Evaluation of the use of individualized patient care plans in frequent emergency department visitors with pain complaints.

BACKGROUND: Pain is one of the most common complaints that patients present to the emergency department for; emergency medicine providers are tasked with providing appropriate pain relief while simultaneously limiting the risk of personal and societal harm that may result from opioid misuse. The Lakeland Regional Medical Center developed a medical management program that identified frequent emergency department visitors with a chief complaint of pain. Individualized care plans were developed for these patients. A retrospective review was then conducted to assess the efficacy of these care plans in reducing the number of emergency department visits for pain-related complaints by the patients entered into the medical management program. RESULTS: There were 294 patients; 65% were male, and the median age was 41 (interquartile range: 33 to 51). A total of 80% percent of the patients were white, and the payors were as follows: 53% were self-pay, 42% were government programs, and 5% had private insurance. The three most common chronic pain complaints were 39% abdominal pain, 24% back/neck pain, and 23% headache/migraine (patients could have more than one area of pain). A total of 60% of the patients had a primary care provider, and another 18% had a pain management provider in addition to primary care. Post plan admissions were significantly reduced to a median of 1 (IQR 0 to 3) with the Wilcoxon signed-rank test's p-value of less than 0.001. CONCLUSION: The authors describe their experience with a quality improvement initiative that identifies frequent emergency department visitors with a chief complaint of pain and provides individualized care plans to these patients. The goals of the program are to improve patient's quality and consistency of care, through interventions that eliminate the prescribing of opioids while providing non-opioid alternatives.

Parenting Children with Cystic Fibrosis: Developmental Acquisition of Expertise.

OBJECTIVE: This study was designed to increase our understanding of parents' experiences managing the needs of their children with cystic fibrosis (CF) and to identify potential gaps in services. METHOD: We used grounded dimensional analysis of anonymous survey data obtained from a quality improvement initiative conducted by the Cystic Fibrosis Foundation (CFF). The Patient and Family Experience of Care (PFEC) survey was administered continuously at 125 CF care centers throughout the United States in 2017. The subsample of data for this study was completed by 80 parents/caregivers of children with CF (younger than 18 years). RESULTS: Two unifying themes emerged from parents' survey responses: (1) parents' expertise expands continually as they learn and adapt to changes in their children's maturity or health and (2) parental expertise is sometimes visible or invisible to clinicians. Parents' expertise evolved with their children's development. Visible to care teams was at-home care, e.g., respiratory treatments and medications. Less visible were intangible management activities, e.g., social processes, emotions, and concerns that were omnipresent for parents but seldom disclosed to or seen/recognized by clinicians. Themes, such as the quality of encounters with care teams, progressive nature of CF, and hope derived from advances in research, were associated with specific contextual factors. CONCLUSION: The findings expand our understanding of lived parental experiences of CF across childhood and offer direction for future quality improvement and research. Online parent surveys offer a valuable tool to identify unmet needs across subgroups of families affected by chronic childhood health conditions.

The use of monoclonal antibody therapy in pediatric patients with COVID-19: a retrospective case series.

BACKGROUND: Monoclonal antibody (MCA) therapies have been utilized under emergency use authorization (EUA) for high-risk pediatric patients with mild to moderate coronavirus disease 2019 (COVID-19) in the outpatient setting since late 2019. The purpose of this study was to describe the use of MCA therapy in pediatric patients in the pediatric emergency department (ED) at a large community hospital. METHODS: This was a retrospective case series of high-risk pediatric patients 12 to 17 years of age who received MCA therapy in the pediatric ED between December 8, 2020 and June 3, 2021. The primary outcome was to describe the patient characteristics, clinical presentation, and safety profile of the pediatric population that received MCA therapy. The secondary outcome was to describe the incidence of hospitalizations or ED visits up to 28 days following therapy. RESULTS: A total of 44 patients were included in the analysis. The median number of days of symptoms was 4 with 41% of patients having symptoms between 0 and 3 days at time of MCA administration. Only one patient experienced a mild adverse event that did not require epinephrine administration. Two patients returned to the ED for reevaluation during the study follow-up period. No patients required admission within 28 days post-therapy. CONCLUSIONS: The administration of MCA therapy in high-risk pediatric patients in the pediatric ED was well-tolerated with subjective improvement noted in COVID-19 symptoms post-therapy. Further studies are necessary to determine the role MCA therapy may play in reducing morbidity from COVID-19 infection in high-risk pediatric patients.

Impact of early versus late administration of bamlanivimab on readmissions in patients with high-risk COVID-19.

BACKGROUND: Recombinant monoclonal antibody therapies have been utilized under emergency use authorization (EUA) for the prevention of clinical decompensation in high-risk COVID-19 positive patients for up to 10 days from symptom onset. The purpose of this study was to determine the impact of the timing of the monoclonal antibody, bamlanivimab, on clinical outcomes in high-risk COVID-19 positive patients. METHODS: This was an IRB-approved, retrospective evaluation of adult patients who received bamlanivimab per EUA criteria in the emergency department (ED). Patients were dichotomized into two groups- 3 days of symptoms or less (early) versus 4 to 10 days (late). The primary outcome was hospitalization for COVID-related illness at 28 days (or treatment failure). Secondary outcomes were COVID-related ED visits at 28 days, hospital and intensive care unit (ICU) length of stay (LOS), and in-hospital mortality at 28 days. RESULTS: A total of 839 patients were included in the analysis. There was no difference observed in COVID-related hospitalization rates within 28 days between the early and late bamlanivimab administration groups (7.5% vs. 8.2%, p = 0.71). There was no difference in COVID-related ED visits within 28 days with 13% of patients returning to the ED. CONCLUSIONS: In conclusion, there were no differences in the rates of hospitalization at 28 days when bamlanivimab was administered in the first 3 days of illness versus days 4 to 10. Future prospective studies are warranted to expand upon the characteristics of patients that may or may not benefit from monoclonal antibody therapy.

Assessing Shared Decision-Making in Cystic Fibrosis Care Using collaboRATE: A Cross-Sectional Study of 159 Programs.

There are numerous opportunities for shared decision-making (SDM) in cystic fibrosis (CF) care, yet little is known about patients' SDM experiences. This study evaluated SDM across 159 CF care programs (4024 participants) in the United States. Shared decision-making was assessed using the patient-reported collaboRATE measure, which was included in the CF Foundation's Patient and Family Experience of Care Survey over 18 months. Overall, 69% of respondents reported experiencing SDM. Respondents at pediatric programs were more likely to experience SDM than those at adult programs (72% vs 67%, P < .001). Multivariable logistic regression analyses showed a relationship between SDM and patient age, whereby SDM was less likely to occur with patients aged 18 to 24 years, compared to some younger and older age groups (P = .02-<.001). Shared decision-making was more likely to occur at pediatric programs when patients had better general health (P = .02-<.01), and at pediatric and adult programs when patients had better mental health (P = .02-<.001). Disparities in SDM experiences highlight a need to improve decision-making processes in CF care. Interventions tailored for improving SDM among specific patient populations may be particularly advantageous.

BREAST-Q Outcomes before and after Bilateral Reduction Mammaplasty.

BACKGROUND: The BREAST-Q is the only questionnaire specific to bilateral breast reduction that was developed according to federal and international standards. Many payors mandate minimum resection weights for preapproval, despite lacking supportive evidence for this practice. This study aimed to assess changes in BREAST-Q scores after bilateral breast reduction, and determine whether compliance with Schnur requirements impacts improvement in patient-reported outcomes. METHODS: Patients presenting for bilateral breast reduction from 2011 to 2017 were asked to complete the BREAST-Q preoperatively and postoperatively. Multivariate regression analysis was performed to isolate factors associated with favorable outcomes. RESULTS: Complete data were available for 238 patients. Mean time to postoperative BREAST-Q was 213 days. Complications occurred in 31 patients (13.0 percent). Mean preoperative BREAST-Q scores were below normative values (p < 0.001), and mean postoperative scores were above normative values (p < 0.001 for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being; and p = 0.05 for Physical Well-being). Postoperative Physical Well-being scores were similar to normative values for resections less than Schnur (p = 0.32), but below norms for resections greater than Schnur (p < 0.0001). On multivariate regression (n = 230), complication and surgeon experience were the only independent predictors of lesser improvement on the Satisfaction with Breasts subscale. CONCLUSIONS: This study is the largest to include both preoperative and postoperative bilateral breast reduction BREAST-Q scores, and to compare multiple subscales to normative data. Scores overwhelmingly increased, regardless of age or Schnur compliance. Complications negatively impacted degree of BREAST-Q improvement. Interestingly, postoperative Physical Well-being was slightly higher in women with non-Schnur-compliant resections. Bilateral breast reduction substantially improves patient welfare, and our data question the validity of insurer-mandated minimum resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patients and families experience with pharmacist care at cystic fibrosis foundation accredited clinics.

Cystic fibrosis (CF) is a complex genetic, multiorgan disease. The CF Foundation (CFF) recommends a multidisciplinary team (physician, nurse, respiratory therapist, dietitian, physical therapist, social worker, mental health coordinator, clinic coordinator, and pharmacist) to work with patients and families. The objective of our study was to describe the impact of a pharmacist involved in the care of patients and families from their perspective. The CF Patient and Family Experience of Care (PFEC) is a voluntary, 50-question telephonic or internet-based survey designed to continuously collect information from patients and their families regarding their care experience. From August of 2017 through February of 2018, five questions were added to the internet survey to assess the impact of the pharmacist on the care experience. From the 666 respondents, 54% reported that a pharmacist was involved in their CF care. At two CF clinics designated as "full access" to a pharmacist, respondents reported a higher percentage of the CF-team discussed medications compared to those from three clinics designated as "limited access" to the pharmacist (95% vs 67%). Respondents in clinics with "full access" to a pharmacist were significantly more likely to get their medications refilled on time (78% vs 63%) and reported using fewer pharmacies to fill their medications. Pharmacist involvement in CF care may improve patient's access to medication and the ability to sustain use.

Improved Outcomes With Standardized Convalescent Preterm Respiratory Care Practices.

BACKGROUND: Chronic lung disease is the most common morbidity affecting very low birthweight (VLBW) infants. Many of these infants are discharged home on oxygen, placing significant emotional and financial burdens on families. We sought to reduce the proportion of VLBW infants requiring discharge home on oxygen by improving convalescent respiratory practices. METHODS: We performed a prospective quality-improvement project for infants with birth weights ≤ 1,500 g in a single neonatal ICU. Using Plan-Do-Study-Act cycles, we developed and implemented a room air challenge, oxygen reference chart, and a standardized oxygen delivery guideline. The primary outcome was the proportion of VLBW infants discharged home on oxygen. Secondary outcomes included rate of chronic lung disease and postmenstrual age when off all respiratory support. Balancing measures were postmenstrual age and weight at discharge, as well as unplanned readmissions. Statistical process control charts were used to monitor outcomes and balancing measures. RESULTS: The proportion of VLBW infants discharged home on oxygen decreased from 34.4% to 18.5% and 21.7% in the following two years (P = .044 and P = .01, respectively). G-Chart analysis showed a higher mean number of successes between failures. The rate of chronic lung disease decreased from 31.2% to 25.4% (P = .03). The mean postmenstrual age at discharge, mean weight at discharge, and readmission rate were unchanged. CONCLUSION: Standardization of convalescent respiratory care practices improved respiratory morbidities in VLBW infants. These interventions could be utilized in other NICUs with high incidence of respiratory morbidities despite improvement in delivery room practices.

End-of-life practice patterns at U.S. adult cystic fibrosis care centers: A national retrospective chart review.

BACKGROUND: There are many challenges to providing end-of-life care (EOLC) to people with cystic fibrosis (CF). METHODS: Chart abstraction was used to examine EOLC in adults with CF who died between 2011 and 2013. RESULTS: We reviewed 248 deaths from 71 CF care centers. Median age at death was 29years (range 18-73). While median FEV1 was in the severe lung disease category (FEV1<40%), 38% had mild or moderate lung disease in the year preceding death. The most common location of death was the intensive care unit (ICU, 39%), and 12% of decedents were listed for lung transplant. Fewer of those dying in the ICU personally participated in advance care planning or utilized hospice or Palliative Care Services (p<0.05). CONCLUSIONS: Adults dying with CF in the United States most commonly die in an ICU, with limited and variable use of hospice and Palliative Care Services. Palliative care and advance care planning are recommended as a routine part of CF care.

Breast Cancer and Reconstruction: Normative Data for Interpreting the BREAST-Q.

BACKGROUND: The BREAST-Q is a patient-reported outcome instrument used to evaluate outcomes in patients undergoing breast cancer surgery and reconstruction. Normative values for the BREAST-Q breast cancer modules have not been established, limiting data interpretation. METHODS: Participants were recruited by means of the Army of Women, an online community of women (with and without breast cancer), to complete Mastectomy, Breast Conserving Therapy, and Reconstruction preoperative BREAST-Q scales. Inclusion criteria were women aged 18 years or older without a history of breast surgery or breast cancer. Analysis included descriptive statistics, a linear multivariate regression, and a comparison of the generated normative data to previously published BREAST-Q findings. RESULTS: The BREAST-Q was completed by 1201 women. The mean patient age was 54 ± 13 years, mean body mass index 26 ± 6 kg/m, and 38 percent (n = 455) had a bra cup size of D or greater. Mean ± SD scores for BREAST-Q scales were as follows: Satisfaction with Breasts (58 ± 18), Psychosocial Well-being (71 ± 18), Sexual Well-being (56 ± 18), Physical Well-being-Chest (93 ± 11), and Physical Well-being Abdomen (78 ± 20). Women with a body mass index of 30 kg/m or greater, cup size of D or greater, age younger than 40 years, and annual income less than $40,000 reported lower scores. Comparing normative scores to published data in breast cancer patients, Satisfaction with Breasts scores were higher after autologous reconstruction and lower after mastectomy; Sexual Well-being scores were lower after mastectomy and breast conserving therapy; and Physical Well-being Chest scores were lower after mastectomy, breast conserving therapy, and reconstruction. CONCLUSION: These are the first published normative scores for the BREAST-Q breast cancer modules and provide a clinical reference point for the interpretation of data.

Understanding the Health Burden of Macromastia: Normative Data for the BREAST-Q Reduction Module.

BACKGROUND: The BREAST-Q Reduction module evaluates outcomes in reduction mammaplasty. However, there are currently no published normative scores, limiting the interpretation of BREAST-Q data. METHODS: The BREAST-Q Reduction module was administered via the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Normative data were generated from women aged 18 years and older, without a history of breast cancer or breast surgery. Data analysis was performed using descriptive statistics and a linear multivariate regression. Generated normative data were compared to published BREAST-Q Reduction findings. RESULTS: The preoperative version of the BREAST-Q Reduction module was completed by 1206 women. Participant mean age was 55 ± 13 years, mean body mass index was 27 ± 6 kg/m, and 40 percent (n = 481) had a bra cup size ≥ D. Mean normative scores were as follows: Satisfaction with Breasts, 57 ± 16; Psychosocial Well-being, 68 ± 19; Sexual Well-being, 55 ± 19; and Physical Well-being, 76 ± 11. Normative scores were lower in women with body mass index ≥ 30 and bra cup size ≥ D. In comparison to normative Army of Women scores, published BREAST-Q scores for women undergoing reduction mammaplasty were lower (worse) for preoperative patients and higher (better) for postoperative patients. CONCLUSION: These new Army of Women normative data provide insights into breast-related satisfaction and well-being in women not pursuing breast reduction, giving new clinical context to better understand the health burden of macromastia, and to demonstrate the value of reduction mammaplasty in certain patients.

Normative Data for Interpreting the BREAST-Q: Augmentation.

BACKGROUND: The BREAST-Q is a rigorously developed, well-validated, patient-reported outcome instrument with a module designed for evaluating breast augmentation outcomes. However, there are no published normative BREAST-Q scores, limiting interpretation. METHODS: Normative data were generated for the BREAST-Q Augmentation module by means of the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Members were recruited by means of e-mail; women aged 18 years or older without a history of breast cancer or breast surgery were invited to participate. Descriptive statistics and a linear multivariate regression were performed. A separate analysis compared normative scores to findings from previously published BREAST-Q augmentation studies. RESULTS: The preoperative BREAST-Q Augmentation module was completed by 1211 women. Mean age was 54 ± 24 years, the mean body mass index was 27 ± 6 kg/m, and 39 percent (n = 467) had a bra cup size of D or greater. Mean scores were as follows: Satisfaction with Breasts, 54 ± 19; Psychosocial Well-being, 66 ± 20; Sexual Well-being, 49 ± 20; and Physical Well-being, 86 ± 15. Women with a body mass index of 30 kg/m or greater and bra cup size of D or greater had lower scores. In comparison with Army of Women scores, published BREAST-Q augmentation scores were lower before and higher after surgery for all scales except Physical Well-being. CONCLUSIONS: The Army of Women normative data represent breast-related satisfaction and well-being in women not actively seeking breast augmentation. These data may be used as normative comparison values for those seeking and undergoing surgery as we did, demonstrating the value of breast augmentation in this patient population.

A New Performance Improvement Model: Adding Benchmarking to the Analysis of Performance Indicator Data.

BACKGROUND: A performance improvement model was developed that focuses on the analysis and interpretation of performance indicator (PI) data using statistical process control and benchmarking. PIs are suitable for comparison with benchmarks only if the data fall within the statistically accepted limit-that is, show only random variation. Specifically, if there is no significant special-cause variation over a period of time, then the data are ready to be benchmarked. METHODS: The proposed Define, Measure, Control, Internal Threshold, and Benchmark model is adapted from the Define, Measure, Analyze, Improve, Control (DMAIC) model. The model consists of the following five steps: Step 1. Define the process; Step 2. Monitor and measure the variation over the period of time; Step 3. Check the variation of the process; if stable (no significant variation), go to Step 4; otherwise, control variation with the help of an action plan; Step 4. Develop an internal threshold and compare the process with it; Step 5.1. Compare the process with an internal benchmark; and Step 5.2. Compare the process with an external benchmark. RESULTS: The steps are illustrated through the use of health care-associated infection (HAI) data collected for 2013 and 2014 from the Infection Control Unit, King Fahd Hospital, University of Dammam, Saudi Arabia. CONCLUSION: Monitoring variation is an important strategy in understanding and learning about a process. In the example, HAI was monitored for variation in 2013, and the need to have a more predictable process prompted the need to control variation by an action plan. The action plan was successful, as noted by the shift in the 2014 data, compared to the historical average, and, in addition, the variation was reduced. The model is subject to limitations: For example, it cannot be used without benchmarks, which need to be calculated the same way with similar patient populations, and it focuses only on the "Analyze" part of the DMAIC model.

Discharge Delays for Patients Requiring In-Hospital Guardianship: A Cohort Analysis.

OBJECTIVE: To assess nonclinical factors delaying hospital discharge of guardianship patients. DATA: Utilization review data over 3 years. DESIGN: Retrospective cohort study. ANALYSIS: Mann-Whitney test was used to compare patients' medically unnecessary days (MUD) of hospitalization with additional subcategories of delays-defined as beyond clinicians' control. FINDINGS: Overall median number of MUD was 19.5; 14 of 48 patients were additionally delayed while awaiting long-term care Medicaid approval (N = 7, 50%), pending insurance (N = 3, 21%), social or transportation difficulties (N = 3, 21%), or preadmission review (N = 1, 7%). The median number of MUD for the 14 delayed patients was 63, a difference of 53 days compared with the routine guardianship cohort (P < .0001) and $5.5M in net revenue opportunity. CONCLUSIONS: Nonclinical discharge delays for guardianship patients are costly and potentially unavoidable. Further exploration into policy change is therefore recommended.

Advance care planning in cystic fibrosis: Current practices, challenges, and opportunities.

BACKGROUND: Studies in cystic fibrosis (CF) report late attention to advance care planning (ACP). The purpose of this study was to examine ACP with patients receiving care at US adult CF care programs. METHODS: Chart abstraction was used to examine ACP with adults with CF dying from respiratory failure between 2011 and 2013. RESULTS: We reviewed 210 deaths among 67 CF care programs. Median age at death was 29 years (range 18-73). Median FEV1 in the year preceding death was 33% predicted (range 13-100%); 68% had severe lung disease with FEV1<40% predicted. ACP was documented for 129 (61%), often during hospitalization (61%). Those with ACP had earlier documentation of treatment preferences, before the last month of life (73% v. 35%; p=<0.01). Advance directives were completed by 93% of those with ACP versus 75% without (p<0.01); DNR orders and health care proxy designation occurred more often for those with ACP. Patients awaiting lung transplant had similar rates of ACP as those who were not (67% v. 61%; p=0.55). The frequency of ACP varied significantly among the 29 programs contributing data from four or more deaths. CONCLUSIONS: ACP in CF often occurs late in the disease course. Important decisions default to surrogates when opportunities for ACP are missed. Provision of ACP varies significantly among adult CF care programs. Careful evaluation of opportunities to enhance ACP and implementation of recommended approaches may lead to better practices in this important aspect of CF care.

Experience of care from the perspective of individuals with cystic fibrosis and families: Results from 70 CF Foundation accredited programs in the USA.

INTRODUCTION: In 2012 and 2013, 30 adult and 40 pediatric CF Foundation-accredited programs across the United States recruited patients and families to complete an experience of care survey. This paper reports the positive attributes and the opportunities for improvement in CF care from the perspective of individuals with CF and families. METHODS: Patients and families completed the survey by web, interactive voice response, or with the help of a telecommunication professional. Funnel plot was used to determine positive attributes and improvement opportunities. Chi-square tests and 95% confidence intervals were used to determine differences between group and logistic regression models were used to determine factors associated with the experience of "best" care. RESULTS: 2090 adults with CF or parents of children with CF, 29% of the 7113 potential respondents, completed a survey. Both the adult and pediatric survey respondents reported the same 5 positive attributes of experience of care: courtesy and respect shown, easy to understand explanations, involved in decision-making, their questions were answered, and enough time with providers. Potential areas for improvement included assessing mental health and improving inpatient hospital staff's knowledge of CF. In general, results from the pediatric survey were significantly better than the adult survey. Variables predictive of "best" care experience from both adult and pediatric respondents were treatments always working and two self-care factors of finding information and working out solutions. CONCLUSION: The CF Foundation developed an experience of care survey to systematically collect and learn directly from individuals with CF and families about their impressions and observations of CF health care delivery. Respondents reported positive and respectful experiences and improvement opportunities were identified, which can help programs target specific areas to enhance the care experience.

Improving the quality of care for patients diagnosed with glioma during the perioperative period.

PURPOSE: Although there is agreement on the oncologic management of patients with glioma, few guidelines exist to standardize other aspects of care, including supportive care. METHODS: A quality improvement (QI) project was chartered to improve the care provided to patients with glioma. A multidisciplinary team was convened and identified 10 best-practice measures. Using a plan-do-study-act framework, the team brainstormed and implemented various improvement interventions between June 2011 and October 2012. Statistical process control charts were used to evaluate progress. A dashboard of quality measures was generated to allow for ongoing measurement and reporting. RESULTS: The retrospective assessment phase consisted of 43 patients with diagnosis of glioma. A manual medical record review for these patients showed that compliance with 10 best-practice measures ranged from 23% to 100%. Several factors contributed to less-than-ideal process performance, including poor communication among disciplines and lack of familiarity with the larger system of care. After implementing improvement interventions, performance was measured in 96 consecutive patients with glioma. The proportion of patients who met criteria for 10 practice measures significantly improved (pre-QI work, 63%; post-QI work, 85%; P = .003). The largest improvement was observed in the measure assessing for preoperative notification of the neuro-oncology program (pre-QI work, 39%; post-QI work, 97%; P < .001). CONCLUSION: QI principles were used by a multidisciplinary team to improve the quality of care for patients with glioma during the perioperative period. Leadership involvement, ongoing dialogue across departments, and reporting of system performance were important for sustaining process improvements.