Interprofessional Care Models for Pregnant and Early-Parenting Persons Who Use Substances: A Scoping Review.

Introduction: Use of substances during pregnancy is a global health concern. Interprofessional care teams can provide an optimal care approach to engage individuals who use substances during the perinatal period. The purpose of this scoping review is to provide a comprehensive summation of published literature reporting on interprofessional care models for perinatal individuals who use substances. Methods: We conducted a systematic search for articles from health-related databases. The Preferred Reporting Items for Systematic Reviews for Scoping Reviews (PRISMA-ScR) was followed. Data were extracted and synthesized to identify the interprofessional care team roles, program and/or provider characteristics, and care outcomes of these models. Results: We screened 645 publications for full text eligibility. Eleven articles met full inclusion criteria and were summarized. Programs were built on co-location of services, partnership with other agencies, available group/peer support and approaches inclusive of cultural care, trauma informed care, and harm reduction principles. Discussion: There is growing evidence supporting integrated care models that are inclusive of relational care providers from multiple health care professions to achieve wraparound care. Conclusions: Many of the interprofessional care models studied have successfully blended social, primary, pregnancy, and addictions care. The success and sustainability of programs varies, and more work is needed to evaluate program and patient outcomes.

Best Practices for Promoting Safe Patient Care Delivery by Hospital-Based Traveling Clinical Staff: An Integrative Review.

BACKGROUND: Hospitals use traveling clinical staff (TCS) to fill personnel shortages. Although this approach may help improve staffing ratios, it is not without risk. PURPOSE: The interdisciplinary team conducted an integrative literature review to determine best practices for promoting safe patient care delivery by TCS. METHODS: Using the Johns Hopkins Evidence-Based Practice model, the authors performed an integrative literature review, including appraisal of quality, synthesis of themes, and best-evidence recommendations. RESULTS: The final synthesis included 16 articles. Evidence demonstrated the importance of preemployment screening, standardized onboarding and orientation, and optimizing the integration of TCS into the work environment. CONCLUSION: Hospitals should use these recommendations when incorporating TCS into their teams.

Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study.

BACKGROUND: We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population. METHODS: Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years. RESULTS: Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups. CONCLUSION: An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Early evaluation of the safety, reactogenicity, and immune response after a single dose of modified vaccinia Ankara-Bavaria Nordic vaccine against mpox in children: a national outbreak response.

BACKGROUND: In response to a national mpox (formerly known as monkeypox) outbreak in England, children exposed to a confirmed mpox case were offered modified vaccinia Ankara-Bavaria Nordic (MVA-BN), a third-generation smallpox vaccine, for post-exposure prophylaxis. We aimed to assess the safety and reactogenicity and humoral and cellular immune response, following the first reported use of MVA-BN in children. METHODS: This is an assessment of children receiving MVA-BN for post-exposure prophylaxis in response to a national mpox outbreak in England. All children receiving MVA-BN were asked to complete a post-vaccination questionnaire online and provide a blood sample 1 month and 3 months after vaccination. Outcome measures for the questionnaire included reactogenicity and adverse events after vaccination. Blood samples were tested for humoural, cellular, and cytokine responses and compared with unvaccinated paediatric controls who had never been exposed to mpox. FINDINGS: Between June 1 and Nov 30, 2022, 87 children had one MVA-BN dose and none developed any serious adverse events or developed mpox disease after vaccination. Post-vaccination reactogenicity questionnaires were completed by 45 (52%) of 87 children. Their median age was 5 years (IQR 5-9), 25 (56%) of 45 were male, and 22 (49%) of 45 were White. 16 (36%) reported no symptoms, 18 (40%) reported local reaction only, and 11 (24%) reported systemic symptoms with or without local reactions. Seven (8%) of 87 children provided a first blood sample a median of 6 weeks (IQR 6·0-6·5) after vaccination and five (6%) provided a second blood sample at a median of 15 weeks (14-15). All children had poxvirus IgG antibodies with titres well above the assay cutoff of OD450nm 0·1926 with mean absorbances of 1·380 at six weeks and 0·9826 at 15 weeks post-vaccination. Assessment of reactivity to 27 recombinant vaccina virus and monkeypox virus proteins showed humoral antigen recognition, primarily to monkeypox virus antigens B6, B2, and vaccina virus antigen B5, with waning of humoral responses observed between the two timepoints. All children had a robust T-cell response to whole modified vaccinia Ankara virus and a select pool of conserved pan-Poxviridae peptides. A balanced CD4+ and CD8+ T-cell response was evident at 6 weeks, which was retained at 15 weeks after vaccination. INTERPRETATION: A single dose of MVA-BN for post-exposure prophylaxis was well-tolerated in children and induced robust antibody and cellular immune responses up to 15 weeks after vaccination. Larger studies are needed to fully assess the safety, immunogenicity, and effectiveness of MVA-BN in children. Our findings, however, support its on-going use to prevent mpox in children as part of an emergency public health response. FUNDING: UK Health Security Agency.

Environmental chamber studies of eye and respiratory irritation from use of a peracetic acid-based hospital surface disinfectant.

Objective: To characterize personal exposures and measures of eye and respiratory tract irritation in controlled environmental chamber studies of 44 healthy adult volunteers simulating upper-bound use of peracetic acid (PAA)-based surface disinfectant for terminal cleaning of hospital patient rooms. Design: Experimental, within-subject, double-blinded cross-over design. Methods: Objective and subjective exposure effects were assessed for PAA and its components: acetic acid (AA) and hydrogen peroxide (HP). Deionized water was included as a control. Breathing-zone concentrations of PAA, AA, and HP were assessed for 8 female multiday volunteers (5 consecutive days) and 36 single-day volunteers (32 females and 4 males). Wetted cloths were used to wipe high-touch surfaces for 20 minutes per trial. Also, 15 objective measures of tissue injury or inflammation and 4 subjective odor or irritation scores were assessed. Results: Disinfectant trials showed 95th percentile breathing zone concentrations of 101 ppb PAA, 500 ppb AA, and 667 ppb HP. None of the volunteers observed over 75 test days exhibited significant increases in IgE or objective measures of eye and respiratory tract inflammation. Subjective ratings for disinfectant and AA-only trials showed similar increases for odor intensity and nose irritation, with lower ratings for eye and throat irritation. Females were 2.5-fold more likely than males to assign moderate + irritation ratings. Conclusions: Simulated upper-bound hospital use of PAA-based disinfectant led to no significant increases in objective markers of tissue injury, inflammation, or allergic sensitization, and no frank signs of eye or respiratory tract irritation.

Incidence of Instability Following Primary Total Hip Arthroplasty Continues to Decline in the Medicare Population.

BACKGROUND: Instability has been the primary cause of failure following primary total hip arthroplasty (THA) leading to revision hip surgery. The purpose of this study was to determine if instability rates have further declined following advances in primary THA, including dual mobility articulations, direct anterior approaches, advanced technologies, and improved knowledge of the hip-spine relationships. METHODS: Using the 5% Medicare Part B claims data from 1999 to 2019, we identified 81,573 patients who underwent primary THA for osteoarthritis. Patients who experienced instability at 3 months, 6 months, 1 year, and 2 years were identified. Multivariate cox regression analyses evaluated the effect of patient and procedure characteristics on the risk of instability. RESULTS: Instability at 1 year following primary THA declined from approximately 4% in 2000 to 2.3% in 2010 and 1.6% in 2018. The leading cause of revision surgery was infection (18.6%), followed by periprosthetic fracture (14%), mechanical loosening (11.5%), and instability (9.4%). High-risk groups for instability continue to include increased age, higher Charlson index, obesity, lumbar spine pathology, and neurocognitive disorders. CONCLUSION: Instability is no longer the leading etiology of failure following primary THA with a decline of approximately 40% over the past decade. Infection, periprosthetic fracture, mechanical loosening, and then instability are now the leading causes of failure. Multiple factors may play a role in the decline of instability, including increased use of dual mobility articulations, direct anterior approaches, improved knowledge of the hip-spine relationships, and use of advanced technologies.

Manipulation Following Primary Total Knee Arthroplasty is Associated With Increased Rates of Infection and Revision.

BACKGROUND: Stiffness following total knee arthroplasty (TKA) is a disabling complication and manipulation under anesthesia (MUA) is often performed as an early intervention. Few studies have focused on the revision risk, infection risk, demographics, and clinical outcomes in Medicare patients undergoing MUA following primary TKA. METHODS: We reviewed 142,440 patients who had primary TKA from a national database and identified 3,652 patients (2.6%) who underwent MUA. Patient demographics and comorbid conditions were evaluated to identify risk factors. Incidence of revision and periprosthetic joint infection (PJI) at 1-, 2-, and 5-year time points in a cohort of MUA patients was compared to patients who did not undergo MUA. Multivariate Cox regressions were used for statistical analyses. RESULTS: The incidence of MUA was higher in Black versus White individuals (4.1 versus 2.5%, P < .001). Revision risk was significantly greater in the MUA group at 1-, 2-, and 5-year time points with a hazard ratio (HR) of, 3.81, 3.90, and 3.22 respectively, P < .001. One- and 2-year revision risk was significantly greater when MUA occurred at 6 to 12 months post-TKA when compared to <3 months, P < .05. Risk of PJI was significantly greater in the MUA group with a HR of 2.2, 2.2, and 2.1 at 1, 2, and 5 years, respectively P < .001. CONCLUSION: The incidence of MUA was 2.6%. There was an increased incidence of revision surgery and PJI in patients undergoing MUA. Patients at increased risk for stiffness following TKA should be closely monitored and treated with early intervention to minimize risk of poor outcomes.

Fetal heart rate responses to maternal sleep-disordered breathing.

BACKGROUND: Maternal sleep-disordered breathing is associated with adverse pregnancy outcomes and is considered to be deleterious to the developing fetus. Maternal obesity potentiates sleep-disordered breathing, which, in turn, may contribute to the effect of maternal obesity on adverse fetal outcomes. However, only a few empirical studies have evaluated the contemporaneous effects of maternal sleep-disordered breathing events on fetal well-being. These events include apnea and hypopnea with accompanying desaturations in oxyhemoglobin. OBJECTIVE: This study aimed to reconcile contradictory findings on the associations between maternal apnea or hypopnea events and clinical indicators of fetal compromise. It also sought to broaden the knowledge base by examining the fetal heart rate and heart rate variability before, during, and after episodes of maternal apnea or hypopnea. To accomplish this, we employed overnight polysomnography, the gold standard for ascertaining maternal sleep-disordered breathing, and synchronized it with continuous fetal electrocardiography. STUDY DESIGN: A total of 84 pregnant women with obesity (body mass index >30 kg/m2) participated in laboratory-based polysomnography with digitized fetal electrocardiography recordings during or near 36 weeks of gestation. Sleep was recorded, on average, for 7 hours. Decelerations in fetal heart rate were identified. Fetal heart rate and heart rate variability were quantified before, during, and after each apnea or hypopnea event. Event-level intensity (desaturation magnitude, duration, and nadir O2 saturation level) and person-level characteristics based on the full overnight recording (apnea-hypopnea index, mean O2 saturation, and O2 saturation variability) were analyzed as potential moderators using linear mixed effects models. RESULTS: A total of 2936 sleep-disordered breathing events were identified, distributed among all but 2 participants. On average, participants exhibited 8.7 episodes of apnea or hypopnea per hour (mean desaturation duration, 19.1 seconds; mean O2 saturation nadir, 86.6% per episode); nearly half (n=39) of the participants met the criteria for obstructive sleep apnea. Only 45 of 2936 apnea or hypopnea events were followed by decelerations (1.5%). Conversely, most (n=333, 88%) of the 378 observed decelerations, including the prolonged ones, did not follow an apnea or a hypopnea event. Maternal sleep-disordered breathing burden, body mass index, and fetal sex were unrelated to the number of decelerations. Fetal heart rate variability increased during events of maternal apnea or hypopnea but returned to initial levels soon thereafter. There was a dose-response association between the size of the increase in fetal heart rate variability and the maternal apnea-hypopnea index, event duration, and desaturation depth. Longer desaturations were associated with a decreased likelihood of the variability returning to baseline levels after the event. The mean fetal heart rate did not change during episodes of maternal apnea or hypopnea. CONCLUSION: Episodes of maternal sleep apnea and hypopnea did not evoke decelerations in the fetal heart rate despite the predisposing risk factors that accompany maternal obesity. The significance of the modest transitory increase in fetal heart rate variability in response to apnea and hypopnea episodes is not clear but may reflect compensatory, delimited autonomic responses to momentarily adverse conditions. This study found no evidence that episodes of maternal sleep-disordered breathing pose an immediate threat, as reflected in fetal heart rate responses, to the near-term fetus.

Current considerations for clinical management and care of non-alcoholic fatty liver disease: Insights from the 1st International Workshop of the Canadian NASH Network (CanNASH).

Non-alcoholic fatty liver disease (NAFLD) affects approximately 8 million Canadians. NAFLD refers to a disease spectrum ranging from bland steatosis to non-alcoholic steatohepatitis (NASH). Nearly 25% of patients with NAFLD develop NASH, which can progress to liver cirrhosis and related end-stage complications. Type 2 diabetes and obesity represent the main risk factors for the disease. The Canadian NASH Network is a national collaborative organization of health care professionals and researchers with a primary interest in enhancing understanding, care, education, and research around NAFLD, with a vision of best practices for this disease state. At the 1st International Workshop of the CanNASH network in April 2021, a joint event with the single topic conference of the Canadian Association for the Study of the Liver (CASL), clinicians, epidemiologists, basic scientists, and community members came together to share their work under the theme of NASH. This symposium also marked the initiation of collaborations between Canadian and other key opinion leaders in the field representative of international liver associations. The main objective is to develop a policy framework that outlines specific targets, suggested activities, and evidence-based best practices to guide provincial, territorial, and federal organizations in developing multidisciplinary models of care and strategies to address this epidemic.

Evidence-based practices in developing and maintaining clinical nurse preceptors: An integrative review.

OBJECTIVES: This integrative review of literature explores the best practice for establishing and maintaining a hospital-based nurse preceptor program. The intent is to provide nurse leadership and educators with guidance for optimizing preceptor programs in order to improve patient, staff, and organizational outcomes. DESIGN: The project team conducted an integrative review of literature to inform best practice using the Johns Hopkins Evidence-Based Practice Model and Guidelines. DATA SOURCES: Data sources included the PubMed, CINAHL, and Cochrane databases. REVIEW METHODS: Each applicable article underwent a rigorous review and appraisal by the project team. The team used the Johns Hopkins Evidence-Based Practice Model to guide the appraisal process and to synthesize results to generate a comprehensive list of recommendations. RESULTS: The search yielded 115 unique articles that answered the evidence-based practice question. What are best practices for establishing and maintaining a hospital-based nursing preceptor program? Due to the abundance of data, the practice question was divided into three separate sub questions that explored preceptor development, continuous preceptor support, and essential competencies of preceptors. Relevant evidence included one level I article, seven level II articles, and one level IV article. Most of the evidence was found in articles ranking as level III (n = 54) and level V (n = 52). CONCLUSIONS: Many preceptorship themes and recommendations resonate throughout multiple levels of evidence. Recommendations include implementing an evidence-based, standardized curriculum that features diverse teaching modalities, critical thinking, and clinical reasoning. Common themes in the literature echo that preceptors need ongoing education, training, and support to improve nursing satisfaction, retention, and the quality of nursing care.

Robotic-Arm Assisted Total Knee Arthroplasty: Cost Savings Demonstrated at One Year.

Purpose: Robotic-arm assisted total knee arthroplasty (RATKA) has the potential to enhance radiographic, clinical, and patient-reported outcomes. The purpose of this study was to compare resource utilization, episode-of-care (EOC) costs, readmissions, and complications of robotic-arm assisted total knee arthroplasty (RATKA) and manual TKA (MTKA). Methods: TKA procedures were identified from a private payer claims database. RATKA procedures required both a robotic arm-assisted procedure code and a 60-day pre-operative computed tomography scan. Propensity score matching (1:5 RATKA to MTKA) was performed, based on various patient characteristics and comorbidities. After matching, 4452 patients (742 RATKA and 3710 MTKA) were analyzed for 90-day and one-year EOC costs, index TKA costs, lengths of stay (LOS), discharge statuses, rehabilitation utilizations, as well as 90-day and one-year readmissions- and knee-related complications. Results: RATKA patients had shorter LOS (mean 1.56 versus 1.91 days; p < 0.001), lower index costs by $1762 ($32,747 versus $34,509; p = 0.003), and higher discharges to home rates (51.8 versus 47.8%; p = 0.049) than MTKA patients. RATKA patients had less 90-day (68.5 versus 72.0%; p = 0.048) and one-year (70.8 versus 75.0%; p = 0.016) home health utilizations. The RATKA cohort had lower 90-day ($39,260 versus $41,458; p = 0.001) and one-year ($51,462 versus $54,171; p = 0.011) EOC costs. No significant differences in readmission and overall complication rates were observed (p > 0.05). Conclusion: RATKA was associated with lower index costs and EOC costs at both 90 days and one year. These patients had shorter LOS, were discharged home more frequently, and used less home health services. Cost savings were demonstrated for RATKA beyond the 90-day period with an increase in savings between 90-day and one-year time points. These data may be of importance to payers and providers interested in the longer-term value of RATKA.

Monitored and Modeled Ambient Air Concentrations of Ethylene Oxide: Contextualizing Health Risk for Potentially Exposed Populations in Georgia.

Recent studies have monitored and modeled long-term ambient air concentrations of ethylene oxide (EO) around emitting facilities in Georgia with the intent of informing risk management of potentially exposed nearby residential populations. Providing health context for these data is challenging because the U.S. Environmental Protection Agency's risk-specific concentrations lack practical utility in distinguishing a health significant increase in exposure. This study analyzes EO data for eight emitting facilities, using a previously published alternative exposure metric, the total equivalent concentration, which is based on U.S. Centers for Disease Control biomarker data for the non-smoking U.S. POPULATION: Mean concentrations for monitoring sites were compared to mean background concentrations to assess whether emissions contribute significantly to environmental concentrations. To assess the health significance of potential exposure at nearby residential locations, the 50th percentile concentration was added to the 50th percentile endogenous equivalent concentration and compared to the total equivalent concentration distribution for the non-smoking U.S. POPULATION: The findings demonstrate that impacts from nearby emission sources are small compared to mean background concentrations at nearby locations, and the total equivalent concentrations for exposed populations are generally indistinguishable from that of the 50th percentile for the non-smoking U.S.

Measuring fetal heart rate and variability: Fetal cardiotocography versus electrocardiography.

Fetal heart rate variability is a key indicator of fetal neurodevelopment and well-being. Most studies have relied on Doppler-based fetal cardiotocography (fCTG) but recent technologies have made fetal electrocardiography (fECG) more widely available. We compared simultaneous recordings of fCTG and fECG in 131 fetuses twice during gestation (28 and 36 weeks) using a commercially available device (Monica AN24). Within-individual correlations for fetal heart rate values, based on averaged data during 50-min recordings, neared 1.0. Continuous and episodic measures of variability were also correlated, particularly at 36 weeks. Data collected during maternal polysomnography at 36 weeks were used to evaluate reliability of variability measures collected during the 50-min recording. Both fCTG- and fECG-derived measures of variability exhibited correspondence with variability during maternal presleep wakefulness and most sleep states. Results did not appreciably differ by data source or method used to calculate variability. fECG monitoring presented challenges, particularly at 28 weeks, when recordings with signal loss of ≤30% were available from only 27% of participants. Success rates improved to 84% at 36 weeks. fCTG was successful in over 90% of participants at each gestational age. Considerations in the selection of fECG versus fCTG in developmental research are discussed.

Fetal neuromaturation in late gestation is affected by maternal sleep disordered breathing and sleep disruption in pregnant women with obesity.

OBJECTIVE: Maternal sleep disordered breathing and sleep disruption have adverse effects on pregnancy outcomes through multiple potential pathophysiologic pathways. We hypothesize that disordered maternal sleep also adversely impacts the neuromaturation of the fetus. METHODS: Participants in this prospective observational study included 102 obese pregnant women (pre-pregnancy body mass index [BMI] of 30 or higher) at 36 weeks of pregnancy. Fetal neuromaturation, defined through measures of fetal heart rate variability, motor activity, and motor-cardiac coupling, was quantified through digitized fetal actocardiography during an afternoon recording. Maternal sleep measures were collected overnight through polysomnography. Data analysis focused on multiple regression, controlling for maternal BMI, blood pressure, and diabetes. RESULTS: Indicators of higher sleep disordered breathing were associated with delayed fetal neuromaturation and greater fetal motor activity. Less maternal sleep disruption (shorter rapid eye movement [REM] latency, more REM sleep, and/or fewer transitions) was associated with higher fetal heart rate variability and coupling-based neuromaturation. CONCLUSION: Characteristics of disordered maternal sleep affect the developing fetal nervous system. It is unknown whether these results extend to populations that are not characterized by obesity. The influence of maternal sleep on the developing fetal nervous system has been understudied and may yield effects that persist beyond pregnancy.

Scoping Review of Best Practice Guidelines for Care in the Labor and Birth Setting of Pregnant Women Who Use Methamphetamines.

OBJECTIVE: To use a scoping review to explore the existing literature on best practice guidelines for safe, dignified, and compassionate care in the labor and birth setting for pregnant women who use methamphetamines. DATA SOURCES: We conducted a systematic search for articles and best practice guidelines from health-related databases (MEDLINE; CINAHL; and the Web of Science, including the Core Collection and Social Science Citation Index, PsycInfo, Women's Studies International, and Sociological Abstracts) and gray literature. Search terms included substance use disorder, methamphetamine, childbirth, and labor and delivery. STUDY SELECTION: We included English-language, peer-reviewed reports of primary research, systematic reviews, and practice guidelines from credible databases and organizations published between 1991 and 2020. We screened 1,297 resources and agreed to review 156 articles and 16 gray literature resources in the full-text analysis. Nine of the 156 articles and 16 gray literature resources met the inclusion criteria. DATA EXTRACTION: We used the Joanna Briggs Institute review guidelines (2015) criteria for extraction of the following data: author(s); year of publication; type of study; objectives; country of origin; study population and sample size (if applicable); inclusion of best practice guidelines for the labor and birth setting; care approaches specific to safety, dignity, compassion; and the targeted substance(s) discussed (e.g., methamphetamine, opioids, etc.). We further documented the phenomena of interest to determine if articles or best practice guidelines included safe, dignified, and compassionate care approaches specific to pregnant women who use methamphetamine. DATA SYNTHESIS: We summarized the best practice guidelines, which included universal screening, assessment, and management of analgesia during labor, as well as broad guidance regarding the inclusion of a multidisciplinary health care team. Safe, dignified, and compassionate care approaches were focused on communication, shared decision making, and the provision of nonjudgmental care. Although evidence about substance use during the childbearing years is increasing, stronger evidence for clinical care approaches in the labor and birth setting is needed, inclusive of all stakeholder perspectives. CONCLUSION: The articles and best practice guidelines reviewed provided broad clinical recommendations that were applicable to pregnant women who use methamphetamine. However, we did not find a complete comprehensive best practice guideline for labor and birth that was specific, was solution focused, and delineated a safe, dignified, and compassionate care approach.

Association between post-hospital clinic and telephone follow-up provider visits with 30-day readmission risk in an integrated health system.

BACKGROUND: Follow-up visits with clinic providers after hospital discharge may not be feasible for some patients due to functional limitations, transportation challenges, need for physical distancing, or fear of exposure especially during the current COVID-19 pandemic. METHODS: The aim of the study was to determine the effects of post-hospital clinic (POSH) and telephone (TPOSH) follow-up provider visits versus no visit on 30-day readmission. We used a retrospective cohort design based on data from 1/1/2017 to 12/31/2019 on adult patients (n = 213,513) discharged home from 15 Kaiser Permanente Southern California hospitals. Completion of POSH or TPOSH provider visits within 7 days of discharge was the exposure and all-cause 30-day inpatient and observation stay readmission was the primary outcome. We used matching weights to balance the groups and Fine-Gray subdistribution hazard model to assess for readmission risk. RESULTS: Unweighted all-cause 30-day readmission rate was highest for patients who completed a TPOSH (17.3%) followed by no visit (14.2%), non-POSH (evaluation and management visits that were not focused on the hospitalization: 13.6%) and POSH (12.6%) visits. The matching weighted models showed that the effects of POSH and TPOSH visits varied across patient subgroups. For high risk (LACE 11+) medicine patients, both POSH (HR: 0.77, 95% CI: 0.71, 0.85, P < .001) and TPOSH (HR: 0.91, 95% CI: 0.83, 0.99, P = .03) were associated with 23 and 9% lower risk of 30-day readmission, respectively, compared to no visit. For medium to low risk medicine patients (LACE< 11) and all surgical patients regardless of LACE score or age, there were no significant associations for either visit type with risk of 30-day readmission. CONCLUSIONS: Post-hospital telephone follow-up provider visits had only modest effects on 30-day readmission in high-risk medicine patients compared to clinic visits. It remains to be determined if greater use and comfort with virtual visits by providers and patients as a result of the pandemic might improve the effectiveness of these encounters.

Temporal trends in heart failure mortality in an integrated healthcare delivery system, California, and the US, 2001-2017.

BACKGROUND: In recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased. METHODS: Between 2001-2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death. RESULTS: In KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI - 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45-64 years old were flat between 2001-2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US. CONCLUSION: Lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.

Essential concepts for interpreting the dose-response of low-level arsenic exposure in epidemiological studies.

Scientifically robust selections of epidemiological studies and assessments of the dose-response of inorganic arsenic in the low-dose range must consider key issues specific to arsenic in order to reduce risk of bias. The abundance of toxicological, mechanistic, and epidemiological evidence on arsenic enables a nuanced assessment of risk of bias in epidemiological studies of low-level arsenic, as opposed to a generic evaluation based only on standard principles. Important concepts in this context include 1) arsenic metabolism and mode of action for toxicity and carcinogenicity; 2) effects of confounding factors such as diet, health status including nutritional deficiencies, use of tobacco and other substances, and body composition; 3) strengths and limitations of various metrics for assessing relevant exposures consistent with the mode of action; and 4) the potential for bias in the positive direction for the observed dose-response relationship as exposure increases in the low-dose range. As an example, evaluation of a recent dose-response modeling using eight epidemiological studies of inorganic arsenic and bladder cancer demonstrated that the pooled risk estimate was markedly affected by the single study that was ranked as having a high risk of bias, based on the above factors. The other seven studies were also affected by these factors to varying, albeit lesser, degrees that can influence the apparent dose-response in the low-dose range (i.e., drinking water concentration of 65 µg/L or dose of approximately ≤1 µg/kg-day). These issues are relevant considerations for assessing health risks of oral exposures to inorganic arsenic in the U.S. population, and setting evidence-based regulatory limits to protect human health.