Implementing mHealth-Enabled Integrated Care for Complex Chronic Patients With Osteoarthritis Undergoing Primary Hip or Knee Arthroplasty: Prospective, Two-Arm, Parallel Trial.

BACKGROUND: Osteoarthritis is a disabling condition that is often associated with other comorbidities. Total hip or knee arthroplasty is an effective surgical treatment for osteoarthritis when indicated, but comorbidities can impair their results by increasing complications and social and economic costs. Integrated care (IC) models supported by eHealth can increase efficiency through defragmentation of care and promote patient-centeredness. OBJECTIVE: This study aims to assess the effectiveness and cost-effectiveness of implementing a mobile health (mHealth)-enabled IC model for complex chronic patients undergoing primary total hip or knee arthroplasty. METHODS: As part of the Horizon 2020 Personalized Connected Care for Complex Chronic Patients (CONNECARE) project, a prospective, pragmatic, two-arm, parallel implementation trial was conducted in the rural region of Lleida, Catalonia, Spain. For 3 months, complex chronic patients undergoing total hip or knee arthroplasty and their caregivers received the combined benefits of the CONNECARE organizational IC model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care (UC). We assessed changes in health status (12-item short-form survey [SF-12]), unplanned visits and admissions during a 6-month follow-up, and the incremental cost-effectiveness ratio. RESULTS: A total of 29 patients were recruited for the mHealth-enabled IC arm, and 30 patients were recruited for the UC arm. Both groups were statistically comparable for baseline characteristics, such as age; sex; type of arthroplasty; and Charlson index, American Society of Anesthesiologists classification, Barthel index, Hospital Anxiety and Depression scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Pfeiffer mental status questionnaire scores. Patients in both groups had significant increases in the SF-12 physical domain and total SF-12 score, but differences in differences between the groups were not statistically significant. IC patients had 50% fewer unplanned visits (P=.006). Only 1 hospital admission was recorded during the follow-up (UC arm). The IC program generated savings in different cost scenarios, and the incremental cost-effectiveness ratio demonstrated cost-effectiveness. CONCLUSIONS: Chronic patients undergoing hip or knee arthroplasty can benefit from the implementation of patient-centered mHealth-enabled IC models aimed at empowering patients and facilitating transitions from specialized hospital care to primary care. Such models can reduce unplanned contacts with the health system and reduce overall health costs, proving to be cost-effective. Overall, our findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement IC for patients undergoing elective surgery.

Adductor canal block performed 20 hours after total knee arthroplasty to improve postoperative analgesia and functional recovery: a double-blind randomized controlled clinical trial.

BACKGROUND: The goal of postoperative pain protocols in total knee arthroplasty (TKA) is to get pain free patients throughout severe pain period without impairing walking ability. The aim of the study was to investigate if an adductor canal block performed 20 hours after TKA, in patients treated with systemic analgesia and intraoperative local infiltration anesthesia (LIA), improves postoperative pain and functional outcomes. METHODS: A prospective randomized, double-blinded controlled study was conducted. One hundred eighty-three patients undergoing primary TKA were randomized to receive either a sham block or an adductor canal block with 20 mL of ropivacaine 0.5%. The primary outcome was resting and dynamic pain scores using the Numerical Pain Rating Scale (NPRS). Secondary outcomes included opioid rescue requirements, quadriceps and adductor muscle strength, patient ability for ambulation and complications. RESULTS: Two hours after the block, in adductor canal block group NPRS was significantly lower at rest (1 [0-2] vs. 3 [2-5], P<0.001) and with mobilization (5 [3-6] vs. 6 [5-8], P<0.001), and quadriceps strength was significantly higher (3.7 [2.7-6] vs. 3 (1.7-4.9), P=0.023). The differences were not maintained beyond 24 hours post-block. In the first 24 hours the percentage of patients with tramadol requirements was lower in the adductor canal block group (36 [38.3] vs. 52 [58.4], P=0.006). Other secondary outcomes were similar between groups. There were no patient falls. CONCLUSIONS: An adductor canal block done 20 hours after total knee arthroplasty reduces pain and opioid requirements without increasing the risk of falls. An optimal pain control, especially at movement was not achieved.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Patients and Professionals' Acceptability Study.

BACKGROUND: Integrated care (IC) can promote health and social care efficiency through prioritization of preventive patient-centered models and defragmentation of care and collaboration across health tiers, and mobile health (mHealth) can be the cornerstone allowing for the adoption of IC. OBJECTIVE: This study aims to assess the acceptability, usability, and satisfaction of an mHealth-enabled IC model for complex chronic patients in both patients and health professionals. METHODS: As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, 2-arm, parallel, hybrid effectiveness-implementation trial was conducted from July 2018 to August 2019 in a rural region of Catalonia, Spain. Home-dwelling patients 55 years and older with chronic conditions and a history of hospitalizations for chronic obstructive pulmonary disease or heart failure (use case [UC] 1), or a scheduled major elective hip or knee arthroplasty (UC2) were recruited. During the 3 months, patients experienced an mHealth-enabled IC model, including a self-management app for patients, a set of integrated sensors, and a web-based platform connecting professionals from different settings or usual care. The Person-Centered Coordinated Care Experience Questionnaire (P3CEQ) and the Nijmegen Continuity Questionnaire (NCQ) assessed person-centeredness and continuity of care. Acceptability was assessed for IC arm patients and staff with the Net Promoter Score (NPS) and the System Usability Scale (SUS). RESULTS: The analyses included 77 IC patients, 58 controls who completed the follow-up, and 30 health care professionals. The mean age was 78 (SD 9) years in both study arms. Perception of patient-centeredness was similarly high in both arms (usual care: mean P3CEQ score 16.1, SD 3.3; IC: mean P3CEQ score 16.3, SD 2.4). IC patients reported better continuity of care than controls (usual care: mean NCQ score 3.7, SD 0.9; IC: mean NCQ score 4.0, SD 1; P=.04). The scores for patient acceptability (UC1: NPS +67%; UC2: NPS +45%) and usability (UC1: mean SUS score 79, SD 14; UC2: mean SUS score 68, SD 24) were outstanding. Professionals' acceptability was low (UC1: NPS -25%; UC2: NPS -35%), whereas usability was average (UC1: mean SUS score 63, SD 20; UC2: mean SUS score 62, SD 19). The actual use of technology was high; 77% (58/75) of patients reported physical activity for at least 60 days, and the ratio of times reported over times prescribed for other sensors ranged from 37% for oxygen saturation to 67% for weight. CONCLUSIONS: The mHealth-enabled IC model showed outstanding results from the patients' perspective in 2 different UCs but lacked maturity and integration with legacy systems to be fully accepted by professionals. This paper provides useful lessons learned through the development and assessment process and may be of use to organizations willing to develop or implement mHealth-enabled IC for older adults.

Evaluation of biological fluid analysis using the sysmex XN automatic hematology analyzer.

BACKGROUND: Hematological cytometers with a biological fluid module could potentially correct the limitations of the manual chamber method. This study evaluates the agreement between the manual technique and the Sysmex XN-1000 analyzer for white blood cell (WBC) and red blood cell (RBC) counts, as well as for leukocyte differentiation in different types of fluids. This study also evaluates the advantages of incorporating the technique in routine laboratory work. METHODS: One hundred and three fluid samples examined were 45 ascite (AF), 21 synovial (SF), 33 pleural (PF), and 31 cerebrospinal (CSF) fluid samples. All cell counting was performed with a Sysmex XN-1000 and a Fuchs-Rosenthal counting chamber. May Gründwald-Giemsa stain was used for manual WBC differentiation. The manual analysis data were obtained in duplicate by the same two observers. Passing-Bablok regression and the Kappa index were used to evaluate the interchangeability and concordance. RESULTS: Good agreement was observed for WBC differentiation in all fluids and for WBC counts in SF and PF. An optimal Kappa index was obtained, which indicated agreement and clinical significance for WBC and RBC counts in CSF and for RBC counts in PF. There was disagreement for WBC and RBC analysis in AF, with significantly higher results from the Sysmex XN-1000 than from the manual method. A reduction in laboratory response time was observed when using the automatic method. CONCLUSIONS: Except for AF, the Sysmex XN-1000 results agree with those of the manual method, although to different degrees depending on the fluid type. © 2017 International Clinical Cytometry Society.

Evaluation of the BacT/Alert and VITAL blood culture systems for the diagnosis of bacteremia.

OBJECTIVE: To evaluate the detection of bacterial growth in the BacT/Alert (Organon Teknika) and VITAL (bioMérieux) automated blood culture systems. METHODS: In accordance with the protocol of study, 1021 blood sample pairs for culture were obtained from adult patients admitted to the Emergency Room and Intensive Care Unit. RESULTS: In total, 139 (13.6%) clinically significant blood cultures were detected, of which 79 (56.8%) were detected by both systems, 48 (34.5%) only by BacT/Alert and 12 (8.6%) only by VITAL (P cent0.0001). The BacT/Alert system detected positive blood cultures more rapidly for all groups of microorganisms. The VITAL system showed six false-negative blood cultures, while the BacT/Alert system showed none (P50.03). There was no significant difference between the number of false-positive blood cultures detected by the two systems. CONCLUSIONS: In our study, overall the BacT/Alert system achieved a better recovery of microorganisms than the VITAL system.