The Influence of the COVID-19 Pandemic on Small Business Support for Youth Physical Activity Opportunities in Urban, Low-Income, Predominantly Black Neighborhoods.

BACKGROUND: A relatively low percentage of Black youth meet physical activity (PA) guidelines. An important resource for helping Black youth be physically active is the availability of quality youth physical activity opportunities (YPAO) which manifest, in part, due to support from small businesses. The coronavirus disease 2019 (COVID-19) pandemic was a devastating negative societal event that disproportionately burdened the Black community. How the pandemic influenced the relationship between small businesses and YPAOs in this community is vital for understanding the promotion of PA in this high-risk population going forward. PURPOSE: To describe small business support for YPAO before and after 2 years of exposure to the COVID-19 pandemic. METHODS: In-person interviews were conducted June through August 2019 (pre-COVID) and 2021 (post-COVID) with owners and managers at small businesses in 20 urban, low-income, predominantly Black neighborhoods. RESULTS: The number of YPAOs supported was significantly greater pre-COVID (n = 104) versus post-COVID (n = 52) (t = 4.6; p < .001). From pre-COVID to post-COVID, the types of YPAOs supported by businesses shifted from a diverse mix to mostly (96%) outdoor, community sports teams. Businesses were more likely to provide goods and services (p = .02) for YPAOs pre-COVID than post-COVID. The major reason for not supporting YPAOs pre-COVID was "not being asked for support" then "not being able to locate YPAOs to support" post-COVID. CONCLUSION: Exposure to COVID-19 is associated with significant changes in how small businesses support YPAOs. The results are useful for informing strategies and public policies aimed at promoting YPAO support through prominent negative societal events.

The Impact of Health Coaching on Weight and Physical Activity in Obese Adults: A Randomized Control Trial.

Health Coaching (HC) is an evidence-based, patient-centered approach to assisting individuals in achieving their health-related goals. Studies have generally shown positive effects of HC on weight loss in obese adults. However, limitations do exist, that if addressed would further clarify HC's viability as a clinical, obesity treatment approach. To examine the effects of HC on weight loss, moderate-to-vigorous physical activity (MVPA), and psychosocial constructs in obese adults. A randomized control trial with 44 [Mean body mass index (BMI) 36.5] middle-aged, White adults. Participants were randomly assigned to HC (n = 22) or control (n = 22) groups. A certified health coach provided bi-weekly, in-person and telehealth HC for 12 weeks. Percent excess weight loss was 15.7% in HC vs. 2.5% in controls (p< .001). The change in MVPA was significantly greater in HC (+50.3 min/wk) vs controls (+7.1 min/wk). Psychosocial constructs also changed more favorably in HC than controls. Health coaching is an effective approach for weight loss in obese adults. The results of this study support the consideration of HC as a treatment option for obese adults looking to lose weight.

Pregnant people's views and knowledge on prenatal screening for fetal trisomy in the absence of a national screening program.

Multiple non-invasive prenatal tests (NIPT) are available to screen for risk of fetal trisomy, however, there is no national prenatal screening program in Republic of Ireland. This study aimed to analyze pregnant people's opinions on availability, cost, and knowledge of NIPT for fetal aneuploidy. An anonymous questionnaire on prenatal screening tests and termination of pregnancy was distributed to patients attending antenatal clinics at a tertiary hospital. Descriptive analyses and chi-squared tests were completed. Among respondents, 62% (200/321) understood the scope of prenatal screening tests, with 77% (251/326) and 76% (245/323) correctly interpreting low- and high-risk test results, respectively. Only 26% (83/319) of participants had heard of NIPT. Chi-square tests showed a higher proportion of these people were ≥40 years old (p-value, <0.001), had post-graduate education (p-value, <0.001), or attended private clinics (p-value <0.001). Over 91% (303/331) of participants said every pregnant person should be offered prenatal screening tests for aneuploidy and 88% (263/299) believed these should be free. While pregnant Irish individuals have reasonable understanding of screening test interpretation, most were unaware of screening options. Additionally, participants' views on availability and associated cost of tests show the need for a national prenatal screening program, including education on fetal aneuploidy. These findings have relevance for countries without screening policies and are pertinent for broader maternity services.

The associations between place-based measures of walkability and physical activity across a range of diverse streetscapes.

Walkability relates to aspects of a physical environment that have the potential to influence walking in that environment. In 2019, the Environmental Protection Agency developed the National Walkability Index (NWI), an easily accessible, U.S. Census block-group-level indicator of walkability. Although the NWI could be the metric of choice for researchers and urban planners, there is a lack of empirical evidence for its validity. The current study examined the validity of the NWI and Walk Score for predicting physical activity (PA) occurring along urban streetscapes. A wearable video device (Gogloo E7 SMART eyewear) was used to capture videos of streetscapes in 24 U.S. Census block groups in three different sized cities. The block groups varied in walkability, income level, and minority composition. The videos, collected over 10 months during 2019 at different times on weekdays and weekends, were reviewed by experts to obtain counts of walkers/h and individuals performing leisure PA/h (dependent variables). The independent variables were the NWI, its components - transit stop proximity, intersection density, employment/household occupancy mix, and employment mix, and Walk Score. Block group was the level of analysis. Linear regression indicated Walk Score, employment/household occupancy mix, and employment mix were associated with walkers/h (p < .001) while only employment/household occupancy mix, and employment mix were associated with leisure PA/h (p < .001). The NWI did not account for a significant portion of the variance in PA outcomes. A place-based examination of PA and walkability indexes favors the use of Walk Score and a modified version of the NWI.

Small Business Support Is Associated with the Quantity, Quality, and Usage of Youth Physical Activity Opportunities in Urban, Low-Income, African American Neighborhoods.

Evidence suggests small businesses could play a significant role in bringing quality youth physical activity opportunities (YPAOs) to urban areas. Knowing more about their involvement with YPAOs in African American neighborhoods would be of significant value given the relatively low PA rates of African American youth. The current study examined associations between small businesses and YPAOs in low-income, African American urban neighborhoods. Surveys were conducted with 46.4% (n = 223) of eligible small business owners/managers and 44.2% (n = 38) of eligible YPAO providers in 20 low-income, African American urban neighborhoods to ascertain business and YPAO characteristics. Audits were conducted at the YPAOs and parks (n = 28) in the study areas to obtain counts of users and data on amenities/incivilities. Analyses included multiple linear regression. Only 33.6% of all businesses were currently supporting YPAOs. The percentage of businesses supporting only local YPAOs (YPAOs near the business) was significantly associated with the number of YPAOs in the area, number of YPAO amenities, youth participants, teams, amenity quality, and the severity of incivilities after controlling for neighborhood demographics. Businesses supporting only local YPAOs were at their location longer, and their owners were more likely to have a sports background, children, and believe small businesses should support YPAOs than business not supporting local YPAOs. This study provides evidence that YPAOs in low-income, African American urban neighborhoods are improved by support from small businesses. Efforts to enhance PA among African American youth living in low-income urban neighborhoods could benefit from involving small businesses.

Perceptions of Weight Change Among Romantic Partners: Considering Body Image, Relationship Experiences, Gender, and Sexual Orientation.

Romantic relationship experiences have been found to be relevant to body image and weight in adulthood. In this study, we investigated predictors of heterosexual, lesbian, and gay romantic partners' (N = 500, M age = 29.3) perceptions of their own and their partners' weight at the beginning of their relationship and 4.8 years later, on average. Perceived changes in participants' own weight status was associated with greater body dissastisfaction and longer relationship length. Perceived changes in partners' weight status was associated with their partners' BMI, as well as relationship quality. We also found that gender was important in understanding some of these associations. Implications of weight perceptions for individuals' and their partners' health and well-being and the critical role of relationship quality are discussed in the context of the health regulation model.

Intraoperative Pancreatic Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Adenocarcinoma in the Era of Neoadjuvant Therapy: A Multi-institutional Analysis from the Central Pancreatic Consortium.

BACKGROUND: Data regarding the survival impact of converting frozen-section (FS):R1 pancreatic neck margins to permanent section (PS):R0 by additional resection (i.e., converted-R0) during upfront pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) are conflicting. The impact of neoadjuvant therapy on this practice and its relationship with overall survival (OS) is incompletely understood. METHODS: We reviewed PDAC patients (80% borderline resectable/locally advanced [BR/LA]) undergoing pancreaticoduodenectomy after neoadjuvant therapy at seven, academic, high-volume centers (2010-2018). Multivariable models examined the association of PS:R0, PS:R1, and converted-R0 margins with OS. RESULTS: Of 272 patients receiving at least 2 (median 4) cycles of neoadjuvant chemotherapy (71% mFOLFIRINOX or gemcitabine/nab-paclitaxel) and undergoing pancreaticoduodenectomy with intraoperative frozen-section assessment of the transected pancreatic neck margin, PS:R0 (n = 220, 80.9%) was observed in a majority of patients; 18 patients (6.6%) had converted-R0 margins following additional resection, whereas 34 patients (12.5%) had persistently positive PS:R1 margins. At a median follow-up of 42 months, PS:R0 resection was associated with improved OS compared with either converted-R0 or PS:R1 resection (median 25 vs. 14 vs. 16 months, respectively; p = 0.023), with no survival difference between the converted-R0 and PS:R1 groups (p = 0.9). On Cox regression, SMA margin positivity (hazard ratio 2.2, p = 0.012), but not neck margin positivity (hazard ratio 1.2, p = 0.65), was associated with worse OS. CONCLUSIONS: In this multi-institutional cohort of predominantly BR/LA PDAC patients undergoing pancreaticoduodenectomy following modern neoadjuvant therapy, pursuing a negative neck margin intraoperatively if the initial margin is positive does not appear to be associated with improved survival.

Racial and Ethnic Disparities in Breast Cancer Survival: Emergence of a Clinically Distinct Hispanic Black Population.

OBJECTIVE: To understand the impact of Black race on breast cancer (BC) presentation, treatment, and survival among Hispanics. SUMMARY OF BACKGROUND DATA: It is well-documented that non-Hispanic Blacks (NHB) present with late-stage disease, are less likely to complete treatment, and have worse survival compared to their non-Hispanic White (NHW) counterparts. However, no data evaluates whether this disparity extends to Hispanic Blacks (HB) and Hispanic Whites (HW). Given our location in Miami, gateway to Latin America and the Caribbean, we have the diversity to evaluate BC outcomes in HB and HW. METHODS: Retrospective cohort study of stage I-IV BC patients treated at our institution from 2005-2017. Kaplan-Meier survival curves were generated and compared using the log-rank test. Multivariable survival models were computed using Cox proportional hazards regression. RESULTS: Race/ethnicity distribution of 5951 patients: 28% NHW, 51% HW, 3% HB, and 18% NHB. HB were more economically disadvantaged, had more aggressive disease, and less treatment compliant compared to HW. 5-year OS by race/ethnicity was: 85% NHW, 84.8% HW, 79.4% HB, and 72.7% NHB (P < 0.001). After adjusting for covariates, NHB was an independent predictor of worse OS [hazard ratio:1.25 (95% confidence interval: 1.01-1.52), P < 0.041)]. CONCLUSIONS: In this first comprehensive analysis of HB and HW, HB have worse OS compared to HW, suggesting that race/ethnicity is a complex variable acting as a proxy for tumor and host biology, as well as individual and neighborhood-level factors impacted by structural racism. This study identifies markers of vulnerability associated with Black race and markers of resiliency associated with Hispanic ethnicity to narrow a persistent BC survival gap.

Axillary response rates to neoadjuvant chemotherapy in breast cancer patients with advanced nodal disease.

PURPOSE: Utilization of sentinel lymph node biopsy (SLNB) in breast cancer patients with positive nodes after neoadjuvant chemotherapy (NAC) has increased. We examine axillary response rates after NAC in patients with clinical N2-3 disease to determine whether SLNB should be considered. METHODS: Breast cancer patients with clinical N2-3 (AJCC 7th Edition) disease who received NAC followed by surgery were selected from our institutional tumor registry (2009-2018). Axillary response rates were assessed. RESULTS: Ninety-nine patients with 100 breast cancers were identified: 59 N2 (59.0%) and 41 (41.0%) N3 disease; 82 (82.0%) treated with axillary lymph node dissection (ALND) and 18 (18.0%) SLNB. The majority (99.0%) received multiagent NAC. In patients undergoing ALND, cCR was observed in 20/82 patients (24.4%), pathologic complete response (pCR) in 15 patients (18.3%), and axillary pCR in 17 patients (20.7%). In patients with a cCR, pCR was identified in 60.0% and was most common in HER2+ patients (34.6%). CONCLUSION: In this analysis of patients with clinical N2-3 disease receiving NAC, 79.3% of patients had residual nodal disease at surgery. However, 60.0% of patients with a cCR also had a pCR. This provides the foundation to consider evaluating SLNB and less extensive axillary surgery in this select group.

Overcoming disparities: Multidisciplinary breast cancer care at a public safety net hospital.

PURPOSE: Public safety net hospitals (SNH) serve a disparate patient population; however, little is known about long-term oncologic outcomes of patients receiving care at these facilities. This study is the first to examine overall survival (OS) and the initiation of treatment in breast cancer patients treated at a SNH. METHODS: Patients presenting to a SNH with stage I-IV breast cancer from 2005 to 2017 were identified from the local tumor registry. The hospital has a weekly breast tumor board and a multidisciplinary approach to breast cancer care. Kaplan-Meier survival analysis was performed to identify patient, tumor, and treatment characteristics associated with OS. Factors with a p < 0.1 were included in the Cox proportional hazards model. RESULTS: 2709 breast cancer patients were evaluated from 2005 to 2017. The patient demographics, tumor characteristics, and treatments received were analyzed. Five-year OS was 78.4% (93.9%, 87.4%, 70.9%, and 23.5% for stages I, II, III, and IV, respectively). On multivariable analysis, higher stage, age > 70 years, higher grade, and non-Hispanic ethnicity were associated with worse OS. Patients receiving surgery (HR = 0.33, p < 0.0001), chemotherapy (HR = 0.71, p = 0.006), and endocrine therapy (HR = 0.61, p < 0.0001) had better OS compared to those who did not receive these treatments. CONCLUSION: Despite serving a vulnerable minority population that is largely poor, uninsured, and presenting with more advanced disease, OS at our SNH approaches national averages. This novel finding indicates that in the setting of multidisciplinary cancer care and with appropriate initiation of treatment, SNHs can overcome socioeconomic barriers to achieve equitable outcomes in breast cancer care.

A review of stillbirth definitions: A rationale for change.

Stillbirth definitions vary between countries around the globe. The purpose of this paper was to explore stillbirth definitions used by high income countries around the world, specifically compared to Ireland, their stillbirth and mortality rates and to examine how these rates are influenced by standards of care, especially resuscitation efforts within the delivery room for very preterm infants. A literature review was performed using PubMed, Academic Search Complete, MEDLINE, and CINAHL. These databases were searched with the terms "(stillbirth OR still birth OR stillborn) AND (definition OR registration OR registry)" and "(fetal OR neonatal OR neonate) AND Viability AND Gestational Age" in two separate searches. The database searches returned 1081 results involving stillbirths and 164 results for neonatal viability. After title, abstract, full text review, and reference review 33 papers remained for use in this study. Within the European Union (EU), 59.2 % (n = 16), 14.8 % (n = 4), 11.1 % (n = 3), and 3.7 % (n = 1) countries classify stillbirths at gestational ages of ≥22 weeks, ≥24 weeks, ≥28 weeks, and ≥180 gestational days respectively. The median stillbirth rate in Europe using ≥28 weeks gestational age as a cut-off was 2.7 per 1000 births, but this increased to 3.3 per 1000 births when stillbirths from 24 to 27 weeks gestation were included. Of the thirteen countries whose mortality data was examined, survival rates for liveborn infants ranged from 0-37.3 %, 1.1-64.5 %, 31.0-77.7 %, and 59.1-85.7 % for the gestational ages of 22, 23, 24, and 25 weeks, respectively. In 1995, survival rates for the United Kingdom and Ireland were only 26 % for those born at 24 weeks gestation, however this has almost doubled in Ireland to 56.6 % in 2014-2017. Survival rates have improved to the point that, in 2014-2017, the survival rate of infants born at 23 weeks gestation (32.3 %) was 6 % higher than the rate for those born at 24 weeks gestation in 1995. Due to the improvement in survival rates, multiple international organisations recommend recording stillbirths from 22 weeks gestation and/or 500 g. Based on the findings from this review, and due to improving survival rates for periviable infants, it is recommended the stillbirth definition in Ireland should be updated to ≥22 weeks' gestation and ≥400 g to comply with improved medical developments.

Surgical Management of the Axilla in Patients with Occult Breast Cancer (cT0 N+) After Neoadjuvant Chemotherapy.

BACKGROUND: Occult breast cancer (OBC) is a rare clinical entity. Current surgical management includes axillary lymphadenectomy (ALND) with or without mastectomy. We sought to investigate the role of sentinel lymph node biopsy (SLNB) in patients with OBC treated with neoadjuvant chemotherapy (NAC). METHODS: Patients with clinical T0N+ breast cancer were selected from the National Cancer Data Base (NCDB, 2004-2014) and compared according to axillary surgical approach, SLNB (≤ 4 LNs) or ALND (> 4 LNs). Primary outcome was overall survival (OS), calculated using Kaplan-Meier methods. Secondary outcome was complete pathological response (pCR). RESULTS: A total of 684 patients with OBC were identified: 470 (68.7%) underwent surgery upfront and 214 (31.3%) received NAC. Of the NAC patients, 34 (15.9%) underwent SLNB and 180 (84.1%) ALND. One hundred and fifty-three (72%) patients received radiotherapy (RT). There was no difference in pCR rates between the ALND and SLNB (34.3% vs 24.5%, respectively p = 0.245). In patients undergoing surgery first, improved OS was observed with ALND compared to SLNB (106.9 vs 85.5 months, p = 0.013); however, no difference in OS was found in patients who received NAC (105.6 vs 111.3 months, p = 0.640). RT improved OS in patients who underwent NAC followed by SLNB (RT, 123 months vs no RT, 64 months, p = 0.034). Of NAC patients who did not undergo RT, ALND had superior survival compared to SLNB (113 vs 64 months, p = 0.013). CONCLUSION: This is the first comparative analysis assessing the surgical management of the axilla in patients with OBC who underwent NAC. In this population, there was a decrease in survival in patients who underwent SLNB alone; however, with the addition of RT, there was no difference in OS between SLNB and ALND. SLNB plus RT may be considered as an alternative to ALND in patients with OBC who have a good response to NAC.

Utility of Radiation After Neoadjuvant Chemotherapy for Surgically Resectable Esophageal Cancer.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) ± radiation (NRT) is the "gold standard" approach for locally advanced esophageal cancer (EC). However, the benefits of RT on overall survival (OS) in patients with resectable EC undergoing neoadjuvant therapy followed by esophagectomy remain controversial. METHODS: The National Cancer Data Base was queried for patients with nonmetastatic EC between 2004 and 2014. Kaplan-Meier, log-rank, and Cox multivariable regression analysis were performed to analyze OS. Logistic regression analyzed factors associated with 90-day mortality, lymph node involvement, and complete pathological response (pCR). RESULTS: A total of 12,238 EC patients who underwent neoadjuvant therapy [neoadjuvant chemoradiation (NACR), 92.1% and NAC, 7.9%] followed by esophagectomy were included. OS was similar in patients undergoing NAC ± RT (35.9 vs. 37.6 mo, respectively, p = 0.393). pCR rate was 18.1% (19.2%, NACR vs. 6.3%, NAC, p < 0.001). NRT was an independent predictor for increased pCR (HR 2.593, p < 0.001). Patients with pCR had increased survival compared with those without pCR (62.3 vs. 34.4 mo, p < 0.001); however, no difference was found between NACR and NAC (61.7 mo vs. median not reached, p = 0.745) in pCR patients. In non-pCR patients, NAC had improved OS compared with NACR (37.3 vs. 30.8 mo, p = 0.002). NRT was associated with worse 90-day mortality (8.2% vs. 7.7%, HR1.872, p = 0.036) In Cox regression, NRT was an independent predictor of worse OS (HR 1.561, p < 0.001). CONCLUSIONS: Neoadjuvant RT is associated with improved pCR rates; however, it had deleterious effects in short- and long-term survival. Also, patients who did not achieve pCR had worse OS after neoadjuvant RT.

Synthetic Small Molecule Characterization and Isomer Discrimination Using Gas-Phase Hydrogen-Deuterium Exchange IMS-MS.

Ion mobility spectrometry-mass spectrometry (IMS-MS) combined with gas-phase hydrogen-deuterium exchange has been used to characterize novel psychoactive substances (NPSs) which are small synthetic compounds designed to mimic the effects of other illicit substances. Here, NPSs containing labile heteroatom hydrogens were evaluated for HDX reactivity in the presence of either deuterated water (D2O) or ammonia (ND3) within the drift tube. An initial evaluation of exchange propensity was performed for six NPSs. Five compounds exchanged in the presence of ND3 while only one NPS (benzyl piperazine) exchanged with D2O. The exchange mechanism of D2O requires stabilization with a nearby charged site; the diamine ring of benzyl piperazine provided this charge site at a fixed length. Three disubstituted benzene isomers ( o-, m-, and p-fluorophenyl piperazine) containing the diamine ring structure and a fluorine atom were subsequently analyzed. Having identical isotopic composition and nearly identical drift time distributions, these isomers could not be distinguished by IMS-MS alone. However, upon undergoing HDX in the drift tube, a t test of means (α = 0.05) showed that discrimination was possible if the exchange data from both reagent gases were included. Molecular dynamics simulations show that the proximity of the fluorine to the diamine ring hinders the dihedral angle rotation between the benzene and the diamine ring; this may partially account for the observed exchange differences.

Have Recent Modifications of Operating Room Attire Policies Decreased Surgical Site Infections? An American College of Surgeons NSQIP Review of 6,517 Patients.

BACKGROUND: After a Department of Health site visit, 2 teaching hospitals imposed strict regulations on operating room attire, including full coverage of ears and facial hair. We hypothesized that this intervention would reduce superficial surgical site infections (SSIs). STUDY DESIGN: We compared NSQIP data from all patients undergoing operations in the 9 months before implementation (n = 3,077) to time-matched data 9 months post-implementation (n = 3,440). Univariate and multivariable analyses were used to examine patient, clinical, and operative factors associated with SSIs. Power analysis was performed using pre-intervention SSI rates. RESULTS: Despite a shift toward more clean cases, there were more SSIs post-implementation (33 vs 30 [1%]; p = 0.95). There were no differences in length of stay, complications, or mortality between the 2 time periods. Overall, SSI increased with wound class: 0.6%, 0.9%, 2.3%, and 3.8% in clean, clean-contaminated, contaminated, and infected cases, respectively. Limiting the review to clean or clean-contaminated cases, incisional SSIs increased from 0.7% (20 of 2,754) to 0.8% (24 of 3,115) (p = 0.85). A multivariable analysis showed that implementation of these policies was not associated with decreased SSIs (odds ratio 1.2; 95% CI 0.70 to 1.96; p = 0.56). The largest predictors of SSIs were preoperative infection, operative time >75th percentile, open wounds, and dirty/contaminated wounds. A hypothetical analysis revealed that a sample size of 485,154 patients would be required to demonstrate a 10% SSI reduction among patients with clean or clean-contaminated wounds. CONCLUSIONS: Implementation of stringent operating room attire policies do not reduce SSI rates. A study to prove this principle further would be impractical to conduct.

Survey of Living Organ Donors' Experience and Directions for Process Improvement.

INTRODUCTION: Understanding living organ donors' experience with donation and challenges faced during the process is necessary to guide the development of effective strategies to maximize donor benefit and increase the number of living donors. METHODS: An anonymous self-administered survey, specifically designed for this population based on key informant interviews, was mailed to 426 individuals who donated a kidney or liver at our institution. Quantitative and qualitative methods including open and axial coding were used to analyze donor responses. FINDINGS: Of the 141 survey respondents, 94% would encourage others to become donors; however, nearly half (44%) thought the donation process could be improved and offered numerous suggestions. Five major themes arose: (1) desire for greater convenience in testing and scheduling; (2) involvement of previous donors throughout the process; (3) education and promotion of donation through social media; (4) unanticipated difficulties, specifically pain; and (5) financial concerns. DISCUSSION: Donor feedback has been translated into performance improvements at our hospital, many of which are applicable to other institutions. Population-specific survey development helps to identify vital patient concerns and provides valuable feedback to enhance the delivery of care.

Patient Perspectives on Transitions of Surgical Care: Examining the Complexities and Interdependencies of Care.

This study examined a thematic network aimed at identifying experiences that influence patients' outcomes (e.g., patients' satisfaction, anxiety, and discharge readiness) in an effort to improve care transitions and reduce patient burden. We drew upon the Sociology and Complexity Science Toolkit to analyze themes derived from 61 semistructured, longitudinal interviews with 20 patients undergoing either a benign or malignant colorectal resection (three interviews per patient over a 30-day after hospital discharge). Thematic interdependencies illustrate how most outcomes of care are significantly influenced by two cascades identified as patients' medical histories and home circumstances. Patients who reported previous medical or surgical histories also experienced less distress during the discharge process, whereas patients with no prior experiences reported more concerns and greater anxiety. Patient dissatisfactions and challenges were due in large part to the contrasts between hospital and home experiences. Our hybrid approach may inform patient-centered guidelines aimed at improving transitions of care among patients undergoing major surgery.

Patient perspective on care transitions after colorectal surgery.

BACKGROUND: The surgical care pathway is characterized by multiple transitions, from preoperative assessment to inpatient stay, discharge from hospital, and follow-up care. Breakdowns in one phase can affect subsequent phases, which in turn can cause delays, cancellations, and complications. Efforts to improve care transitions focused primarily on post-discharge care coordination and inpatient education for medically complex patients have not demonstrated consistent effects. This study aimed to understand the expectations and perceptions of postoperative inpatients regarding transition from hospital to home in an effort to reduce patient burden. MATERIALS AND METHODS: Patients who underwent a colorectal resection at a large academic medical center and were discharged home were eligible to participate in the study. Patients were recruited during their postoperative hospital stays and interviewed over the phone within a week after discharge about their perceptions of care, values, and attitudes. Overall, we recruited 16 patients with benign (n = 8) and malignant (n = 8) indications. Recruitment continued until theme saturation. RESULTS: Factors that shaped patients' understanding of postsurgical recovery and that motivated them to seek provider attention post-discharge fell into three major groups: patient expectations versus reality, availability and role of informal caregivers in the postoperative recovery process, and communication as a key to patient confidence and trust. CONCLUSIONS: For patients and caregivers, postoperative planning starts long before surgery and hospital admission. Providers should consider these dynamics in designing interventions to improve care transitions, patient satisfaction, and long-term outcomes. This study was limited to colorectal surgical patients treated in a single institution and may be not generalizable to other surgical procedures, non-academic settings or different regions.