The role of community-level characteristics in comparing United States hospital performance by magnet designation: A propensity score matched study.

AIMS: To assess the impact of community-level characteristics on the role of magnet designation in relation to hospital value-based purchasing quality scores, as health disparities associated with geographical location could confound hospitals' ability to meet outcome metrics. DESIGN: This cross-sectional study was carried out between October 2021 and March 2022 using data from 2016 to 2021. METHODS: Propensity score analysis was used to match hospital and community-level characteristics, implementing nearest neighbour matching to adjust for pre-treatment differences between magnet and non-magnet hospitals to account for multi-level differences. Secondary data were obtained from all operational acute-care facilities in the United States that participated in the Centers for Medicare and Medicaid Services' hospital value-based purchasing (HVBP) program. Dependent variables were the four value-based purchasing domains that comprise the Total Performance Score (TPS; Clinical Care, Person and Community Engagement, Safety, and Efficiency and Cost Reduction). RESULTS: Magnet hospitals had increased odds for better scores in the HVBP domains of Clinical Care and Person and Community Engagement, and decreased odds for having better Safety. However, no statistically significant difference was found for the Efficiency domain or the TPS. CONCLUSION: Measuring performance equitably across organizations of various sizes serving diverse communities remains a key factor in ensuring distributive justice. Analysing the TPS components can identify complex influences of community-level characteristics not evident at the composite level. More research is needed where community and nurse-level factors may indirectly affect patient safety. IMPACT: This study's findings on the role of community contexts can inform policymakers designing value-based care programs and healthcare management administrators deliberating on magnet certification investments across diverse community settings. NO PATIENT OR PUBLIC CONTRIBUTION: For this study of US hospitals' organizational performance, we did not engage members of the patient population nor the general public. However, the multi-disciplinary research team does include diverse perspectives.

Financial Hardship Among Nonelderly Adults With CKD in the United States.

RATIONALE & OBJECTIVE: The burden of financial hardship among individuals with chronic kidney disease (CKD) has not been extensively studied. Therefore, we describe the scope and determinants of financial hardship among a nationally representative sample of adults with CKD. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: Nonelderly adults with CKD from the 2014-2018 National Health Interview Survey. EXPOSURE: Sociodemographic and clinical characteristics. OUTCOME: Financial hardship based on medical bills and consequences of financial hardship (high financial distress, food insecurity, cost-related medication nonadherence, delayed/forgone care due to cost). Financial hardship was categorized into 3 levels: no financial hardship, financial hardship but able to pay bills, and unable to pay bills at all. Financial hardship was then modeled in 2 different ways: (1) any financial hardship (regardless of ability to pay) versus no financial hardship and (2) inability to pay bills versus no financial hardship and financial hardship but able to pay bills. ANALYTICAL APPROACH: Nationally representative estimates of financial hardship from medical bills were computed. Multivariable logistic regression models were used to examine the associations of sociodemographic and clinical factors with the outcomes of financial hardship based on medical bills. RESULTS: A total 1,425 individuals, representing approximately 2.1 million Americans, reported a diagnosis of CKD within the past year, of whom 46.9% (95% CI, 43.7%-50.2%) reported experiencing financial hardship from medical bills; 20.9% (95% CI, 18.5%-23.6%) reported inability to pay medical bills at all. Lack of insurance was the strongest determinant of financial hardship in this population (odds ratio, 4.06 [95% CI, 2.18-7.56]). LIMITATIONS: Self-reported nature of CKD diagnosis. CONCLUSIONS: Approximately half the nonelderly US population with CKD experiences financial hardship from medical bills that is associated strongly with lack of insurance. Evidence-based clinical and policy interventions are needed to address these hardships.

Donation after circulatory death liver transplantation: An in-depth analysis and propensity score-matched comparison.

BACKGROUND: Careful donor-recipient matching and reduced ischemia times have improved outcomes following donation after circulatory death (DCD) liver transplantation (LT). This study examines a single-center experience with DCD LT including high-acuity and hospitalized recipients. METHODS: DCD LT outcomes were compared to a propensity score-matched (PSM) donation after brain death (DBD) LT cohort (1:4); 32 DCD LT patients and 128 PSM DBD LT patients transplanted from 2008 to 2018 were included. Analyses included Kaplan-Meier estimates and Cox proportional hazards models examining patient and graft survival. RESULTS: Median MELD score in the DCD LT cohort was 22, with median MELD of 27 for DCD LT recipients with decompensated cirrhosis. No difference in mortality or graft loss was found (p < .05) between DCD LT and PSM DBD LT at 3 years post-transplant, nor was DCD an independent risk factor for patient or graft survival. Post-LT severe acute kidney injury was similar in both groups. Ischemic-type biliary lesions (ITBL) occurred in 6.3% (n = 2) of DCD LT recipients, resulting in 1 graft loss and 1 death. CONCLUSION: This study supports that DCD LT outcomes can be similar to DBD LT, with a low rate of ITBL, in a cohort including high-acuity recipients. Strict donor selection criteria, ischemia time minimization, and avoiding futile donor/recipient combinations are essential considerations.

Quantifying Patient Portal Use: Systematic Review of Utilization Metrics.

BACKGROUND: Use of patient portals has been associated with positive outcomes in patient engagement and satisfaction. Portal studies have also connected portal use, as well as the nature of users' interactions with portals, and the contents of their generated data to meaningful cost and quality outcomes. Incentive programs in the United States have encouraged uptake of health information technology, including patient portals, by setting standards for meaningful use of such technology. However, despite widespread interest in patient portal use and adoption, studies on patient portals differ in actual metrics used to operationalize and track utilization, leading to unsystematic and incommensurable characterizations of use. No known review has systematically assessed the measurements used to investigate patient portal utilization. OBJECTIVE: The objective of this study was to apply systematic review criteria to identify and compare methods for quantifying and reporting patient portal use. METHODS: Original studies with quantifiable metrics of portal use published in English between 2014 and the search date of October 17, 2018, were obtained from PubMed using the Medical Subject Heading term "Patient Portals" and related keyword searches. The first search round included full text review of all results to confirm a priori data charting elements of interest and suggest additional categories inductively; this round was supplemented by the retrieval of works cited in systematic reviews (based on title screening of all citations). An additional search round included broader keywords identified during the full-text review of the first round. Second round results were screened at abstract level for inclusion and confirmed by at least two raters. Included studies were analyzed for metrics related to basic use/adoption, frequency of use, duration metrics, intensity of use, and stratification of users into "super user" or high utilizers. Additional categories related to provider (including care team/administrative) use of the portal were identified inductively. Additional analyses included metrics aligned with meaningful use stage 2 (MU-2) categories employed by the US Centers for Medicare and Medicaid Services and the association between the number of portal metrics examined and the number of citations and the journal impact factor. RESULTS: Of 315 distinct search results, 87 met the inclusion criteria. Of the a priori metrics, plus provider use, most studies included either three (26 studies, 30%) or four (23 studies, 26%) metrics. Nine studies (10%) only reported the patient use/adoption metric and only one study (1%) reported all six metrics. Of the US-based studies (n=76), 18 (24%) were explicitly motivated by MU-2 compliance; 40 studies (53%) at least mentioned these incentives, but only 6 studies (8%) presented metrics from which compliance rates could be inferred. Finally, the number of metrics examined was not associated with either the number of citations or the publishing journal's impact factor. CONCLUSIONS: Portal utilization measures in the research literature can fall below established standards for "meaningful" or they can substantively exceed those standards in the type and number of utilization properties measured. Understanding how patient portal use has been defined and operationalized may encourage more consistent, well-defined, and perhaps more meaningful standards for utilization, informing future portal development.

Assessing Patient Needs During Natural Disasters: Mixed Methods Analysis of Portal Messages Sent During Hurricane Harvey.

BACKGROUND: Patient portals play an important role in connecting patients with their medical care team, which improves patient engagement in treatment plans, decreases unnecessary visits, and reduces costs. During natural disasters, patients' needs increase, whereas available resources, specifically access to care, become limited. OBJECTIVE: This study aims to examine patients' health needs during a natural crisis by analyzing the electronic messages sent during Hurricane Harvey to guide future disaster planning efforts. METHODS: We explored patient portal use data from a large Greater Houston area health care system focusing on the initial week of the Hurricane Harvey disaster, beginning with the date of landfall, August 25, 2017, to August 31, 2017. A mixed methods approach was used to assess patients' immediate health needs and concerns during the disruption of access to routine and emergent medical care. Quantitative analysis used logistic regression models to assess the predictive characteristics of patients using the portal during Hurricane Harvey. This study also included encounters by type (emergency, inpatient, observation, outpatient, and outpatient surgery) and time (before, during, and after Hurricane Harvey). For qualitative analysis, the content of these messages was examined using the constant comparative method to identify emerging themes found within the message texts. RESULTS: Out of a total of 557,024 patients, 4079 (0.73%) sent a message during Hurricane Harvey, whereas 31,737 (5.69%) used the portal. Age, sex, race, and ethnicity were predictive factors for using the portal and sending a message during the natural disaster. We found that prior use of the patient portal increased the likelihood of portal use during Hurricane Harvey (odds ratio 13.688, 95% CI 12.929-14.491) and of sending a portal message during the disaster (odds ratio 14.172, 95% CI 11.879-16.907). Having an encounter 4 weeks before or after Hurricane Harvey was positively associated with increased use of the portal and sending a portal message. Patients with encounters during the main Hurricane Harvey week had a higher increased likelihood of portal use across all five encounter types. Qualitative themes included: access, prescription requests, medical advice (chronic conditions, acute care, urgent needs, and Hurricane Harvey-related injuries), mental health, technical difficulties, and provider constraints. CONCLUSIONS: The patient portal can be a useful tool for communication between patients and providers to address the urgent needs and concerns of patients as a natural disaster unfolds. This was the first known study to include encounter data to understand portal use compared with care provisioning. Prior use was predictive of both portal use and message sending during Hurricane Harvey. These findings could inform the types of demands that may arise in future disaster situations and can serve as the first step in intentionally optimizing patient portal usability for emergency health care management during natural disasters.

Bariatric Surgery in End-Stage Heart Failure: Feasibility in Successful Attainment of a Target Body Mass Index.

INTRODUCTION: Orthotopic heart transplantation (OHT) is contraindicated in morbidly obese patients with end-stage heart failure (HF), for whom cardiac allograft is the only means for long-term survival. Bariatric surgery may allow them to achieve target body mass index (BMI) for OHT METHODS: From 4/2014 to 12/2018, 26 morbidly obese HF patients who did not meet BMI eligibility criteria for OHT underwent laparoscopic bariatric surgery. Outcomes of interest were median difference in BMI, number of patients achieving target BMI for OHT, and 30-day mortality. RESULTS: Median age was 49 (IQR 14) years, and 13 (50%) were women. HF was mainly systolic (15 patients, 58%). The median LVEF was 27% (IQR 37%). At the time of bariatric surgery, 12 (46%) patients had mechanical circulatory support: 2 (8%) concomitant left ventricular assist device (LVAD) placements, 8 (31%) LVAD already-in-place, and 2 (8%) intra-aortic balloon pumps. There was no 30-day mortality, but one mortality on postoperative day 48. Over a median follow-up of 6 months (range 0-36 months, IQR 17), there was a significant reduction in BMI (p<0.0001). The median postoperative BMI was 36.7 (IQR 8.7), compared to preoperative median BMI of 42.7 (IQR 9.4). Target BMI of < 35 was achieved in 11 (42%) patients. Three patients (12%) have undergone OHT. CONCLUSION: Bariatric surgery in end-stage HF is feasible and results in a high number of patients achieving target BMI, increasing their probability of undergoing OHT. The presence of a LVAD should not preclude these patients from undergoing a bariatric intervention.

Relation between surgeon age and postoperative outcomes: a population-based cohort study.

BACKGROUND: Aging may detrimentally affect cognitive and motor function. However, age is also associated with experience, and how these factors interplay and affect outcomes following surgery is unclear. We sought to evaluate the effect of surgeon age on postoperative outcomes in patients undergoing common surgical procedures. METHODS: We performed a retrospective cohort study of patients undergoing 1 of 25 common surgical procedures in Ontario, Canada, from 2007 to 2015. We evaluated the association between surgeon age and a composite outcome of death, readmission and complications. We used generalized estimating equations for analysis, accounting for relevant patient-, procedure-, surgeon- and hospital-level factors. RESULTS: We found 1 159 676 eligible patients who were treated by 3314 surgeons and ranged in age from 27 to 81 years. Modelled as a continuous variable, a 10-year increase in surgeon age was associated with a 5% relative decreased odds of the composite outcome (adjusted odds ratio [OR] 0.95, 95% confidence interval [CI] 0.92 to 0.98, p = 0.002). Considered dichotomously, patients receiving treatment from surgeons who were older than 65 years of age had a 7% lower odds of adverse outcomes (adjusted OR 0.93, 95% CI 0.88-0.97, p = 0.03; crude absolute difference = 3.1%). INTERPRETATION: We found that increasing surgeon age was associated with decreasing rates of postoperative death, readmission and complications in a nearly linear fashion after accounting for patient-, procedure-, surgeon- and hospital-level factors. Further evaluation of the mechanisms underlying these findings may help to improve patient safety and outcomes, and inform policy about maintenance of certification and retirement age for surgeons.

Post-bariatric surgery lab tests: are they excessive and redundant?

INTRODUCTION: Following bariatric surgery, ongoing postoperative testing is required to measure nutritional deficiencies; the purpose of this study was to quantify the prevalence of these nutritional deficiencies based on two-year follow-up tests at recommended time points. METHODS AND PROCEDURES: A retrospective data analysis was conducted of all laboratory tests for bariatric patients who underwent surgery between May 2016 and January 2018 with available lab data (n = 397). Results for nine different nutritional labs were categorized into six recommended postoperative time periods based on time elapsed since the procedure date. Binary variables were created for each laboratory result to calculate descriptive statistics of abnormalities for each lab test over time and used in the individual GEE logistic regression models. Grouped logistic regression examined the total nutritional deficiencies of the nine combined nutrients considering total available labs. RESULTS: Multiple lab tests indicated a very low frequency of abnormalities (e.g., Vitamin A, Vitamin B12, Copper, and Folate). Many of the nine included nutritional labs had an average deficiency of less than 10% across all time points. The grouped logistic model found preoperative nutritional deficiency to be predictive of postoperative nutritional deficiency (OR 3.70, p < 0.001). CONCLUSIONS: We found the vast majority of routine lab test results to be normal at multiple time points. Current practice can add up to significant lab expenses over time. The frequency of postoperative testing in this population may be redundant and of very little value. Unnecessary follow-up laboratory testing costs the patients and the health care system in both time and resources. Patients with preoperative deficiencies appear to be at higher risk for nutritional deficiencies when compared to bariatric surgery patients that did not have preoperative nutritional deficiencies. Future research should focus on defining cost effective postoperative lab testing guidelines for at risk bariatric patients.

Growth Dynamics of Patient-Provider Internet Communication: Trend Analysis Using the Health Information National Trends Survey (2003 to 2013).

BACKGROUND: Communication is key in chronic disease management, and the internet has altered the manner in which patients and providers can exchange information. Adoption of secure messaging differs among patients due to the digital divide that keeps some populations from having effective access to online resources. OBJECTIVE: This study aimed to examine the current state of online patient-provider communication, exploring trends over time in the use of online patient-provider communication tools. METHODS: A 3-part analytic process was used to study the following: (1) reanalysis, (2) close replication across years, and (3) trend analysis extension. During the reanalysis stage, the publicly available Health Information National Trends Survey (HINTS) 1 and 2 data were used with the goal of identifying the precise analytic methodology used in a prior study, published in 2007. The original analysis was extended to add 3 additional data years (ie, 2008, 2011, and 2013) using the original analytical approach with the purpose of identifying trends over time. Multivariate logistic regression was used to analyze pooled data across all years, with year as an added predictor, in addition to a model for each individual data year. RESULTS: The odds of internet users to communicate online with health care providers was significantly and increasingly higher year-over-year, starting in 2003 (2005: odds ratio [OR] 1.31, 95% CI 1.03-1.68; 2008: OR 2.14, 95% CI 1.76-2.59; 2011: OR 2.92, 95% CI 2.33-3.66; and 2013: OR 5.77; 95% CI 4.62-7.20). Statistically significant socio-economic factors found to be associated with internet users communicating online with providers included age, having health insurance, having a history of cancer, and living in an urban area of residence. CONCLUSIONS: The proportion of internet users communicating online with their health care providers has significantly increased since 2003. Although these trends are encouraging, access challenges still exist for some groups, potentially giving rise to a new set of health disparities related to communication.

An Organizational Intervention to Reduce Physician Burnout.

EXECUTIVE SUMMARY: Burnout is an individual's specific, personal, and intimate stress reaction to the workplace, characterized by emotional exhaustion, depersonalization, and reduced self-efficacy. Even though it particularly affects the helping professions, there has been relatively little exploration into the causes and determinants of burnout among physicians; instead, the focus has been on documenting the prevalence and consequences of physician burnout. Furthermore, while the theory of burnout is based on the relationship between the individual and his or her workplace, interventions have focused on improving the resilience of an individual to withstand this imbalance rather than identifying and ameliorating the cause.This study observed a natural experiment to measure changes in primary care providers' burnout before and after the implementation of a workload intervention that changed the work process within primary care clinics. Four clinics received the intervention, while four others served as comparisons. Among physicians in clinics receiving the intervention, the results show significant impacts, with an improvement in workload of 0.61 units (p = 0.037) and a decrease in the emotional exhaustion dimension of burnout of 6.989 units (p = 0.039).Self-care interventions are inconsistent with the theory of burnout; success of such interventions may be due to participants self-selecting these interventions, and individuals' inability to change their workplace without management approval. Leaders need to consider the impact of the workplace itself on physicians, in addition to results or outcomes.

Burnout Among Primary Care Physicians: A Test of the Areas of Worklife Model.

Examinations of the current state of the physician workforce, in the United States and globally, indicate a declining overall well-being, and specifically increasing levels of burnout. The consequences of these effects include early retirements or exits from the medical profession, difficulties improving the patient experience, and low levels of provider engagement with clinic-level and system-level initiatives. Such consequences affect physicians, healthcare organizations, and patients. While most research has focused on identifying burnout, cataloging its effects, and creating a case for attending to its impact, relatively few studies have focused on exploring the antecedents of burnout for physicians. The goal of this study was to test an etiological model, the Areas of Worklife Scale (AWS), for practicing primary care physicians. Using the AWS and the Maslach Burnout Inventory, the study used a longitudinal survey research design method to query primary care physicians employed at a large integrated delivery system in the United States. Data collected successfully fit the AWS model for burnout among primary care physicians, supporting our theory that workplace drivers are responsible for burnout. Workload, control, and values congruence are the largest drivers of burnout for practicing primary care physicians. The AWS model provides key insights into the domains of work that cause stress and ultimately burnout for physicians, and these domains can guide physicians and managers to develop interventions to fight the rising incidence of burnout.

The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes.

UNLABELLED: Policy Points: The perioperative surgical home (PSH) is complementary to the patient-centered medical home (PCMH) and defines methods for improving the patient experience and clinical outcomes, and controlling costs for the care of surgical patients. The PSH is a physician-led care delivery model that includes multi-specialty care teams and cost-efficient use of resources at all levels through a patient-centered, continuity of care delivery model with shared decision making. The PSH emphasizes "prehabilitation" of the patient before surgery, intraoperative optimization, improved return to function through follow-up, and effective transitions to home or post-acute care to reduce complications and readmissions. CONTEXT: The evolving concept of more rigorously coordinated and integrated perioperative management, often referred to as the perioperative surgical home (PSH), parallels the well-known concept of a patient-centered medical home (PCMH), as they share a vision of improved clinical outcomes and reductions in cost of care through patient engagement and care coordination. Elements of the PSH and similar surgical care coordination models have been studied in the United States and other countries. METHODS: This comprehensive review of peer-reviewed literature investigates the history and evolution of PSH and PSH-like models and summarizes the results of studies of PSH elements in the United States and in other countries. We reviewed more than 250 potentially relevant studies. At the conclusion of the selection process, our search had yielded a total of 152 peer-reviewed articles published between 1980 and 2013. FINDINGS: The literature reports consistent and significant positive findings related to PSH initiatives. Both US and non-US studies stress the role of anesthesiologists in perioperative patient management. The PSH may have the greatest impact on preparing patients for surgery and ensuring their safe and effective transition to home or other postoperative rehabilitation. There appear to be some subtle differences between US and non-US research on the PSH. The literature in non-US settings seems to focus strictly on the comparison of outcomes from changing policies or practices, whereas US research seems to be more focused on the discovery of innovative practice models and other less direct changes, for example, information technology, that may be contributing to the evolution toward the PSH model. CONCLUSIONS: The PSH model may have significant implications for policymakers, payers, administrators, clinicians, and patients. The potential for policy-relevant cost savings and quality improvement is apparent across the perioperative continuum of care, especially for integrated care organizations, bundled payment, and value-based purchasing.

Multiproject interdependencies in health systems management: a longitudinal qualitative study.

BACKGROUND: A health care organization often engages in the simultaneous implementation of multiple organization change initiatives. However, the degree to which these initiatives are implemented and can be enhanced based on their interdependencies is an open question. How organizations and the change initiatives they pursue might benefit from more careful examination of potential interdependencies among projects was explored in this article. PURPOSE: The aim of this study was to introduce a multiproject management conceptualization that stresses project interdependencies and suggests synergies can be found to enhance overall project and organizational performance. It examines this conceptualization in the context of a health system pursuing several major initiatives to capture insights into the nature of such interdependencies. METHODOLOGY/APPROACH: Longitudinal qualitative analysis of interviews conducted with hospital leaders attempting to manage multiple initiatives being implemented by the system's leadership team was used in this study. FINDINGS: The implementation of an electronic medical record (EMR) is empirically identified as the most central among multiple projects based on other projects dependencies on the EMR. Furthermore, concerns for data are identified most frequently as success factors across all projects. This reinforces the depiction of the EMR as a central organizational focus. PRACTICAL IMPLICATIONS: A unique perspective on multiproject management in hospitals and on EMR projects is presented. In addition, the interdependency conceptualization and its application and results provide insights into multiproject management that can help ensure that benefits of individual projects are more fully optimized or exploited in leveraging the effectiveness of other project initiatives.

COVID-19 and communication: A sentiment analysis of US state governors' official press releases.

OBJECTIVES: This study examines the contents of official communication from United States governors' offices related to the COVID-19 pandemic to assess patterns in communication and to determine if they correlate with trends for COVID cases and deaths. METHODS: We collected text data for all COVID-19 related press releases between March 1 and December 31, 2020 from the US governors' office websites in all 50 states. An automated parsing and sentiment analyzer assessed descriptive statistics and trends in tone, including positivity and negativity. RESULTS: We included a total of 7,720 press releases in this study. We found that both positive and negative sentiments were homogenous across states at the beginning of the pandemic but became heterogeneous as the pandemic evolved. The same trend applied to the frequency and tone of press releases. Sentiments across states were overall positive with a small level of negativity. We observed a reactive official communication to the evolution of the number of COVID-19 cases rather than responsive or preventive. CONCLUSIONS: The findings of both positivity and negativity in press communications suggest that the effect of discounted importance was present in official communications. Our findings support a state-dependent optimal communication frequency and tone, agreeing with the curvilinear communication model of organizational theory and implying that feedback cycles between government officials and public response should be shortened to rapidly maximize communication efficacy during the pandemic. Future research should identify and evaluate the drivers of the large differences in communication tone across states and validate the reactive characteristics of COVID-19 official communications.

Outcomes of a High-Volume Organ Procurement Organization in the Era of Increasing Donation After Circulatory Death.

Introduction: Donation after circulatory death (DCD) is rapidly increasing in the United States. Detailed data outlining the process from referral to organ transplantation is lacking. Project Aims: We sought to quantify differences at each stage along the referral to donation pathway by donor type. Additionally, we examined factors associated with successful DCD organ utilization. Design: This program evaluation analyzed data from a single organ procurement organization in 2018 to assess demographic and clinical predictors of progression through the donation process, including the role of first-person authorization in DCD. Descriptive statistics were examined by donation stage for demographic characteristics using chi-square; univariate and multivariate logistic regression was used to model predictors of utilization and authorization by organ type, respectively. Results: There were 2466 organ donation referrals during 2018, including 575 donations after brainstem death (DBD), 1890 controlled DCD referrals, and 1 uncontrolled DCD referral. Univariate and multivariate logistic regression models highlighted differences in authorization rates by donor type (DCD vs DBD) and by age, race, and ethnicity. Next-of-kin authorization was declined in 23% of first-person authorized potential DCD, highlighting issues related to the role of donor registration in DCD. Pre-mortem heparin administration was predictive of DCD organ utilization; donor age and warm ischemia time of less than 30 min was statistically significantly associated with DCD extra-renal organ utilization. Conclusion: These results provided insight into strategies for increasing authorization and transplantation of organs from DCD donors and identified areas of improvement for process standardization and policy development.

Hospitalization and survival of solid organ transplant recipients with coronavirus disease 2019: A propensity matched cohort study.

BACKGROUND: Solid organ transplant (SOT) recipients are predicted to have worse COVID-19 outcomes due to their compromised immunity. However, this association remains uncertain because published studies have had small sample sizes and variability in chronic comorbidity adjustment. METHODS: In this retrospective cohort study conducted at a multihospital health system, we compared COVID-19 outcomes and survival up to 60 days following hospital admission in SOT recipients taking baseline immunosuppressants versus hospitalized control patients. RESULTS: The study included 4,562 patients who were hospitalized with COVID-19 (108 SOT recipients and 4,454 controls) from 03/2020 to 08/2020. Mortality at 60 days was higher for SOT recipients (17% SOT vs 10% control; unadjusted odds ratio (OR) = 1.74, 95% confidence interval (CI) 1.04-2.91, P = 0.04). We then conducted a 1:5 propensity matched cohort analysis (100 SOT recipients; 500 controls) using age, sex, race, body mass index, hypertension, diabetes, chronic kidney disease, liver disease, admission month, and area deprivation index. Within 28 days of admission, SOT recipients had fewer hospital-free days (median; 17 SOT vs 21 control; OR = 0.64, 95%CI 0.46-0.90, P = 0.01) but had similar ICU-free days (OR = 1.20, 95%CI 0.72-2.00, P = 0.49) and ventilator-free days (OR = 0.91, 95%CI 0.53-1.57, P = 0.75). There was no statistically significant difference in 28-day mortality (9% SOT vs 12% control; OR = 0.76, 95%CI 0.36-1.57, P = 0.46) or 60-day mortality (16% SOT vs 14% control; OR = 1.15, 95%CI 0.64-2.08, P = 0.64). CONCLUSIONS: Hospitalized SOT recipients appear to need additional days of hospital care but can achieve short-term mortality outcomes from COVID-19 that are similar to non-SOT recipients in a propensity matched cohort study.

Comprehensive cost-effectiveness of diabetes management for the underserved in the United States: A systematic review.

BACKGROUND: Diabetes mellitus affects almost 10% of U.S. adults, leading to human and financial burden. Underserved populations experience a higher risk of diabetes and related complications resulting from a combination of limited disposable income, inadequate diet, and lack of insurance coverage. Without the requisite resources, underserved populations lack the ability to access healthcare and afford prescription drugs to manage their condition. The aim of this systematic review is to synthesize the findings from cost-effectiveness studies of diabetes management in underserved populations. METHODS: Original, English, peer-reviewed cost-effectiveness studies of diabetes management in U.S. underserved populations were obtained from 8 databases, and PRISMA 2009 reporting guidelines were followed. Evidence was categorized as strong or weak based on a combination of GRADE and American Diabetes Association guidelines. Internal validity was assessed by the Cochrane methodology. Studies were classified by incremental cost-effectiveness ratio as very cost-effective (ICER≤US$25,000), cost-effective (US$25,000US$100,000). Reporting and quality of economic evaluations was assessed using the CHEERS guidelines and Recommendations of Second Panel for Cost-Effectiveness in Health and Medicine, respectively. FINDINGS: Fourteen studies were included. All interventions were found to be cost-effective or very cost-effective. None of the studies reported all 24 points of the CHEERS guidelines. Given the considered cost categories vary significantly between studies, assessing cost-effectiveness across studies has many limitations. Program costs were consistently analyzed, and a third of the included studies (n = 5) only examined these costs, without considering other costs of diabetes care. INTERPRETATION: Cost-effectiveness studies are not based on a standardized methodology and present incomplete or limited analyses. More accurate assessment of all direct and indirect costs could widen the gap between intervention and usual care. This demonstrates the urgent need for a more standardized and comprehensive cost-effectiveness framework for future studies.

Validating Visual Stimuli of Nature Images and Identifying the Representative Characteristics.

This study fills a void in the literature by both validating images of nature for use in future research experiments and examining which characteristics of these visual stimuli are found to be most representative of nature. We utilized a convenience sample of university students to assess 129 different nature images on which best represented nature. Participants (n = 40) viewed one image per question (n = 129) and were asked to rate images using a 5-point Likert scale, with the anchors "best represents nature" (5) and "least represents nature" (1). Average ratings across participants were calculated for each image. Canopies, mountains, bodies of water, and unnatural elements were identified as semantic categories of interest, as well as atmospheric perspectives and close-range views. We conducted the ordinary least squares (OLS) regression and the ordered logistic regression analyses to identify semantic categories highly representative of nature, controlling for the presence/absence of other semantic categories. The results showed that canopies, bodies of water, and mountains were found to be highly representative of nature, whereas unnatural elements and close-range views were inversely related. Understanding semantic categories most representative of nature is useful in developing nature-centered interventions in behavioral performance research and other neuroimaging modalities. All images are housed in an online repository and we welcome the use of the final 10 highly representative nature images by other researchers, which will hopefully prompt and expedite future examinations of nature across multiple research formats.

Rapid Response to Drive COVID-19 Research in a Learning Health Care System: Rationale and Design of the Houston Methodist COVID-19 Surveillance and Outcomes Registry (CURATOR).

BACKGROUND: The COVID-19 pandemic has exacerbated the challenges of meaningful health care digitization. The need for rapid yet validated decision-making requires robust data infrastructure. Organizations with a focus on learning health care (LHC) systems tend to adapt better to rapidly evolving data needs. Few studies have demonstrated a successful implementation of data digitization principles in an LHC context across health care systems during the COVID-19 pandemic. OBJECTIVE: We share our experience and provide a framework for assembling and organizing multidisciplinary resources, structuring and regulating research needs, and developing a single source of truth (SSoT) for COVID-19 research by applying fundamental principles of health care digitization, in the context of LHC systems across a complex health care organization. METHODS: Houston Methodist (HM) comprises eight tertiary care hospitals and an expansive primary care network across Greater Houston, Texas. During the early phase of the pandemic, institutional leadership envisioned the need to streamline COVID-19 research and established the retrospective research task force (RRTF). We describe an account of the structure, functioning, and productivity of the RRTF. We further elucidate the technical and structural details of a comprehensive data repository-the HM COVID-19 Surveillance and Outcomes Registry (CURATOR). We particularly highlight how CURATOR conforms to standard health care digitization principles in the LHC context. RESULTS: The HM COVID-19 RRTF comprises expertise in epidemiology, health systems, clinical domains, data sciences, information technology, and research regulation. The RRTF initially convened in March 2020 to prioritize and streamline COVID-19 observational research; to date, it has reviewed over 60 protocols and made recommendations to the institutional review board (IRB). The RRTF also established the charter for CURATOR, which in itself was IRB-approved in April 2020. CURATOR is a relational structured query language database that is directly populated with data from electronic health records, via largely automated extract, transform, and load procedures. The CURATOR design enables longitudinal tracking of COVID-19 cases and controls before and after COVID-19 testing. CURATOR has been set up following the SSoT principle and is harmonized across other COVID-19 data sources. CURATOR eliminates data silos by leveraging unique and disparate big data sources for COVID-19 research and provides a platform to capitalize on institutional investment in cloud computing. It currently hosts deeply phenotyped sociodemographic, clinical, and outcomes data of approximately 200,000 individuals tested for COVID-19. It supports more than 30 IRB-approved protocols across several clinical domains and has generated numerous publications from its core and associated data sources. CONCLUSIONS: A data-driven decision-making strategy is paramount to the success of health care organizations. Investment in cross-disciplinary expertise, health care technology, and leadership commitment are key ingredients to foster an LHC system. Such systems can mitigate the effects of ongoing and future health care catastrophes by providing timely and validated decision support.