Resource and Service Use after Discharge among Infants Born 22-25 Weeks' Gestation at the First High-risk Infant Follow-up Visit.

OBJECTIVE: To examine resource and service use after discharge among infants born extraordinarily preterm in California who attended high-risk infant follow-up (HRIF) clinic by 12 months corrected age (CA). METHODS: We included infants born 2010-2017 between 22+0/7 and 25+6/7 weeks' gestational age (GA) in the California Perinatal Quality Care Collaborative (CPQCC) and CPQCC-California Children's Services HRIF databases. We evaluated rates of hospitalization, surgeries, medications, equipment, medical service and special service use, and referrals. We examined factors associated with receiving >2 medical services, and >1 special service. RESULTS: 3941 of 5284 infants received a HRIF visit by 12 months CA. Infants born at earlier GAs used more medications, equipment, medical services, and special services and had higher rates of referral to medical and special services at the first HRIF visit. Infants with major morbidity, surgery, caregiver concerns, and mothers with more years of education had higher odds of receiving >2 medical services. Infants with Black maternal race, younger maternal age, female sex, and discharge from lower level NICUs had lower odds of receiving >2 medical services. Infants with more educated mothers, multiple gestation, major morbidity, surgery, caregiver concerns, and discharge from lower level NICUs had increased odds of receiving a special service. CONCLUSIONS: Infants born extraordinarily preterm have substantial resource use after discharge. High resource utilization was associated with maternal/sociodemographic factors and expected clinical factors. Early functional and service use information is valuable to parents and underscores the need for NICU providers to appropriately prepare and refer families.

Rural Residence and Factors Associated with Attendance at the Second High-Risk Infant Follow-up Clinic Visit for Very Low Birth Weight Infants in California.

OBJECTIVE: This study was aimed to determine factors associated with attendance at the second high-risk infant follow-up (HRIF) visit (V2) by 20 months of corrected age after a successful first visit (V1), and the impact of rural residence on attendance rates in a statewide population of very low birth weight (VLBW; <1,500 g) infants. STUDY DESIGN: Data linked from the California Perinatal Quality of Care Collaborative (CPQCC) Neonatal Intensive Care Unit (NICU) database and CPQCC-California Children's Services (CCS) HRIF database. Multivariable logistic regression evaluated independent associations of sociodemographic, maternal, family, neonatal clinical, and individual HRIF program differences (factors) with successful V2 in VLBW infants born in 2010 to 2012. RESULTS: Of 7,295 eligible VLBW infants, 75% (5,475) attended V2. Sociodemographic factors independently associated with nonattendance included maternal race of Black (adjusted odds ratio [aOR] = 0.61; 95% confidence interval [CI]: 0.5-0.75), public insurance (aOR = 0.79; 95% CI: 0.69-0.91), and rural residence (aOR = 0.74; 95% CI: 0.61-0.9). Factors identified at V1that were associated with V2 attendance included attending V1 within the recommended window (aOR = 2.34; 95% CI: 1.99-2.75) and early intervention enrollment (aOR = 1.39; 95% CI: 1.12-1.61). Neonatal factors associated with attendance included birth weight ≤750 g (aOR = 1.83; 95% CI: 1.48-2.5). There were significant program differences with risk-adjusted rates ranging from 43.7 to 99.7%. CONCLUSION: Sociodemographic disparities and HRIF program factors are associated with decreased attendance at V2 among VLBW infants. These findings highlight opportunities for quality and process improvement interventions starting in the NICU and continuing through transition to home and community to assure participation in HRIF. KEY POINTS: · Only 75% of VLBW infants attended the second HRIF visit.. · Those less likely to attend were Black or had rural residence.. · Infants in early intervention or attending first visit within recommended ages were more likely to attend..

Disparities and Early Engagement Associated with the 18- to 36-Month High-Risk Infant Follow-Up Visit among Very Low Birthweight Infants in California.

OBJECTIVE: To determine follow-up rates for the high-risk infant follow-up (HRIF) visit at 18-36 months among infants with very low birthweights and identify factors associated with completion. STUDY DESIGN: We completed a retrospective cohort study using linked California Perinatal Quality of Care Collaborative neonatal intensive care unit, California Perinatal Quality of Care Collaborative California Children's Services HRIF, and Vital Statistics Birth Cohort databases. We identified maternal, sociodemographic, neonatal, clinical, and HRIF program level factors associated with the 18- to 36-month follow-up using multivariable Poisson regression. RESULTS: From 2010 to 2015, among 19 284 infants with very low birthweight expected to attend at least 1 visit at 18-36 months, 10 249 (53%) attended. On multivariable analysis, factors independently associated with attendance at an 18- to 36-month visit included estimated gestational age (relative risk [RR], 1.21; 95% CI, 1.15-1.26; <26 weeks vs ≥31 weeks), maternal education (RR, 1.09; 95% CI, 1.06-1.12; college degree or more vs high school), distance from clinic (RR, 0.92; 95% CI, 0.89-0.97; fourth quartile vs first quartile), and Black non-Hispanic race vs White race (RR, 0.88; 95% CI, 0.84-0.92). However, completion of an initial HRIF visit within the first 12 months was the factor most strongly associated with completion of an 18- to 36-month visit (RR, 6.47; 95% CI, 5.91-7.08). CONCLUSIONS: In a California very low birthweight cohort, maternal education, race, and distance from the clinic were associated with sustained HRIF participation, but attendance at a visit by 12 months was the most significantly associated factor. These findings highlight the importance of early engagement with all families to ensure equitable follow-through for children born preterm.

Enhancing active patient participation in nursing handover: A mixed methods study.

AIMS AND OBJECTIVES: To explore: i) the frequency and nature of patient participation in nursing handover and ii) patients' and nurses' perceived strategies to enhance patient involvement in nursing handover. BACKGROUND: Patient participation in nursing handover is important for patient-centred care, shared decision-making, patient safety and a positive healthcare experience DESIGN: A multi-site prospective study using a mixed methods design. METHODS: Between September and December 2019, nursing handovers were observed on ten randomly selected wards, followed by semi-structured interviews with patients (n = 33), and nurses (n = 20) from the observed handovers. Data were analysed using descriptive statistics for structured observations and thematic analysis of interviews, and triangulated to develop a greater understanding of patient participation in nursing handover. This study is reported using the Good Reporting of Mixed Methods Study guidelines. RESULTS: The median patient age was 77 years and 47% (n = 55) patients were female. Of the 117 handovers, 76.9% (n = 90) were conducted in the patient's presence. Patients were active participants in 33.3% (n = 30) and passive participants in 46.7% (n = 42) of handovers; in 20% of handovers (n = 18), the patient had no input at all. Active participation was more likely in women (vs. men), surgical patients (vs. medical patients) and when nurses displayed engagement behaviours (eye contact, opportunity to ask questions, explanations). Three major themes were identified from the interviews: 'Being Involved', 'Layers of Influence' and 'Information Exchange'. CONCLUSIONS: The main finding was that patient participation in handover was low and strongly influenced by a complex interplay of factors including patient and nurse preferences and perceptions. RELEVANCE TO CLINICAL PRACTICE: Handover is an essential tool in the provision of safe patient care. Patients were able to actively participate in nursing handover when they understood the purpose and timing of handover and had rapport with nurses.

Factors Associated with Successful First High-Risk Infant Clinic Visit for Very Low Birth Weight Infants in California.

OBJECTIVES: To determine rates of at least 1 high-risk infant follow-up (HRIF) visit by 12 months corrected age, and factors associated with successful first visit among very low birth weight (VLBW) infants in a statewide population-based setting. STUDY DESIGN: We used the linked California Perinatal Quality of Care Collaborative and California Perinatal Quality of Care Collaborative-California Children's Services HRIF databases. Multivariable logistic regression examined independent associations of maternal, sociodemographic, neonatal clinical, and HRIF program factors with a successful first HRIF visit among VLBW infants born in 2010-2011. RESULTS: Among 6512 VLBW children referred to HRIF, 4938 (76%) attended a first visit. Higher odds for first HRIF visit attendance was associated with older maternal age (OR, 1.48; 95% CI, 1.27-1.72; 30-39 vs 20-29 years), lower birth weight (OR, 2.11; 95% CI, 1.69-2.65; ≤750 g vs 1251-1499 g), private insurance (OR, 1.65; 95% CI, 1.19-2.31), a history of severe intracranial hemorrhage (OR, 1.61; 95% CI, 1.12-2.30), 2 parents as primary caregivers (OR, 1.18, 95% CI 1.03-1.36), and higher HRIF program volume (OR, 2.62; 95% CI, 1.88-3.66; second vs lowest quartile); and lower odds with maternal race African American or black (OR, 0.65; 95% CI, 0.54-0.78), and greater distance to HRIF program (OR, 0.69; 95% CI, 0.57-0.83). Rates varied substantially across HRIF programs, which remained after risk adjustment. CONCLUSIONS: In a population-based California VLBW cohort, maternal, sociodemographic, and home- and program-level disparities were associated with HRIF non-attendance. These findings underscore the need to identify challenges in access and resource risk factors during hospitalization in the neonatal intensive care unit, provide enhanced education about the benefits of HRIF, and create comprehensive neonatal intensive care unit-to-home transition approaches.

Programmatic and Administrative Barriers to High-Risk Infant Follow-Up Care.

OBJECTIVE: This article characterizes programmatic features of a population-based network of high-risk infant follow-up programs and identifies potential challenges associated with attendance from the providers' perspective. STUDY DESIGN: A web-based survey of high-risk infant follow-up program directors, coordinators, and providers of a statewide high-risk infant follow-up system. Frequencies and percentages were used to describe the survey responses. RESULTS: Of the 68 high-risk infant follow-up programs in California, 56 (82%) responded to the survey. The first visit no-show rate between 10 and 30% was estimated by 44% of programs with higher no-show rates for subsequent visits. Common strategies to remind families of appointments were phone calls and mailings. Most programs (54%) did not have a strategy to help families who lived distant to the high-risk infant follow-up clinic. CONCLUSION: High-risk infant follow-up programs may lack resources and effective strategies to enhance follow-up, particularly for those living at a distance.

Hospital in the Home nurses' recognition and response to clinical deterioration.

AIMS AND OBJECTIVES: To obtain an understanding of how Hospital in the Home (HITH) nurses recognise and respond to clinical deterioration in patients receiving care at home or in their usual place of residence. BACKGROUND: Recognising and responding to clinical deterioration is an international safety priority and a key nursing responsibility. Despite an increase in care delivery in home environments, how HITH nurses recognise and respond to clinical deterioration is not yet fully understood. DESIGN: A prospective, descriptive exploratory design was used. A survey containing questions related to participant characteristics and 10 patient scenarios was used to collect data from 47 nurses employed in the HITH units of three major health services in Melbourne, Australia. The 10 scenarios reflected typical HITH patients and included medical history and clinical assessment findings (respiratory rate, oxygen saturation, heart rate, blood pressure, temperature, conscious state and pain score). RESULTS: The three major findings from this study were that: (i) nurse and patient characteristics influenced HITH nurses' assessment decisions; (ii) the cues used by HITH nurses to recognise clinical deterioration varied according to the clinical context; and (iii) although HITH nurses work in an autonomous role, they engage in collaborative practice when responding to clinical deterioration. CONCLUSION: Hospital in the Home nurses play a fundamental role in patient assessment, and the context in which they recognise and respond to deterioration is markedly different to that of hospital nurses. RELEVANCE TO CLINICAL PRACTICE: The assessment, measurement and interpretation of clinical data are a nursing responsibility that is crucial to early recognition and response to clinical deterioration. The capacity of HITH services to care for increasing numbers of patients in their home environment, and to promptly recognise and respond to clinical deterioration should it occur, is fundamental to safety within the healthcare system. Hospital in the Home nurses are integral to a sustainable healthcare system that is responsive to dynamic changes in public health policies, and meets the healthcare needs of the community.

Referral of very low birth weight infants to high-risk follow-up at neonatal intensive care unit discharge varies widely across California.

OBJECTIVES: To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative. STUDY DESIGN: Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral. RESULTS: In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ≤ 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment. CONCLUSIONS: There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.

Factors associated with follow-up of infants with hypoxic-ischemic encephalopathy in a high-risk infant clinic in California.

OBJECTIVE: To determine the rates of high-risk infant follow-up (HRIF) attendance and the characteristics associated with follow-up among infants with hypoxic-ischemic encephalopathy (HIE) in California. STUDY DESIGN: Using population-based datasets, 1314 infants with HIE born in 2010-2016 were evaluated. The characteristics associated with follow-up were identified through multivariable logistic regression. RESULTS: 73.9% of infants attended HRIF by age 1. Follow-up rates increased and variation in follow-up by clinic decreased over time. Female infants; those born to African-American, single, less than college-educated, or publicly insured caregivers; and those referred to high-volume or regional programs had lower follow-up rates. In multivariable analysis, Asian and Pacific Islander race/ethnicity had lower odds of follow-up; infants with college- or graduate school-educated caregivers or referred to mid-volume HRIF programs had greater odds. CONCLUSION: Sociodemographic and program-level characteristics were associated with lack of follow-up among HIE infants. Understanding these characteristics may improve the post-discharge care of HIE infants.

Trait anger management style moderates effects of actual ("state") anger regulation on symptom-specific reactivity and recovery among chronic low back pain patients.

OBJECTIVES: We examined whether "state" anger regulation-inhibition or expression-among chronic low back pain (CLBP) patients would affect lower paraspinal (LP) muscle tension following anger-induction, and whether these effects were moderated by trait anger management style. METHOD: Eighty-four CLBP patients underwent harassment, then they regulated anger under one of two conditions: half expressed anger by telling stories about people depicted in pictures, whereas half inhibited anger by only describing objects appearing in the same pictures. They completed the anger-out and anger-in subscales (AOS; AIS) of the anger expression inventory. RESULTS: General Linear Model procedures were used to test anger regulation condition by AOS/AIS by period interactions for physiological indexes. Significant three-way interactions were found such that: a) high trait anger-out patients in the inhibition condition appeared to show the greatest LP reactivity during the inhibition period followed by the slowest recovery; b) high trait anger-out patients in the expression condition appeared to show the greatest systolic blood pressure (SBP) reactivity during the expression period followed by rapid recovery. CONCLUSIONS: Results implicate LP muscle tension as a potential physiological mechanism that links the actual inhibition of anger following provocation to chronic pain severity among CLBP patients. Results also highlight the importance of mismatch situations for patients who typically regulate anger by expressing it. These CLBP patients may be at particular risk for elevated pain severity if circumstances at work or home regularly dictate that they should inhibit anger expression.

Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model.

OBJECTIVE: Evidence for links between anger inhibition or suppression and chronic pain severity is based mostly on studies with correlation designs. Following from ironic process theory, we proposed that attempts to suppress angry thoughts during provocation would increase subsequent pain intensity among chronic low back pain (CLBP) patients, and do so through paradoxically enhanced accessibility of anger. DESIGN: CLBP patients (N = 58) were assigned to suppression and nonsuppression conditions while performing a computer maze task with a harassing confederate. A structured pain behavior task (SPBT) followed. MAIN OUTCOME MEASURES: Self-reported anger, anxiety, and sadness following maze task. Self-reported pain severity and number of observed pain behaviors during SPBT. RESULTS: Patients told to suppress during provocation: (a) reported greater anger following the maze task, reported greater pain intensity during the SPBT, and exhibited more pain behaviors than patients not suppressing; (b) postmaze anger levels significantly mediated group differences on pain behaviors. CONCLUSION: Attempts by CLBP patients to suppress anger may aggravate pain related to their clinical condition through ironically increased feelings of anger.

Hospital in the home nurses' assessment decision making: an integrative review of the literature.

AIM: To describe what is currently known about nurses' assessment decisions when providing care to patients at home or in their usual place of residence. METHODS: In August 2018, an integrative literature review using a systematic approach was conducted using specific search terms to search Informit, MEDLINE and Cumulative Index of Nursing and Allied Health Literature (CINAHL). The literature search was not limited by date, and included published papers or unpublished dissertations written between 1980 and 2018. RESULTS: In total 25 full papers were assessed for inclusion in this review; seven met the inclusion criteria. Three themes were identified from this review: i) nurse education and experience; ii) assessment informing decision-making and iii) knowing the patient. CONCLUSION: Nurses' education, experience, abilities, prior learning, beliefs, attitudes and values are key factors in the delivery of home-based nursing care, and strongly influence how assessments, clinical judgements and decisions are made. Impact Statement: An understanding of home based nurses' decisions and response to clinical deterioration is needed to inform Hospital in the Home nursing-specific curricula.

Baseline behavior, but not sensitivity to stimulant drugs, differs among spontaneously hypertensive, Wistar-Kyoto, and Sprague-Dawley rat strains.

Deficits in temporal processing are implicated in Attention Deficit Hyperactivity Disorder (ADHD) for which the most common rodent model is the Spontaneously Hypertensive Rat (SHR). To assess strain differences in temporal processing, males and females of the SHR, Wistar-Kyoto (WKY), and Sprague-Dawley (SD) strains were compared on two timing tasks: one requiring maintenance of a lever press for 10-14 s (TRD, temporal response differentiation) and the other requiring withholding of a lever press for 10-14 s (DRL, differential reinforcement of low rates). Performance of the progressive ratio (PR) task more directly assessed food-motivated behavior. Strains did not differ in task acquisition; however, steady state TRD and DRL performance of the SHR and WKY strains was less accurate which was related to increased burst (non-timing related) responses in those strains relative to the SD. PR performance demonstrated that the SHR and WKY strains exhibited higher response rates and breakpoints than the SD. Subsequently, methylphenidate (1, 3.25, 4.50, 7.50, and 12.0 mg/kg) and d-amphetamine (0.1, 0.25, 0.65, 1.0, and 2.0 mg/kg) were administered intraperitoneally pre-testing. Both drugs disrupted TRD and DRL performances by increasing burst response frequency; however, the strains were not differentially sensitive to either drug. Strain differences were generally maintained throughout the drug and extinction portions of the study. These results indicate increased similarity between the SHR and WKY strains relative to the SD in performance of timing and motivation tasks. Further, the current results do not support continued use of the SHR as a model for ADHD.

Provider Opinions Regarding Expanding Access to Hormonal Contraception in Pharmacies.

PURPOSE: Expanding access to hormonal contraception may reduce the barrier created with the current prescription requirement. The goal of this study was to gain a better understanding of health care providers' opinions on expanding access to hormonal contraception (oral pill, transdermal patch, vaginal ring, and injectable) and the role of pharmacists as direct providers of this reproductive health service. METHODS: A voluntary, self-administered survey was distributed to participating national professional associations' physician and midlevel provider members who provide reproductive health services. Outcomes of providers' opinions on expanded access to hormonal contraception in pharmacies were analyzed by provider type (n = 482). FINDINGS: Almost three-quarters (74%) of the 482 providers surveyed, 76% of physicians and 70% of midlevels, were supportive of expanding access for the pill, patch, and ring contraceptives to include pharmacist-initiated access. Despite overall support for pharmacist-initiated access, more than 70% of respondents were concerned that expanded access would result in decreased reproductive health preventive screening. Slightly fewer providers supported or were neutral towards behind-the-counter (65% for pill/patch/ring, 55% injectable) and over-the-counter (47% for pill/patch/ring, 36% injectable) access than for pharmacist-initiated access. CONCLUSIONS: The majority of reproductive health providers support pharmacist-initiated access to the pill, patch, ring, and injectable contraceptives. There is some support for behind-the-counter and over-the-counter access. Provider concerns about lower rates of reproductive health preventive screenings and pharmacist training issues would need to be appropriately addressed along with any policy changes.

Aging effects on elevated plus maze behavior in spontaneously hypertensive, Wistar-Kyoto and Sprague-Dawley male and female rats.

Male and female spontaneously hypertensive (SHR), Wistar-Kyoto (WKY), and Sprague-Dawley (SD) rats were assessed at one of two ages (postnatal day 74 or 346) for open field locomotor activity and anxiety-related behavior in the elevated plus maze (EPM). In general, the SHR displayed the least anxiety-related behavior, an effect that was magnified with age. At 11 months of age, the SHR more frequently entered and remained longer in the open arms than either the SD or the WKY strains. EPM behavior of the WKY strain was much less affected by age than that of the SD strain which displayed increased anxiety-related behavior with age. At the younger age, the typical sex effects were apparent; specifically, females exhibited a shorter duration in the closed arms. While the SHR were the most active strain in the EPM at both ages, they were more active in the open field only at the older age. In general, age-related changes in open field activity mirrored those of the EPM. These results provide a more comprehensive illustration of aging-related behavioral changes in male and female SHR, WKY and SD rats.

Early behavioral development in the spontaneously hypertensive rat: a comparison with the Wistar-Kyoto and Sprague-Dawley strains.

The spontaneously hypertensive rat (SHR) is often used as a model for childhood attention-deficit/hyperactivity disorder (ADHD). To investigate behavioral maturation in SHR, body weight, age at eye opening, and performance in several behavioral tasks in male and female SHR, Wistar-Kyoto (WKY), and Sprague-Dawley rats were compared. SHRs were slower in performing the righting reflex on PND 4 and negative geotaxis compared with WKY and Sprague-Dawley. Both SHR and WKY were delayed relative to Sprague-Dawley in eye opening and beam walking. Rotarod performance was comparable in the 3 strains. Males were faster to right themselves than females, but there were no other significant sex differences nor Sex X Strain interactions. Delayed development in SHR may be related to a maturational delay observed in children with ADHD. Research assessing early behaviors in SHR, WKY, and other strains will help determine the most appropriate model for childhood ADHD and may help predict later behavioral dysfunction.

Shifts in attention biases in response to acute pain induction: examination of a model of "conversion" among repressors.

Unlike most people, those who are characterized by a repressive coping style report high levels of physical (sensory) pain but low levels of emotional distress (affective pain), which is a discrepancy that may suggest a "conversion" process. In two studies, we tested an attention allocation model, proposing that repressors direct attention away from threatening negative affective information and toward nonthreatening physical pain information during emotionally arousing (painful) situations. In Study 1, 84 participants underwent a cold pressor and then recovered. Repressors reported greater pain during recovery than low- and high-anxious participants, but they reported lower distress than high-anxious participants. Repressors reported significant and large discrepancies between high pain and low distress, whereas these differences were less pronounced for other groups. In Study 2, 77 participants underwent an ischemic pain task while performing a modified dot-probe task with sensory and negative affective pain words as stimuli. Repressors showed increasing biases away from affective pain words and toward sensory pain words as the pain task continued, whereas low- and high-anxious participants did not show these shifts in attention. The results support the notion that conversion among repressors may involve a process by which attention is directed away from emotional distress during noxious stimulation and is focused instead on sensory information from pain.