Integrated Model for Patient-Centered Advanced Liver Disease Care.

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

Evaluation of a train-the-trainer workshop on sickle cell disease for ED providers.

OBJECTIVE: (1) Determine the difference in pre-test and post-test knowledge scores for attendees of a train-the-trainer workshop and (2) determine the number of attendees who disseminated the content within 6 months of attending the workshop. METHODS: A 1-day, train-the-trainer workshop focusing on sickle cell disease (SCD) was developed. ED nurses and physicians from the emergency departments with the highest number of patients with SCD were invited to participate at no cost. A panel consisting of 6 SCD and ED experts planned the workshop and developed 20 items for pre-test and post-test knowledge evaluation. The pre-test and post-test were administered at the beginning and end of the workshop, respectively. All attendees received a flash drive with all conference materials and were asked to disseminate workshop content to other ED colleagues. After 6 months, a brief survey was sent to the participants using Survey Monkey asking the number and type of providers trained. RESULTS: Fifty-five participants attended the workshop. The mean (SD) pre-test score for the entire cohort was 13 (2) and the post-test score was 16 (2); mean difference (95% CI) 2.96 (2.36, 3.57). Items that scored low included questions dealing with pathophysiologic complications, addiction, or ED utilization. Eighteen participants completed the 6-month follow-up survey. Seven participants reported disseminating workshop content to a total of 99 providers. CONCLUSION: A train-the-trainer workshop specifically designed for emergency physicians and nurses that discussed the broad spectrum of SCD was well attended, and 6 months later, 99 additional providers received training.

The what matters most survey: A measurement evaluation of a self-reported patient values elicitation tool among cancer survivors.

OBJECTIVES: Patients with multiple chronic conditions, especially cancer survivors, face challenges in medical decision making. Previous research demonstrates how patient values can guide medical decisions, however facilitating patient values elicitation remains a challenge. This study aims to evaluate the psychometric properties of and refine the What Matters Most (WMM) Survey, a self-reported values elicitation tool, in a cohort of older veteran cancer survivors. METHODS: An observational cohort study was conducted to evaluate the psychometric properties of the WMM Survey in older, multimorbid cancer survivors. 262 patients were administered the assessment at two timepoints, between 14 and 30 days apart. RESULTS: Exploratory factor analyses revealed four factors for assessing healthcare values among older adults with good internal consistency for all factors: Functioning (Cronbach's alpha coefficient, α = 0.88), Enjoying Life (α = 0.79), Connecting (α = 0.84), and Managing Health (α = 0.88). Demographic and clinical characteristics were not uniformly associated with specific healthcare values. CONCLUSIONS: Future studies are required to refine the proposed assessment and to evaluate its application in a general patient population. PRACTICE IMPLICATIONS: The WMM Survey is an innovative resource in health values elicitation, allowing for facilitation of patient-clinician communication for whole-person medical approaches and measurement of health values for research.

An Analysis of the Timing for Closure of a Diverting Loop Ileostomy.

A diverting loop ileostomy (DLI) is used to protect a distal gastrointestinal anastomosis at risk of leakage. While patients typically prefer early DLI closure, surgeons vary in opinion regarding optimal timing. This study evaluated whether the timing of DLI closure impacts outcomes.A retrospective review was performed on patients who underwent DLI creation within one health care system between 2012 and 2020. Patient characteristics and postoperative outcomes were compared across ileostomies closed in ≤2 months, 2-4 months, and >4 months. Outcomes examined included anastomotic leak, other complications, reintervention, and death within 30 days.A total of 500 DLIs were analyzed for the study, 455 of which were closed. The three closure groups were similar in patient characteristics and comorbidities. None of the outcome variables analyzed in this study demonstrated a statistically significant difference between groups, suggesting that in patients otherwise fit for surgery, DLI closure can be safely performed within 2 months of creation.

Nurse practitioner certification and practice settings: implications for education and practice.

PURPOSE: Nurse Practitioners (NPs) are certified within a population-focused specialty area, practice in a variety of settings, and treat a wide range of patients. Little is known about what agreement exists between certification obtained and actual site of practice. The purpose of this study was to examine NP practice sites as compared with their certification and examine additional education they received after employment. DESIGN: Adult (ANP), family (FNP), and acute care nurse practitioners (ACNPs) certified by the American Nurses Credentialing Center were surveyed regarding certification, demographic information, practice setting, routine responsibilities, and additional training they may have obtained. METHODS: An expert panel defined categories of traditional practice settings consistent with NP credentialing examinations and scopes of practice. Equal numbers of randomly chosen ANPs, ACNPs, and FNPs (N = 2,000) were mailed surveys. Responses were coded and analyzed. FINDINGS: The overall survey response was 69.8% (n= 1216). Of the FNP, ANP, and ACNP respondents, 5%, 7%, and 42%, respectively, reported practicing in a nontraditional practice setting. Of nurses practicing in a nontraditional setting, 74% (135 of 182) were ACNPs, with 90% practicing in a nontraditional, ambulatory care setting. Sixty-five percent (13 of 20) of the FNPs practicing in a nontraditional setting were practicing in a high-acuity emergency department, and 56% (15 of 27) of the ANPs practicing in a nontraditional setting were practicing in a high-acuity intensive care unit. The top responses of additional education received were pharmacology, laboratory interpretation, and ordering diagnostic tests. CONCLUSIONS: While greater than 90% of ANPs and FNPs practice in settings consistent with their certification, a proportion of NPs practice in nontraditional settings and may benefit from additional education (formal, on-the-job, and continuing education) and mentoring.