospitalar de Emergência , Manejo da Dor/métodos , Pediatria/métodos , Ansiedade/psicologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Medição da Dor , Estudos Prospectivos , Queensland , Sugestão , Resultado do Tratamento , Jogos de VídeoRESUMO
OBJECTIVE: To evaluate the impact of buprenorphine (Butrans®) transdermal System (BTDS) treatment on sleep outcomes for patients with moderate-to-severe chronic low back pain (CLBP). METHODS: Two enriched-enrollment, randomized-withdrawal, double-blind, controlled trials examined BTDS treatment for patients with moderate-to-severe CLBP. Trial I evaluated BTDS 10 and 20 mcg/hour against a placebo control among opioid-naïve patients. Trial II compared BTDS 20 mcg/hour against a lower-dose control (BTDS 5 mcg/hour) among opioid-experienced patients. The patient-reported Medical Outcomes Study Sleep Scale (MOS-SS) assessed overall sleep quality (Sleep Problems Index [SPI]), Disturbance, and other sleep outcomes. In each trial, MOS-SS scores were compared between target treatment and control arms during the 12-week double-blind phase. Correspondence of changes in sleep outcomes and pain severity and the degree to which pain reduction mediates treatment impact on sleep outcomes were examined. RESULTS: Medical Outcomes Study Sleep Scale scores were collected from 541 (Trial I) and 441 (Trial II) patients prior to randomization and from 369 (Trial I) and 274 (Trial II) patients at week 12. Patients receiving target treatment showed statistically significantly more improvement in SPI and Disturbance scores at 12 weeks than their respective controls (Ps < 0.05). Improvements in SPI and Disturbance for target treatment arms were statistically larger those of the controls by week 4 of the double-blind phase. The clinical significance of these differences was not determined. Pain reduction predicted improvements in sleep outcomes. CONCLUSION: Buprenorphine Transdermal System improved sleep quality and disturbance for opioid-naïve and opioid-experienced patients with moderate-to-severe CLBP. Benefits of BTDS for these sleep outcomes emerged within 4 weeks and were maintained over the entire 12-week treatment period.
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Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Buprenorfina/administração & dosagem , Buprenorfina/uso terapêutico , Dor Lombar/complicações , Dor Lombar/tratamento farmacológico , Transtornos do Sono-Vigília/prevenção & controle , Sono/efeitos dos fármacos , Administração Cutânea , Adulto , Idoso , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Transtornos do Sono-Vigília/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: Chronic pain (CP) patients with depression typically exhibit worse post-treatment outcomes than nondepressed CP patients. The cause is often assumed to reflect a differential response to treatment, neglecting other potential explanations, such as the continuation of differences in pretreatment outcomes. This post hoc analysis examines whether worse post-treatment outcomes for depressed patients with chronic low back pain (CLBP) are driven by reduced treatment efficacy. METHODS: Data were from opioid-naïve adult patients with moderate-to-severe CLBP who participated in a randomized, placebo-controlled, double-blind clinical trial of Butrans(®) (buprenorphine) Transdermal System (BTDS) for pain relief. Depression screening was based on baseline SF-36v2 Mental Health subscale scores. Patient-reported measures of pain severity, pain interference, quality of life, sleep problems, and functional disability were administered at screening and during the study. Differential treatment efficacy for each outcome was examined using analysis of covariance models that included interaction terms between treatment arm and depression status. RESULTS: At baseline, patients classified as depressed showed greater pain interference, lower quality of life, more sleep problems, and greater functional disability than nondepressed patients; the two groups did not differ in pain severity. No statistically significant interactions between treatment arm and depression status were observed. The direction of improvement post-treatment favored the depressed group on nine of seventeen outcomes. CONCLUSIONS: Results do not support a differential response to BTDS treatment between depressed and nondepressed CLBP patients across a variety of patient-reported outcomes. These findings raise the question of whether depressed mood actually moderates the effectiveness of treatment in CP patients.
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Analgésicos Opioides/administração & dosagem , Buprenorfina/administração & dosagem , Depressão/complicações , Dor Lombar/tratamento farmacológico , Dor Lombar/psicologia , Administração Cutânea , Adulto , Dor Crônica/tratamento farmacológico , Dor Crônica/psicologia , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Qualidade de Vida , Resultado do TratamentoRESUMO
We examined the effects of the Zemko Dam removal on the Eightmile River system in Salem, Connecticut, USA. The objective of this research was to quantify spatiotemporal variation in fish community composition in response to small dam removal. We sampled fish abundance over a 6-year period (2005-2010) to quantify changes in fish assemblages prior to dam removal, during drawdown, and for three years following dam removal. Fish population dynamics were examined above the dam, below the dam, and at two reference sites by indicator species analysis, mixed models, non-metric multidimensional scaling, and analysis of similarity. We observed significant shifts in fish relative abundance over time in response to dam removal. Changes in fish species composition were variable, and they occurred within 1 year of drawdown. A complete shift from lentic to lotic fishes failed to occur within 3 years after the dam was removed. However, we did observe increases in fluvial and transition (i.e., pool head, pool tail, or run) specialist fishes both upstream and downstream from the former dam site. Our results demonstrate the importance of dam removal for restoring river connectivity for fish movement. While the long-term effects of dam removal remain uncertain, we conclude that dam removals can have positive benefits on fish assemblages by enhancing river connectivity and fluvial habitat availability.
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Conservação dos Recursos Naturais/métodos , Ecossistema , Peixes/crescimento & desenvolvimento , Rios , Movimentos da Água , Animais , Biodiversidade , Connecticut , Modelos Teóricos , Dinâmica Populacional , Especificidade da EspécieRESUMO
BACKGROUND: Prior studies demonstrate that 20%-50% of adolescents and young adults (age 15-39 years) with acute lymphoblastic leukemia (ALL) receive care at specialty cancer centers, yet a survival benefit has been observed for patients at these sites. Our objective was to identify patients at risk of severe geographic barriers to specialty cancer center-level care. METHODS: We used data from the North American Association of Central Cancer Registries Cancer in North America database to identify adolescent and young adult ALL patients diagnosed between 2004 and 2016 across 43 US states. We calculated driving distance and travel time from counties where participants lived to the closest specialty cancer center sites. We then used multivariable logistic regression models to examine the relationship between sociodemographic characteristics of counties where adolescent and young adult ALL patients resided and the need to travel more than 1 hour to obtain care at a specialty cancer center. RESULTS: Among 11â813 adolescent and young adult ALL patients, 43.4% were aged 25-39 years, 65.5% were male, 32.9% were Hispanic, and 28.7% had public insurance. We found 23.6% of adolescent and young adult ALL patients from 60.8% of included US counties would be required to travel more than 1 hour one way to access a specialty cancer center. Multivariable models demonstrate that patients living in counties that are nonmetropolitan, with lower levels of educational attainment, with higher income inequality, with lower internet access, located in primary care physician shortage areas, and with fewer hospitals providing chemotherapy services are more likely to travel more than 1 hour to access a specialty cancer center. CONCLUSIONS: Substantial travel-related barriers exist to accessing care at specialty cancer centers across the United States, particularly for patients living in areas with greater concentrations of historically marginalized communities.
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Institutos de Câncer , Acessibilidade aos Serviços de Saúde , Leucemia-Linfoma Linfoblástico de Células Precursoras , Viagem , Humanos , Adolescente , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Masculino , Feminino , Adulto Jovem , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Adulto , Viagem/estatística & dados numéricos , Estados Unidos , Institutos de Câncer/estatística & dados numéricos , Fatores de Tempo , Modelos Logísticos , Sistema de RegistrosRESUMO
Importance: Infections and complications following cesarean delivery are a significant source of maternal mortality in Ethiopia. Objective: To study the effectiveness of a program to strengthen compliance with perioperative standards and reduce postoperative complications following cesarean delivery. Design, Setting, and Participants: This stepped-wedge cluster randomized clinical trial included patients undergoing cesarean delivery from August 24, 2021, to January 31, 2023, at 9 hospitals organized into 5 clusters in Ethiopia. Intervention: Clean Cut, a multimodal surgical quality improvement program that includes process-mapping 6 perioperative standards and creating site-specific, systems-level improvements. The control period was the period before implementation of the intervention. Main Outcomes and Measures: The primary end point was surgical site infection rate, and secondary end points were maternal mortality and perinatal mortality and a composite outcome of infections and both mortality outcomes. All were assessed at 30 days postoperatively in the intervention and control groups, adjusting for clustering and demographics. Compliance with standards and the relationship between compliance and outcomes were also compared between the 2 arms. Results: Among 9755 women undergoing cesarean delivery, 5099 deliveries (52.3%) occurred during the control period (2722 emergency cases [53.4%]) and 4656 (47.7%) during the intervention period (2346 emergency cases [50.4%]). Mean (SD) patient age was 27.04 (0.05) years. Thirty-day follow-up was completed for 5153 patients (52.8%). No significant reduction in infection rates was detected after the intervention (OR, 0.84; 95% CI, 0.55-1.27; P = .40). Intraoperative infection prevention standards improved significantly in the intervention arm vs control arm for compliance with at least 5 of the 6 standards (odds ratio [OR], 2.95; 95% CI, 2.40-3.62; P < .001). Regardless of trial arm, high compliance was associated with reduced odds of maternal (OR, 0.32; 95% CI, 0.11-0.93; P = .04) and perinatal (OR, 0.64; 95% CI, 0.47-0.89; P = .008) mortality. Conclusions and Relevance: In this stepped-wedge cluster randomized clinical trial of patients undergoing cesarean delivery, no significant reductions in surgical site infections were observed. However, compliance with perioperative standards improved following the intervention. Trial Registration: ClinicalTrials.gov Identifier: NCT04812522; Pan-African Clinical Trials Registry Identifier: PACTR202108717887402.
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Cesárea , Mortalidade Materna , Melhoria de Qualidade , Humanos , Feminino , Cesárea/efeitos adversos , Etiópia/epidemiologia , Gravidez , Adulto , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/epidemiologia , Assistência Perioperatória/normas , Assistência Perioperatória/métodos , Mortalidade Perinatal , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Análise por Conglomerados , Adulto JovemRESUMO
OBJECTIVE: To estimate clinical and social benchmarks for interpretation of score differences on the Short-Form 36 Health Survey, and apply these benchmarks to populations with diabetes mellitus (DM). METHODS: Using survival and logistic regression models, we reanalyzed data from three US cohorts: the Medical Outcomes Study (N = 3,445; 541 patients with DM), the Medicare Health Outcomes Survey (N = 78,183; 16,388 patients with DM), and the QualityMetric 2009 Norming Study (N = 4,040; 580 patients with DM). Outcome variables were mortality, hospitalization, current inability to work, and loss of ability to work. RESULTS: Benchmarks were robust across disease groups, but varied according to age and score level. A 1-point lower score on the Physical Function, General Health, and Physical Component Summary scales was associated with a 1.05 to 1.09 relative risk (RR) of mortality for the typical patient with DM, with stronger associations in the younger age groups. For several scales (Physical Function, Role Physical, Bodily Pain, General Health, Vitality, Social Function, and Role Emotional), the associations with mortality also depended on score level, with stronger associations in the lower score ranges (i.e., patients in worse health). A 1-point lower score on the Physical Function, Role Physical, Bodily Pain, General Health, Vitality, Social Function, and Physical Component Summary scales implied a 1.02 to 1.04 RR of hospitalization, a 1.07 to 1.12 RR of being unable to work, and a 1.04 to 1.07 RR of losing the ability to work. CONCLUSIONS: A 1-point lower score on selected Short-Form 36 Health Survey scales is associated with an excess risk of up to 9% for mortality and 12% for inability to work.
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Benchmarking , Interpretação Estatística de Dados , Diabetes Mellitus , Nível de Saúde , Qualidade de Vida , Inquéritos e Questionários/normas , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados UnidosRESUMO
Importance: Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system. Objective: To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded. Design, Settings, and Participants: This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023. Exposures: Acute painful traumatic injuries including burns. Main Outcomes and Measures: Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine. Results: The study cohort included 4â¯781â¯396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2â¯497â¯053 female [52.2%]; 31â¯266 American Indian or Alaskan Native [0.7%]; 59â¯713 Asian [1.2%]; 742â¯931 Black [15.5%], 411â¯934 Hispanic or Latino [8.6%], 10â¯747 Native Hawaiian or other Pacific Islander [0.2%]; 2â¯764â¯499 White [57.8%]; 16â¯161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients. Conclusions and Relevance: In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.
Assuntos
Analgésicos Opioides , Serviços Médicos de Emergência , Disparidades em Assistência à Saúde , Ketamina , Dor , Ferimentos e Lesões , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Analgesia , Analgésicos Opioides/uso terapêutico , Negro ou Afro-Americano , Estudos de Coortes , Serviços Médicos de Emergência/estatística & dados numéricos , Etnicidade , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Ketamina/uso terapêutico , Grupos Minoritários , Dor/tratamento farmacológico , Dor/etiologia , Manejo da Dor , Ferimentos e Lesões/complicações , Ferimentos e Lesões/etnologia , Masculino , Adulto , Adolescente , Adulto Jovem , Idoso de 80 Anos ou mais , Estados Unidos/epidemiologia , Asiático/estatística & dados numéricos , Brancos/estatística & dados numéricos , Indígena Americano ou Nativo do Alasca/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Havaiano Nativo ou Outro Ilhéu do Pacífico/estatística & dados numéricosRESUMO
PURPOSE: Unlike children with ALL who receive cancer care primarily at specialized cancer centers (SCCs; National Cancer Institute and/or Children's Oncology Group centers), adolescents and young adults (AYAs; 15-39 years) receive care in a variety of settings. Using population-based data, we describe where AYAs with ALL receive treatment and determine associations with overall survival (OS). METHODS: Data from the 2004 to 2018 California (CA, n = 2,283), New York (NY, n = 795), and Texas (TX, n = 955) state cancer registries were used to identify treatment setting of AYAs with newly diagnosed ALL. Multivariable Cox proportional hazards regression models evaluated associations with OS. RESULTS: Seventy percent were older than 18 years, and 65% were male. A majority in CA (63%) and TX (64%) were Hispanic while most in NY were non-Hispanic White (50%). Treatment at an SCC occurred in 48.2% (CA), 44.4% (NY), and 19.5% (TX). Across states, AYAs who were older or uninsured were less likely to receive treatment at an SCC. Treatment at an SCC was associated with superior OS in CA (hazard ratio [HR], 0.73; 95% CI, 0.63 to 0.85) and TX (HR, 0.61; 95% CI, 0.45 to 0.83); a nonsignificant association was seen in NY (HR, 0.83; 95% CI, 0.64 to 1.08). CONCLUSION: Only 20%-50% of AYA patients with ALL received frontline treatment at SCCs. Treatment of ALL at an SCC was associated with superior survival, highlighting the importance of policy efforts to improve access and reduce inequities in AYA ALL care.
Assuntos
Leucemia-Linfoma Linfoblástico de Células Precursoras , Taxa de Sobrevida , Adolescente , Feminino , Humanos , Masculino , Adulto Jovem , Pessoas sem Cobertura de Seguro de Saúde , Modelos de Riscos Proporcionais , Adulto , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapiaRESUMO
Aging is characterized by chronic systemic inflammation and metabolic changes. When we compared B cells from young and elderly donors, we found that aging induces higher oxygen consumption rates, and especially higher extracellular acidification rates, measures of oxidative phosphorylation and of anaerobic glycolysis, respectively. Importantly, this higher metabolic status, which reflects the age-associated expansion of pro-inflammatory B cell subsets, was found associated with higher secretion of lactate and autoimmune antibodies after in vitro stimulation. B cells from elderly individuals, induce in vitro generation of pro-inflammatory CD4+ T cells from young individuals through metabolic pathways mediated by lactate secretion. Lactate also induces immunosenescent B cells that are glycolytic and express transcripts for multiple pro-inflammatory molecules. These results altogether may have relevant clinical implications and suggest novel targets for therapeutic interventions in patients with inflammatory conditions and diseases.
RESUMO
We compared four methods to screen emergency department (ED) patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI) in a 5-year retrospective cohort through observed practice, objective application of screening protocol criteria, a predictive model, and a model augmenting human practice. We measured screening performance by sensitivity, missed acute coronary syndrome (ACS) and STEMI, and the number of ECGs required. Our cohort of 279,132 ED visits included 1397 patients who had a diagnosis of ACS. We found that screening by observed practice augmented with the model delivered the highest sensitivity for detecting ACS (92.9%, 95%CI: 91.4-94.2%) and showed little variation across sex, race, ethnicity, language, and age, demonstrating equity. Although it missed a few cases of ACS (7.6%) and STEMI (4.4%), it did require ECGs on an additional 11.1% of patients compared to current practice. Screening by protocol performed the worst, underdiagnosing young, Black, Native American, Alaskan or Hawaiian/Pacific Islander, and Hispanic patients. Thus, adding a predictive model to augment human practice improved the detection of ACS and STEMI and did so most equitably across the groups. Hence, combining human and model screening--rather than relying on either alone--may maximize ACS screening performance and equity.