Real-World Implications of Updated Surviving Sepsis Campaign Antibiotic Timing Recommendations.

OBJECTIVE: To evaluate real-world implications of updated Surviving Sepsis Campaign (SSC) recommendations for antibiotic timing. DESIGN: Retrospective cohort study. SETTING: Twelve hospitals in the Southeastern United States between 2017 and 2021. PATIENTS: One hundred sixty-six thousand five hundred fifty-nine adult hospitalized patients treated in the emergency department for suspected serious infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We determined the number and characteristics of patients affected by updated SSC recommendations for initiation of antibiotics that incorporate a risk- and probability-stratified approach. Using an infection prediction model with a cutoff of 0.5 to classify possible vs. probable infection, we found that 30% of the suspected infection cohort would be classified as shock absent, possible infection and thus eligible for the new 3-hour antibiotic recommendation. In real-world practice, this group had a conservative time to antibiotics (median, 5.5 hr; interquartile range [IQR], 3.2-9.8 hr) and low mortality (2%). Patients categorized as shock absent, probable infection had a median time to antibiotics of 3.2 hours (IQR, 2.1-5.1 hr) and mortality of 3%. Patients categorized as shock present, the probable infection had a median time to antibiotics 2.7 hours (IQR, 1.7-4.6 hr) and mortality of 17%, and patients categorized as shock present, the possible infection had a median time to antibiotics 6.9 hours (IQR, 3.5-16.3 hr) and mortality of 12%. CONCLUSIONS: These data support recently updated SSC recommendations to align antibiotic timing targets with risk and probability stratifications. Our results provide empirical support that clinicians and hospitals should not be held to 1-hour targets for patients without shock and with only possible sepsis.

Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial.

OBJECTIVES: To evaluate whether a nurse navigator-led, multicomponent Sepsis Transition And Recovery program improves 30-day mortality and readmission outcomes after sepsis hospitalization. DESIG: n: Multisite pragmatic randomized clinical trial. SETTING: Three hospitals in North Carolina from January 2019 to March 2020. PATIENTS: Eligible patients hospitalized for suspected sepsis and deemed high-risk for mortality or readmission by validated internal risk models. INTERVENTIONS: Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% CI, 0.58-1.11; adjusted odds ratio, 0.80; 95% CI, 0.64-0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]). CONCLUSIONS: In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

The Association Between Antibiotic Delay Intervals and Hospital Mortality Among Patients Treated in the Emergency Department for Suspected Sepsis.

OBJECTIVES: Rapid delivery of antibiotics is a cornerstone of sepsis therapy, although time targets for specific components of antibiotic delivery are unknown. We quantified time intervals comprising the task of antibiotic delivery and evaluated the association between interval delays and hospital mortality among patients treated in the emergency department for suspected sepsis. DESIGN: Retrospective cohort. SETTING: Twelve hospitals in Southeastern United States from 2014 to 2017. PATIENTS: Twenty-four thousand ninety-three encounters among 20,026 adults with suspected sepsis in 12 emergency departments. MEASUREMENTS AND MAIN RESULTS: We divided antibiotic administration into two intervals: time from emergency department triage to antibiotic order (recognition delay) and time from antibiotic order to infusion (administration delay). We used generalized linear mixed models to evaluate associations between these intervals and hospital mortality. Median time from emergency department triage to antibiotic administration was 3.4 hours (interquartile range, 2.0-6.0 hr), separated into a median recognition delay (time from emergency department triage to antibiotic order) of 2.7 hours(interquartile range, 1.5-4.7 hr) and median administration delay (time from antibiotic order to infusion) of 0.6 hours (0.3-1.2 hr). Adjusting for other risk factors, both recognition delay and administration delay were associated with mortality, but pairwise comparison with a no-delay reference group was not significant for up to 6 hours of recognition delay or up to 1.5 hours of administration delay. CONCLUSIONS: Both recognition delays and administration delays were associated with increased hospital mortality, but only for longer delays. These results suggest that both metrics may be important to measure and improve for patients with suspected sepsis but do not support targets less than 1 hour.

First-to-second antibiotic delay and hospital mortality among emergency department patients with suspected sepsis.

OBJECTIVE: To evaluate whether delay between the first and second antibiotic administered for suspected sepsis is associated with hospital mortality. DESIGN: Retrospective cohort. SETTING: Twelve hospitals in Southeastern United States from 2014 to 2017. PATIENTS: 25,717 adults with suspected sepsis presenting to 12 Emergency Departments who received at least two antibiotics within 12 h. MEASUREMENTS AND MAIN RESULTS: The primary exposure was first-to-second antibiotic delay >1 h. We used generalized linear mixed models to model the association between first-to-second antibiotic delay and hospital death in the overall cohort, and in subgroups of patients with and without septic shock. Overall, 13,852 (54%) patients had first-to-second antibiotic delay >1 h and 1666 (7%) died. Adjusting for other risk factors, first-to-second antibiotic delay was associated with increased risk of hospital death in the subgroup of patients with septic shock (OR 1.34; 95% CI: 1.05-1.70), but not among patients without shock (OR 0.99; 95% CI: 0.88-1.12) or in the overall cohort (OR 1.08; 95% CI: 0.97-1.20). CONCLUSIONS: First-to-second antibiotic delay of greater than one hour was associated with an increased risk of hospital death among patients meeting criteria for septic shock but not all patients with suspected sepsis. Tracking and improving first-to-second antibiotic delays may be considered in septic shock.

Where Is the Implementation Science? An Opportunity to Apply Principles During the COVID-19 Pandemic.

The coronavirus disease 2019 pandemic represents a global crisis that has received extraordinary response from healthcare workers and scientists. One critical but potentially overlooked field in a pandemic is implementation science-the study of methods to reduce the research-to-practice gap. In this Viewpoint, we discuss the important role of implementation science during this and future pandemics and highlight considerations to maximize the utility of implementation research.

Predictive Accuracy of Quick Sequential Organ Failure Assessment for Hospital Mortality Decreases With Increasing Comorbidity Burden Among Patients Admitted for Suspected Infection.

OBJECTIVES: Evaluate the accuracy of the quick Sequential Organ Failure Assessment tool to predict mortality across increasing levels of comorbidity burden. DESIGN: Retrospective observational cohort study. SETTING: Twelve acute care hospitals in the Southeastern United States. PATIENTS: A total of 52,187 patients with suspected infection presenting to the Emergency Department between January 2014 and September 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital mortality. We used electronic health record data to calculate quick Sequential Organ Failure Assessment risk scores from vital signs and laboratory values documented during the first 24 hours. We calculated Charlson Comorbidity Index scores to quantify comorbidity burden. We constructed logistic regression models to evaluate differences in the performance of quick Sequential Organ Failure Assessment greater than or equal to 2 to predict hospital mortality in patients with no documented (Charlson Comorbidity Index = 0), low (Charlson Comorbidity Index = 1-2), moderate (Charlson Comorbidity Index = 3-4), or high (Charlson Comorbidity Index ≥ 5) comorbidity burden. Among the cohort, 2,030 patients died in the hospital (4%). No comorbidities were documented for 5,038 patients (10%), 9,235 patients (18%) had low comorbidity burden, 12,649 patients (24%) had moderate comorbidity burden, and 25,265 patients (48%) had high comorbidity burden. Overall model discrimination for quick Sequential Organ Failure Assessment greater than or equal to 2 was the area under the receiver operating characteristic curve of 0.71 (95% CI, 0.69-0.72). A model including both quick Sequential Organ Failure Assessment and Charlson Comorbidity Index had improved discrimination compared with Charlson Comorbidity Index alone (area under the receiver operating characteristic curve, 0.77; 95% CI, 0.76-0.78 vs area under the curve, 0.61; 95% CI, 0.59-0.62). Discrimination was highest among patients with no documented comorbidities (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.84; 95% CI; 0.79-0.89) and lowest among high comorbidity patients (quick Sequential Organ Failure Assessment area under the receiver operating characteristic curve, 0.67; 95% CI, 0.65-0.68). The strength of association between quick Sequential Organ Failure Assessment and mortality ranged from 30.5-fold increased likelihood in patients with no comorbidities to 4.7-fold increased likelihood in patients with high comorbidity. CONCLUSIONS: The accuracy of quick Sequential Organ Failure Assessment to predict hospital mortality diminishes with increasing comorbidity burden. Patients with comorbidities may have baseline abnormalities in quick Sequential Organ Failure Assessment variables that reduce predictive accuracy. Additional research is needed to better understand quick Sequential Organ Failure Assessment performance across different comorbid conditions with modification that incorporates the context of changes to baseline variables.

Use of boosted protease inhibitors reduces Kaposi sarcoma incidence among male veterans with HIV infection.

BACKGROUND: Kaposi sarcoma (KS) incidence has decreased since combination antiretroviral therapy (cART). However, effects of cART type and duration on KS remain difficult to interpret secondary to KS-associated immune reconstitution inflammatory syndrome (IRIS). METHODS: We performed a retrospective study of Veterans Affairs Human Immunodeficiency Virus Clinical Case Registry data from 1985 to 2010. We analyzed the relationship between cART regimens and KS using multivariable Poisson regression, stratified or adjusted for timing around cART initiation. KS was identified by ≥ 1 inpatient or ≥ 2 outpatient International Classification of Diseases, Ninth Revision codes (176.0-9). Percent of cART on specific regimen and total duration on specific regimen were examined. RESULTS: There were 341 KS cases among 25 529 HIV-infected male veterans (incidence rate = 2.02/1000 person-years). Stratified by years after starting cART, every additional 10% time on boosted protease inhibitors (BPIs) was associated with reduced KS incidence in the third year of cART (incidence rate ratio [IRR] = 0.79; 95% confidence interval [CI], .69-.90). Months on BPIs was associated with lower KS incidence (P = .02). KS incidence was lower at 12-23 (IRR = 0.47; 95% CI, .23-.95) and ≥ 36 (IRR = 0.14; 95% CI, .02-1.00) months on BPIs compared with <6 months. Longer duration on other regimens was not associated with decreased KS incidence. CONCLUSIONS: Lower KS incidence was observed with longer BPI use, after accounting for potential IRIS and other factors. Future research should evaluate newer cART regimens and long-term benefits of PI-based cART on KS in other cohorts and prospective studies.

Changes in sexual roles and quality of life for gay men after prostate cancer: challenges for sexual health providers.

INTRODUCTION: Gay men with prostate cancer (GMPCa) may have differential health-related quality of life (HRQOL) and sexual health outcomes than heterosexual men with prostate cancer (PCa), but existing information is based on clinical experience and small studies. AIMS: Our goals were to: (i) describe HRQOL and examine changes in sexual functioning and bother; (ii) explore the psychosocial aspects of sexual health after PCa; and (iii) examine whether there were significant differences on HRQOL and sexual behavior between GMPCa and published norms. METHODS: A convenience sample of GMPCa completed validated disease-specific and general measures of HRQOL, ejaculatory function and bother, fear of cancer recurrence, and satisfaction with prostate cancer care. Measures of self-efficacy for PCa management, illness intrusiveness, and disclosure of sexual orientation were also completed. Where possible, scores were compared against published norms. MAIN OUTCOME MEASURES: Main outcome measures were self-reported sexual functioning and bother on the Expanded Prostate Cancer Index. RESULTS: Compared with norms, GMPCa reported significantly worse functioning and more severe bother scores on urinary, bowel, hormonal symptom scales (Ps < 0.015-0.0001), worse mental health functioning (P < 0.0001), greater fear of cancer recurrence (P < 0.0001), and were more dissatisfied with their PCa medical care. However, GMPCa reported better sexual functioning scores (P < 0.002) compared with norms. Many of the observed differences met criteria for clinical significance. Physical functioning HRQOL and sexual bother scores were similar to that of published samples. GMPCa tended to be more "out" about their sexual orientation than other samples of gay men. CONCLUSIONS: GMPCa reported substantial changes in sexual functioning after PCa treatment. They also reported significantly worse disease-specific and general HRQOL, fear of recurrence, and were less satisfied with their medical care than other published PCa samples. Sexual health providers must have an awareness of the unique functional and HRQOL differences between gay and heterosexual men with PCa.

Educational opportunities in bladder cancer: increasing cystoscopic adherence and the availability of smoking-cessation programs.

Cancer survivors who continue to smoke following diagnosis are at increased risk for recurrence. Yet, smoking prevalence among survivors is similar to the general population. Adherence to cystoscopic surveillance is an important disease-management strategy for non-muscle-invasive bladder cancer (NMIBC) survivors, but data from Surveillance, Epidemiology, and End Results program (SEER) suggest current adherence levels are insufficient to identify recurrences at critically early stages. This study was conducted to identify actionable targets for educational intervention to increase adherence to cystoscopic monitoring for disease recurrence or progression. NMIBC survivors (n = 109) completed telephone-based surveys. Adherence was determined by measuring time from diagnosis to interview date; cystoscopies received were then compared to American Urological Association (AUA) guidelines. Data were analyzed using non-parametric tests for univariate and logistic regression for multivariable analyses. Participants averaged 65 years (SD = 9.3) and were primarily white (95 %), male (75 %), married (75 %), and non-smokers (84 %). Eighty-three percent reported either Ta- or T1-stage bladder tumors. Forty-five percent met AUA guidelines for adherence. Compared to non-smokers, current smokers reported increased fear of recurrence and psychological distress (p < 0.05). In regression analyses, non-adherence was associated with smoking (OR = 33.91, p < 0.01), providing a behavioral marker to describe a survivor group with unmet needs that may contribute to low cystoscopic adherence. Research assessing survivorship needs and designing and evaluating educational programs for NMIBC survivors should be a high priority. Identifying unmet needs among NMIBC survivors and developing programs to address these needs may increase compliance with cystoscopic monitoring, improve outcomes, and enhance quality of life.

Characterizing Program Delivery for an Effective Multicomponent Sepsis Recovery Intervention.

Rationale: A recent randomized controlled trial revealed that a multicomponent sepsis transition and recovery (STAR) program delivered through specialized nurse navigators was effective in reducing a composite of 30-day readmission and mortality. Better understanding of patterns of care provided by the STAR program is needed to promote implementation and dissemination of this effective program.Objectives: This study characterizes individual care activities and distinct "packages" of care delivered by the STAR program.Methods: We performed a secondary analysis of data from the intervention arm of the IMPACTS (Improving Morbidity during Post-Acute Care Transitions for Sepsis) randomized controlled trial, conducted at three urban hospitals in the southeastern United States from January 2019 to March 2020. We used a structured data collection process to identify STAR nurse navigator care activities from electronic health record documentation. We then used latent class analysis to identify groups of patients receiving distinct combinations of intervention components. We evaluated differences in patient characteristics and outcomes between groups receiving distinct intervention packages.Results: The 317 sepsis survivors enrolled into the intervention arm of the IMPACTS trial received one or more of nine unique care activities delivered by STAR nurse navigators (care coordination, health promotion counseling, emotional listening, symptom management, medication management, chronic disease management, addressing social determinants of health, care setting advice and guidance, and primary palliative care). Patients received a median of three individual care activities (interquartile range, 2-5). Latent class analysis revealed four distinct packages of care activities delivered to patients with different observable characteristics and different frequency of 30-day readmission and mortality.Conclusions: We identified nine care activities delivered by an effective STAR program and four distinct latent classes or packages of intervention delivery. These results can be leveraged to increase widespread implementation and provide targets to augment future program delivery.

Variations in definitions of mortality have little influence on neonatal intensive care unit performance ratings.

OBJECTIVE: To measure the influence of varying mortality time frames on performance rankings among regional neonatal intensive care units (NICUs) in a large state. STUDY DESIGN: We performed a cross-sectional data analysis of very low birth weight infants receiving care at 24 level 3 NICUs. We tested the effect of 4 definitions of mortality: (1) death between admission and end of birth hospitalization or up to 366 days; (2) death between 12 hours of age and the end of birth hospitalization or up to 366 days; (3) death between admission and 28 days; and (4) death between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and dividing them into 3 tiers: top 6, bottom 6, and in between. RESULTS: There was wide interinstitutional variation in risk-adjusted mortality for each definition (observed minus expected z-score range, -6.08 to 3.75). However, mortality-based NICU rankings and classification into performance tiers were very similar for all institutions in each of our time frames. Among all 4 definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier. CONCLUSION: The time frame used to ascertain mortality had little effect on comparative NICU performance.

The medical home experience among children with sickle cell disease.

BACKGROUND: While a large body of research documents acute care services for children with sickle cell disease (SCD), little is known about the primary care experiences of this population. The goal of this study was to determine to what extent children with SCD experienced care consistent with a patient-centered medical home (PCMH). PROCEDURE: We collected and analyzed data from 150 children, ages 1-17 years, who received care within a large children's hospital. The primary dependent variable was access to a PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care) as determined by parental report. Multivariate logistic regression was conducted to investigate associations between socio-demographic variables and having access to a PCMH. RESULTS: Only 11% (16/150) of children qualified as having a PCMH, achieving the required thresholds in all four components. Approximately half of children had access to two or fewer components. Over 90% of children were reported to have a personal provider. Two-thirds of children had access to comprehensive care. Almost 60% of children were reported to receive family-centered care. Only 20% of children had access to coordinated care. No consistent associations were found between socio-demographic variables and having access to a PCMH or its individual components. CONCLUSIONS: Within our study sample, children with SCD experienced multiple deficiencies in having access to a PCMH, particularly with respect to care coordination. However, further studies with larger samples are needed to determine associations between socio-demographic variables and having a PCMH.

Trends in blood transfusion among hospitalized children with sickle cell disease.

BACKGROUND: Blood transfusions represent a major therapeutic option in acute management of sickle cell disease (SCD). Few data exist documenting trends in transfusion among children with SCD, particularly during hospitalization. PROCEDURE: This was an analysis of cross-sectional data of hospital discharges within the Kid's Inpatient Database (years 1997, 2000, 2003, 2006, 2009). Hospitalizations for children (0-18 years) with a primary or secondary SCD-related diagnosis were examined. The primary outcome was blood transfusion. Trends in transfusion were assessed using weighted multivariate logistic regression in a merged dataset with year as the primary independent variable. Co-variables consisted of child and hospital characteristics. Multivariate logistic regression was conducted for 2009 data to assess child and hospital-level factors associated with transfusion. RESULTS: From 1997 to 2009, the percentage of SCD-related hospitalizations with transfusion increased from 14.2% to 28.8% (P < 0.0001). Among all SCD-related hospitalizations, the odds of transfusion increased over 20% for each successive study interval. Hospitalizations with vaso-occlusive pain crisis (OR 1.35, 95% CI 1.27-1.43) or acute chest syndrome/pneumonia (OR 1.24, 95% CI 1.13-1.35) as the primary diagnoses had the highest odds of transfusion for each consecutive study interval. Older age and male gender were associated with higher odds of transfusion. CONCLUSIONS: Blood transfusion is increasing over time among hospitalized children with SCD. Further study is warranted to identify indications contributing to the rise in transfusions and if transfusions in the inpatient setting have been used appropriately. Future studies should also assess the impact of rising trends on morbidity, mortality, and other health-related outcomes.

Parental information, motivation, and adherence behaviors among children with sickle cell disease.

BACKGROUND: Identification of psychosocial correlates of health care utilization has become an important strategy in improving clinical care. The objective of the study was to examine the fit of the Information-Motivation-Behavioral Skills (IMB) model, applied to health care utilization among children with sickle cell disease (SCD). PROCEDURE: Participants were parents of 150 children, ages 1-17 years, receiving care in a sickle cell center. Parents completed questionnaires assessing information, motivation, adherence behaviors, and other factors with respect to SCD management. Data regarding health care utilization in the previous 12 months were obtained from parent report and electronic medical records. Stepwise multiple regression analysis was conducted to determine associations between IMB factors and health care use. RESULTS: Parents rated highly in the domains of information, motivation, and adherence behaviors for managing their child's SCD. Children of parents reporting higher satisfaction with social supports had higher odds (OR 1.49, 95% CI 1.03-2.15) of two or more routine hematology visits in the previous 12 months. Neither information nor adherence behavior was associated with urgent or routine care use. Among other variables measured, high parental illness-related stress and child health status reported as fair/poor were the strongest predictors of urgent care use while private insurance type was the strongest predictor of routine care use. CONCLUSIONS: Among IMB factors, social support was associated with routine health care utilization. Social support and parental illness-related stress may serve as important, modifiable targets in interventions to allocate needed resources to families and reduce unnecessary medical care.

Association of care in a medical home and health care utilization among children with sickle cell disease.

OBJECTIVE: Sickle cell disease (SCD) is marked by high utilization of medical services. The aim of this study was to determine whether having a patient-centered medical home (PCMH) is associated with a reduction in emergency care (ED) utilization or hospitalizations among children with SCD. METHODS: We collected and analyzed data from parents of 150 children, ages 1 to 17 years, who received care within a large children's hospital. The primary dependent variables were rates of parent-reported ED visits and hospitalizations. The principal independent variable was parent-reported experience with an overall PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care). Multivariate negative binomial regression, yielding incident rate ratios (IRR), was used for analysis. RESULTS: Children who received comprehensive care had half the rate of ED visits (IRR 0.51, 95% confidence interval, 0.33-0.78) and nearly half the rate of hospitalizations (IRR 0.56, 95% confidence interval, 0.33-0.93) compared to children without comprehensive care. No other component of the PCMH was significantly associated with ED visits or hospitalizations. Children reported to have excellent/very good/good health status had lower odds of ED visits and hospitalizations compared to those reported to be in fair/poor condition. CONCLUSIONS: Children with SCD reported to experience comprehensive care had lower rates of ED encounters and hospitalizations after controlling for demographics and health status. The overall findings highlight that the provision of comprehensive care--having a usual source of care and no problems with referrals--may provide a strategy for improving pediatric SCD care.

Symptom management strategies for men with early-stage prostate cancer: results from the Prostate Cancer Patient Education Program (PC PEP).

While the literature on prostate cancer health-related quality of life has grown extensively, little is known about symptom management strategies used by men to manage treatment-related side effects and the effectiveness of those strategies. We collected 628 symptom management reports from 98 men treated for localized prostate cancer. Participants were recruited from email lists and a prostate cancer clinic in Northern California. Data were collected using the Critical Incident Technique. Symptom management reports were assigned to categories of urinary, sexual, bowel, mental health, systemic, or "other." We calculated descriptive statistics by symptom type and management strategy effectiveness. The most common symptoms were urinary (26 %) and sexual (23 %). Participants' symptom management strategies varied widely, from medical and surgical interventions (20 %) to behavioral strategies (11 %) to diet and lifestyle interventions (12 %). The effectiveness of symptom management strategies varied, with sexual symptoms being managed effectively only 47 % of the time to mental health symptom management strategies considered effective 89 % of the time. Doing nothing was a commonly reported (15 %) response to symptoms and was effective only 14 % of the time. Men report the least effectiveness in symptom management for sexual dysfunction after prostate cancer treatment. Including men's experience with managing treatment side effects may be an important way to improve survivorship programs and make them more acceptable to men. More work is needed to find out why men frequently do nothing in response to symptoms when effective solutions exist and how providers can successfully engage such men.

Passing the SNF Test: A Secondary Analysis of a Sepsis Transition Intervention Trial Among Patients Discharged to Post-Acute Care.

OBJECTIVES: Sepsis survivors discharged to post-acute care facilities experience high rates of mortality and hospital readmission. This study compared the effects of a Sepsis Transition and Recovery (STAR) program vs usual care (UC) on 30-day mortality and hospital readmission among sepsis survivors discharged to post-acute care. DESIGN: Secondary analysis of a multisite pragmatic randomized clinical trial. SETTING AND PARTICIPANTS: Sepsis survivors discharged to post-acute care. METHODS: We conducted a secondary analysis of patients from the IMPACTS (Improving Morbidity During Post-Acute Care Transitions for Sepsis) randomized clinical trial who were discharged to post-acute care. IMPACTS evaluated the effectiveness of STAR, a nurse-navigator-led program to deliver best practice post-sepsis care. Subjects were randomized to receive either STAR or UC. The primary outcome was 30-day readmission and mortality. We also evaluated hospital-free days alive as a secondary outcome. RESULTS: Of 691 patients enrolled in IMPACTS, 175 (25%) were discharged to post-acute care [143 (82%) to skilled nursing facilities, 12 (7%) to long-term acute care hospitals, and 20 (11%) to inpatient rehabilitation]. Of these, 87 received UC and 88 received the STAR intervention. The composite 30-day all-cause mortality and readmission endpoint occurred in 26 (29.9%) patients in the UC group vs 18 (20.5%) in the STAR group [risk difference -9.4% (95% CI -22.2 to 3.4); adjusted odds ratio 0.58 (95% CI 0.28 to 1.17)]. Separately, 30-day all-cause mortality was 8.1% in the UC group compared with 5.7% in the STAR group [risk difference -2.4% (95% CI -9.9 to 5.1)] and 30-day all-cause readmission was 26.4% in the UC group compared with 17.1% in the STAR program [risk difference -9.4% (95% CI -21.5 to 2.8)]. CONCLUSIONS AND IMPLICATIONS: There are few proven interventions to reduce readmission among patients discharged to post-acute care facilities. These results suggest the STAR program may reduce 30-day mortality and readmission rates among sepsis survivors discharged to post-acute care facilities.

Perception of cancer and inconsistency in medical information are associated with decisional conflict: a pilot study of men with prostate cancer who undergo active surveillance.

UNLABELLED: Men with prostate cancer who choose active surveillance may experience anxiety and depression. Higher anxiety related to uncertainty surrounding cancer has been shown to increase the likelihood of choosing active treatment in the absence of a clinical indication. Certain characteristics, including physician influence and a neurotic personality, may also increase the risk of psychological distress. Our study identified particular areas that may affect the degree of satisfaction or uncertainty experienced by men choosing active surveillance. We showed that men with a positive outlook who perceived that they were receiving consistent medical information had improved ability to manage uncertainty and felt more in control of their decision-making. Men who were confident in their ability to manage prostate-related symptoms also had less insecurity with their decision. OBJECTIVE: To understand the factors associated with decision-making, we conducted a telephone-based survey as part of a pilot study to develop a psychoeducational intervention for men with prostate cancer who undergo active surveillance. PATIENTS AND METHODS: From 2007 to 2008, we conducted a cross-sectional study of 34 individuals on active surveillance for prostate cancer. We examined how specific mental health, quality of life and sociodemographic characteristics relate to decision-making. Five validated decision-making scales were used as primary outcomes reflecting the amount of satisfaction, regret and conflict a participant experienced about his decision to undergo active surveillance. A multivariate regression model was developed to identify specific psychosocial factors related to the decision-making outcomes. RESULTS: Primary analyses focused on the decisional satisfaction and conflict measures, as the decisional regret measure showed poor reliability (α < 0.70) in this sample. Four psychosocial measures showed strong associations across the decision-making subscales, including the Fife Constructed Meaning Scale (Pearson r > 0.26), Mishel Uncertainty in Illness Scale - Inconsistency (r > 0.32), Mental Health Index-5 (r > 0.33), and Lepore self-efficacy for prostate symptom management scale (r > 0.33). Individuals with higher self-efficacy for prostate cancer symptom management (P = 0.02) and higher positive meaning for cancer (P = 0.03) were less likely to express decision-making conflict as the result of uncertainty. Individuals reporting higher positive meaning for cancer (P = 0.01) and less uncertainty in illness attributed to inconsistency (P = 0.02) were less likely to exhibit decision-making conflict related to the perceived effectiveness of treatment. CONCLUSIONS: Men choosing active surveillance represent a patient group with unique vulnerabilities that require new psychoeducational interventions to provide information and support that will maintain and improve quality of life. We describe specific characteristics that may put patients at higher risk during the decision-making process and indicate their increased need for such interventions.