Primary Care Physicians' Conceptualization of Quality in Medicare's Merit-Based Incentive Payment System.

BACKGROUND: While administrators of pay-for-performance may have good intentions, physicians may be reluctant to participate for various reasons, including poor program alignment with realities of clinical practice. In this study, we sought to characterize how primary care physicians (PCPs) participating in Medicare's Merit-Based Incentive Payment System (MIPS) conceptualize the quality of health care to help inform future measurement strategies that physicians would understand and appreciate. METHODS: We performed semi-structured qualitative interviews with a nationwide sample of 20 PCPs in MIPS. We asked PCPs how they would characterize quality and what distinguished exceptional, good, and poor quality. Interviews were transcribed and 2 coders independently read transcripts, allowing data to emerge from the interviews and developing theories about the data. The coders met intermittently to discuss findings, harmonize the coding scheme, develop a final list of themes and subthemes, and aggregate a list of representative quotations. RESULTS: Participants described quality as consisting of 2 components: (1) evidence-based care that is safe, which included health maintenance and chronic disease control, accurate diagnoses, and guideline adherence, and (2) patient-centered care, which included spending enough time with patients, responding to patient concerns, and establishing long-term relationships founded on trust. CONCLUSIONS: PCPs consider patient-centered care necessary for the provision of exceptional quality. Program administrators for quality measurement and pay-for-performance programs should explore new ways to reward PCPs for providing outstanding patient-centered care. Future research should be undertaken to determine whether patient-centered activities such as forging long-term, favorable patient-physician relationships, are associated with improved health outcomes.

Extremely Preterm Infant Born to a Mother With Severe COVID-19 Pneumonia.

Little is known about the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on pregnant women, fetuses, and neonates, especially when the virus is contracted early in pregnancy. The literature is especially lacking on the effects of SARS-CoV-2 on extremely preterm (<28 weeks gestation) infants who have underdeveloped immune systems. We report the case of an extremely preterm, 25-week 5-days old infant, born to a mother with severe COVID-19 (coronavirus disease-2019) pneumonia. In this case, there is no evidence of vertical transmission of SARS-CoV-2 based on reverse transcription-polymerase chain reaction testing, despite extreme prematurity. However, it appears that severe maternal COVID-19 may have been associated with extremely preterm delivery, based on observed histologic chorioamnionitis. This is the first reported case of an extremely preterm infant born to a mother with severe COVID-19 pneumonia who required intubation, and was treated with hydroxychloroquine, azithromycin, remdesivir, tocilizumab, convalescent plasma, inhaled nitric oxide, and prone positioning for severe hypoxemic respiratory failure prior to and after delivery of this infant. The infant remains critically ill with severe respiratory failure on high-frequency ventilation, inotropic support, hydrocortisone for pressor-resistant hypotension, and inhaled nitric oxide for severe persistent pulmonary hypertension with a right to left shunt across the patent ductus arteriosus and foramen ovale. Pregnant women or women planning to get pregnant should take all precautions to minimize exposure to SARS-CoV-2 to decrease adverse perinatal outcomes.

Child and Parent Perspectives on the Acceptability of Virtual Reality to Mitigate Medical Trauma in an Infusion Center.

INTRODUCTION: Children may experience medical trauma when undergoing medical procedures even when procedures are minor. While virtual reality (VR) is effective for managing procedural pain and anxiety, few studies address how families feel about using VR. We explore pediatric patient and guardian views regarding the acceptability of using VR during procedures to mitigate medical trauma. METHODS: Semi-structured qualitative interviews with 18 patient-guardian dyads at a tertiary outpatient infusion center for inflammatory bowel disease (IBD) treatment. Interviews explored how VR may change the infusion experience, including benefits, risks, and recommendations for clinical integration. Interviews were recorded, transcribed, and analyzed in ATLAS.ti. Two coders used a 3-step coding approach to: (1) identify themes; (2) develop a codebook and code transcripts using the constant comparative method; and (3) describe themes/patterns. RESULTS: Potential benefits of VR were distraction from infusion-related anxiety and pain and generating excitement for the appointment. Potential challenges were VR-side effects (dizziness, nausea), limited mobility during the procedure, disorientation/immersion leading to shock upon IV-placement, and a lost opportunity to build coping skills. Families queried when VR should first be introduced and when during the appointment use would be optimal. Parents expressed concerns about pushing VR when their child was already under stress. A limited number of families doubted the utility of VR. CONCLUSIONS: Patients and parents found VR to be an acceptable option for helping to manage medical trauma during infusions but highlighted that the VR experience must be carefully crafted to avoid unintended consequences, including lost opportunities to build resilience.

The relationship of nursing practice laws to suicide and homicide rates: a longitudinal analysis of US states from 2012 to 2016.

BACKGROUND: Nursing resources can have a protective effect on patient outcomes, but nurses and nursing scope of practice have not been studied in relation to injury outcomes. The purpose of this study was to examine whether scope of practice and ease of practice laws for nurse practitioners and registered nurses are associated with suicide and homicide rates in the United States. METHODS: This state-level analysis used data from 2012 to 2016. The outcome variables were age-adjusted suicide and homicide rates. The predictor variables were NP scope of practice by state (limited, partial, or full) and RN ease of practice (state RN licensure compact membership status). Covariates were state sociodemographic, healthcare, and firearm/firearm policy context variables that have a known relationship with the outcomes. RESULTS: Full scope of practice for NPs was associated with lower rates of suicide and homicide, with stronger associations for suicide. Likewise, greater ease of practice for RNs was associated with lower suicide and homicide rates. CONCLUSIONS: Findings suggest that nurses are an important component of the healthcare ecosystem as it relates to injury outcomes. Laws supporting full nursing practice may have a protective effect on population health in the area of injuries and future studies should explore this relationship further.

Child and Family Perspectives on Adjustment to and Coping With Pediatric Inflammatory Bowel Disease.

OBJECTIVES: Children with inflammatory bowel disease (IBD) are at increased risk for poor mental health. The etiology of this risk is not clear, though may be related to the disease, its treatment, and/or the experience of these. We sought to describe the challenges that children with IBD and their families face in living with a chronic condition and undergoing repeated intravenous infusions; and identify coping mechanisms to understand how medical systems may support resilience. METHODS: Semistructured qualitative interviews with 18 patient-guardian dyads at a tertiary outpatient infusion center, explored feelings related to IBD, the infusion process, and coping. Interviews were recorded, transcribed, and analyzed in ATLAS.ti. Two coders identified themes; developed a codebook and coded transcripts using the constant comparative method; and described themes/patterns. RESULTS: Participants identified challenges related to IBD (unpredictable nature, disrupted normalcy, treatment decisions, managing relationships, life transitions) and a subset of challenges related to the infusion procedure (anxiety of unknown, managing pain/anxiety during IV placement, logistics). Participants coped through social support, cognitive strategies (positive attitude) and/or behavioral strategies for managing emotions (preparation for intravenous [IV] placement), and confidence in the medical care. By employing these coping strategies, participants came to accept IBD, adapt to the "new norm," and learned life lessons and resilience. CONCLUSIONS: To support coping, clinical teams might provide anticipatory guidance to decrease anxiety of the unknown and identify cognitive-behavioral strategies for managing emotions. Delivery systems that build relationships, maintain normalcy, and consider needs of the family may further facilitate coping.

Longitudinal Associations Between Healthcare Resources, Policy, and Firearm-Related Suicide and Homicide from 2012 to 2016.

BACKGROUND: Firearm-related violence is a leading cause of mortality in the United States (US). Prior research suggests that public policy plays a role in firearm mortality, but the role of healthcare resources (physicians, insurance coverage) within the US policy context has not yet been studied. OBJECTIVE: To examine how healthcare resources and social/firearm policy affect firearm-related suicide and homicide rates in the US. DESIGN: Longitudinal, ecological study. SETTING: US. PARTICIPANTS: US states from 2012 to 2016 (N = 242). MEASUREMENT: The outcome variables were age-adjusted, firearm-related suicide and homicide rates. Predictor variables were healthcare resources (physicians, Medicaid benefits generosity) and policy context (social policy, firearm policy) with covariates for sociodemographic factors. RESULTS: Healthcare provider variables did not have significant associations to firearm-related suicide or homicide. In fully saturated models, more worker protection laws, greater average population density, more alcohol regulation, and more firearm prohibition policies were associated with fewer firearm-related suicides. Higher generosity of Medicaid benefits was associated with fewer firearm-related homicides. Poverty rate was a predictor of both outcomes. LIMITATIONS: This state-level study cannot make individual-level inferences. Only proxy variables were available for measuring gun ownership and actual gun ownership rates may not have been ideally captured at the state level. CONCLUSIONS: At the state level, there are protective associations of certain social, healthcare, and firearm policies to firearm-related suicide and homicide rates. Healthcare resources play a role in population-level firearm outcomes but alone are not sufficient to decrease firearm-related homicide or suicide.

Primary Care Physicians in the Merit-Based Incentive Payment System (MIPS): a Qualitative Investigation of Participants' Experiences, Self-Reported Practice Changes, and Suggestions for Program Administrators.

BACKGROUND: While both administrators of pay-for-performance programs and practicing physicians strive to improve healthcare quality, they sometimes disagree on the best approach. The Medicare Access and CHIP Reauthorization Act of 2015 mandated the creation of the Merit-Based Incentive Payment System (MIPS), a program that incentivizes more than 700,000 physician participants to report on four domains of care, including healthcare quality. While MIPS performance scores were recently released, little is known about how primary care physicians (PCPs) and their practices are being affected by the program and what actions they are taking in response to MIPS. OBJECTIVES: To (1) describe PCP perspectives and self-reported practice changes related to quality measurement under MIPS and (2) disseminate PCP suggestions for improving the program. DESIGN: Qualitative study employing semi-structured interviews. PARTICIPANTS: Twenty PCPs trained in internal medicine or family medicine who were expected to report under MIPS for calendar year 2017 were interviewed between October 2017 and June 2018. Eight PCPs self-reported to be knowledgeable about MIPS. Seven PCPs worked in small practices. KEY RESULTS: Most PCPs identified advantages of quality measurement under MIPS, including the creation of practice-level systems for quality improvement. However, they also cited disadvantages, including administrative burdens and fears that practices serving vulnerable patients could be penalized. Many participants reported using technology or altering staffing to help with data collection and performance improvement. A few participants were considering selling small practices or joining larger ones to avoid administrative tasks. Suggestions for improving MIPS included simplifying the program to reduce administrative burdens, protecting practices serving vulnerable populations, and improving communication between program administrators and PCPs. CONCLUSIONS: MIPS is succeeding in nudging PCPs to develop quality measurement and improvement systems, but PCPs are concerned that administrative burdens are leading to the diversion of clinical resources away from patient-centered care and negatively impacting patient and clinician satisfaction. Program administrators should improve communication with participants and consider simplifying the program to make it less burdensome. Future work should be done to investigate how technical assistance programs can target PCPs that serve vulnerable patient populations and are having difficulty adapting to MIPS.

Association of Team Sports Participation With Long-term Mental Health Outcomes Among Individuals Exposed to Adverse Childhood Experiences.

Importance: Adverse childhood experiences (ACEs) are associated with long-term poor mental health. Less is known about factors that improve long-term mental health among those with ACEs. Objective: To evaluate, among those exposed to ACEs, whether team sports participation during adolescence is associated with better mental health in adulthood and whether the association between team sports participation and mental health varies by sex. Design, Setting, and Participants: This study used data from 9668 individuals who participated in waves 1 (1994-1995) and 4 (2008) of the National Longitudinal Study of Adolescent to Adult Health. Individuals were included if they had complete data on exposure to ACEs (physical and sexual abuse, emotional neglect, parental alcohol misuse, parental incarceration, and living with a single parent) and a valid sample weight. Statistical analysis was performed from November 6, 2017, to January 4, 2019. Main Outcomes and Measures: The association between team sports participation in grades 7 to 12 (wave 1) and diagnosis of depression and/or anxiety and current depressive symptoms (determined by Center for Epidemiologic Studies Depression scale-10 scores) at ages 24 to 32 years (wave 4) among individuals exposed to ACEs. Multivariable logistic regression models were weighted based on propensity scores for factors associated with team sports participation and controlled for individual, family, and school characteristics. Interaction terms tested whether associations between team sports participation and mental health varied by sex. Results: Of 9668 individuals included in the study (4470 male [50.0%]; mean [SD] age, 15.2 [1.75] years), 4888 (49.3%) reported 1 or more ACE and 2084 (21.3%) reported 2 or more ACEs. Among those with ACEs, team sports participation during adolescence was significantly associated with lower odds of receiving a diagnosis of depression (unadjusted rate, 16.8% vs 22.0%; propensity score-weighted [PSW] adjusted odds ratio [aOR], 0.76; 95% CI, 0.59-0.97) or anxiety (11.8% vs 16.8%; PSW aOR, 0.70; 95% CI, 0.56-0.89) and having current depressive symptoms (21.9% vs 27.5%; PSW aOR, 0.85; 95% CI, 0.71-1.01). There were no significant differences in associations between team sports participation and mental health by sex. Stratified analyses showed significant associations for all outcomes among males (depression: PSW aOR, 0.67 [95% CI, 0.46-0.99]; anxiety: PSW aOR, 0.66 [95% CI, 0.45-0.96]; depressive symptoms: PSW aOR, 0.75 [95% CI 0.56-0.99]) but only 1 outcome among females (anxiety: PSW aOR, 0.73; 95% CI, 0.54-0.98). Conclusions and Relevance: Among individuals affected by ACEs, team sports participation in adolescence was associated with better adult mental health. Team sports may be an important and scalable resilience builder.

Intervention Models for Increasing Access to Behavioral Health Services Among Youth: A Systematic Review.

OBJECTIVE: The purpose of this systematic literature review is to examine interventions designed to improve access to behavioral health services among youth in the United States and to identify how the concept of access to health care has been measured and conceptualized in these studies. METHOD: The review used a systematic search strategy to identify articles published in medical, nursing, and psychological literature. The search yielded 579 initial articles, of which 69 appeared to be candidates for inclusion in the review. In the end, 19 studies qualified for synthesis in the review. Studies were required to use an experimental or quasi-experimental design and include a comparison group. RESULTS: Results indicated that access to behavioral health services can be improved by providing services in schools, using telehealth models, or delivering multicomponent interventions in clinical settings. Models that incorporated parental support, peer support from other parents, or other ways of engaging parents in the utilization process, as well as multicomponent and policy interventions, helped improve access to care. In the studies reviewed, access was operationalized primarily in terms of child behavioral health service utilization. CONCLUSION: Interventions delivered in schools, engaging parents, or utilizing telehealth technology show promise for increasing access for youth affected by behavioral health disorders.

Older age increases short-term surgical complications after primary knee arthroplasty.

BACKGROUND: Age is a known risk factor for complications after knee arthroplasty; however, age-related risks for a variety of complications of total and partial knee arthroplasties have not been well quantified. QUESTIONS/PURPOSES: Our study addressed three questions to better understand age-related risk of complications: (1) At what age do different types of complications increase? (2) Is the increase in complications with age resulting from age-related patient comorbidities, sociodemographic characteristics, and surgical conditions? (3) What is the probability of complications at different ages for an average patient? METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2009 was used to analyze complications for 8950 patients. Complications included NSQIP events, and complications described by the 2003 National Institutes of Health (NIH) consensus statement on total knee arthroplasty as well as 30-day mortality, deep vein thrombosis, return to the operating room, extended length of stay, and technical aspects of the surgery itself. Logistic regression analysis was performed. RESULTS: Mortality was higher for those aged 85 and older. NSQIP complications increased starting at age 70 years and NIH complications at 85 years. Age remained an independent risk factor for multiple complications with controls. The predicted risk for an average patient ranged from 4% (40-64 years old) to 17% (90 years or older) for NSQIP complications and 2.8% to 8.8% for NIH complications. CONCLUSIONS: Age is an important independent predictor of surgical complications after knee arthroplasties. Surgeons can share these quantified age-specific risks with patients to guide management decisions.

Demystifying sample-size calculation for clinical trials and comparative effectiveness research: the impact of low-event frequency in surgical clinical research.

BACKGROUND: Type II error, or not meeting sample-size requirement, has been identified as an issue in the surgical literature. The root of this problem is the low frequency of events in the majority of surgical clinical research. This exponentially increases the sample size needed to achieve statistical significance. METHODS: The methodology and mechanics of sample-size calculations are presented to demonstrate how sample-size requirements change based on baseline event rate and relative reduction in event rate. These concepts are then illustrated using real-life clinical scenarios. RESULTS: If a hypothetical baseline event rate is 1 % and the event rate in the experimental group is 0.5 % (therefore representing a 50 % reduction), then the total number of study patients required is 10,130. If the baseline event rate is 1 %, and the event rate in the experimental group is 0.9 % (a 10 % reduction), then the total number of study patients required is 299,410. CONCLUSIONS: Sample-size calculations are affected by the frequency of the event or events of interest. Given advances in clinical medicine, many clinical outcomes of interest occur at very low frequencies. These low frequencies exponentially increase the sample size required to find statistically significant differences, making randomized clinical trials difficult to conduct properly. Surgical clinical researchers should advocate for the establishment of robust, prospective, large, multi-institutional clinical databases along with the establishment of proper outcomes research methodology as a way to augment randomized trials.

Adoption of endovascular repair of abdominal aortic aneurysm in California: lessons for future dissemination of surgical technology.

BACKGROUND: Knowledge of the pattern of adoption of endovascular approach (endovascular aortic repair [EVAR]) to abdominal aortic aneurysm (AAA) could direct future dissemination of complex surgical technology. METHODS: Retrospective longitudinal analysis of the California Office of Statewide Health Planning and Development inpatient database from 2001 to 2008, accompanied by a cross-sectional survey of surgeons. The setting was all inpatient hospitals in California. Patients were those who underwent repair of AAA. The main outcome measure was the endovascular repair of AAA and the training experience of the surgeons. RESULTS: Of the 33,277 patients with AAA, 11,755 (35%) underwent endovascular repair; 76% were men, mean age was 73 (median, 75) years, 13% of aneurysms were ruptured, and 20% were treated at teaching hospitals. The rate of EVAR increased from 19% in 2001 to 55% in 2008. On multivariate analysis, calendar year, older age, male gender, nonruptured status, teaching hospitals, and high-volume hospitals, but not race or insurance status, were identified as independent predictors of EVAR. The survey revealed that surgeons with ≥15 years of experience obtained their training primarily from the manufacturer (58.8%), whereas those with <15 years of experience obtained their training primarily during residency or fellowship (96.7%). CONCLUSION: Between 2001 and 2008, there was a 290% increase in the rate of EVAR for AAA in California. The early adopters obtained their training directly or indirectly from the manufacturers. Training programs did not begin to offer formal training in this technology until the rapid growth was already taking place. This suggests that academic medical centers and/or professional organizations should develop plans to play a stronger and earlier role in educating physicians about a new technology.