Prevalence and Predictability of Occult Satellite Nodules in Clinical Stage Ia Non-small Cell Lung Cancer following Lobectomy.

INTRODUCTION: We sought to assess the prevalence and clinical predictors of satellite nodules in patients undergoing lobectomy for clinical stage Ia disease. PATIENTS AND METHODS: The National Cancer Database was queried for patients who underwent lobectomy for clinical stage cT1N0 NSCLC. Collaborative staging information was used to identify patients who were pathologically upstaged based on having separate tumor nodules in the same lobe as the primary tumor. Multivariable logistic regression was used to assess the association of clinical factors with the detection of separate nodules. RESULTS: A separate tumor nodule was recorded in 2.8% (n = 1284) of 45,842 clinical stage Ia patients treated with lobectomy or bilobectomy. Female gender (3.1% vs. male 2.5%; P = .002) and non-squamous histology (adenocarcinoma 3.2% and large cell neuroendocrine 3.0% vs. squamous cell 1.9% tumors; P < .001) were associated with the presence of separate nodules. The frequency increased for tumors larger than 3 cm (≤ 3cm, 2.7% vs. > 3cm, 3.8%; P < .001). Other factors associated with separate nodules were upper lobe location, pleural and/or lymphovascular invasion and occult lymph node disease. The best predictive model for separate nodules based on the available clinical variables resulted in an area under the curve of 0.645 (95% CI 0.629-0.660). CONCLUSION: Separate tumor nodules may be detected with a low but relatively consistent frequency across the spectrum of patients with clinical stage Ia NSCLC. The predictive ability using basic clinical factors in the database is limited.

"Giving the patients less work": A thematic analysis of telehealth use and recommendations to improve usability for autistic adults.

LAY ABSTRACT: Real-time telehealth visits, called "virtual visits," are live video chats between patients and healthcare professionals. There are lots of steps involved in setting up a virtual visit, which may be difficult for some autistic adults. We interviewed 7 autistic adults, 12 family members of autistic adults, and 6 clinic staff from one clinic in the United States. Our goal was to understand their experiences with virtual visits and see how we can make virtual visits easier to use. We re-read text from the interviews to organize experiences and advice that was shared into topics. We found that autistic adults (or their family members) had to connect with clinic staff many times by phone or online over several days to set up a virtual visit. Participants said that having more experience with technology and using the online patient portal made virtual visits easier to use. But, having issues with technology before the visit could make autistic adults and family members anxious. Clinic staff said it was hard for them to meet the needs of people who were using virtual visits and those who were being seen in person at the clinic. Participants recommended reducing the number of calls between staff and autistic adults or family members using the online patient portal instead. Participants also recommended reminder messages, instruction videos, and approximate wait-times to help autistic adults and family members know what to expect for the virtual visit. Our results are based on peoples' experiences at one clinic, but could help other clinics make virtual visits easier to use for autistic adults and their family members.

Perceptually Discriminating the Highest Priority Alarms Reduces Response Time: A Retrospective Pre-Post Study at Four Hospitals.

OBJECTIVE: Reduce nurse response time for emergency and high-priority alarms by increasing discriminability between emergency and all other alarms and suppressing redundant and likely false high-priority alarms in a secondary alarm notification system (SANS). BACKGROUND: Emergency alarms are the most urgent, requiring immediate action to address a dangerous situation. They are clinician-triggered and have higher positive predictive value (PPV). High-priority alarms are automatically triggered and have lower PPV. METHOD: We performed a retrospective pre-post study, analyzing data 15 months before and 25 months after a SANS redesign was implemented in four hospitals. For emergency alarms, we incorporated digitized human speech to distinguish them from automatically triggered alarms, leaving their onset and escalation pathways unchanged. For automatically triggered alarms, we suppressed some by delaying initial onset and escalation by 20 s. We used linear mixed models to assess the change in response time, Fisher's exact test for the proportion of response times longer than 120 s, and control charts for process stability. RESULTS: Response time for emergency alarms decreased at all hospitals (main, from 26.91 s to 22.32 s, p < .001; cardiac, from 127.10 s to 52.43 s, p < .001; cancer, from 18.03 s to 15.39 s, p < .001). Improvements were sustained. Automatically triggered alarms decreased 25.0%. Response time for the three automatically triggered cardiac alarms increased at the four hospitals. CONCLUSION: Auditory sound disambiguation was associated with a sustained reduced nurse response time for emergency alarms, but suppressing some high-priority automatically triggered alarms was not. APPLICATION: Distinguishing and escalating urgent, actionable alarms with higher PPV improves response time.

Wedge Resection vs Lobectomy for Clinical Stage IA Non-Small Cell Lung Cancer With Occult Lymph Node Disease.

BACKGROUND: Sublobar resection is increasingly performed for stage Ia non-small cell lung cancer, but pathologic lymph node upstaging remains a common clinical scenario. This study compares the long-term prognosis of patients with clinical stage Ia disease and occult lymph node disease undergoing wedge resection vs lobectomy. METHODS: The National Cancer Database was queried for patients treated with wedge resection or lobectomy for clinical stage Ia (cT1N0) non-small cell lung cancer and who were pathologically upstaged with either pN1/pN2 disease. Overall survival (OS) was compared by extent of resection using inverse probability treatment weighting-adjusted Cox regression analyses. RESULTS: Of 5437 clinical stage Ia patients included, 3408 (62.7%) were found to have occult pN1 and 2029 (37.3%) to have occult pN2. Of 5437 patients, 93.5% (5082) were treated with lobectomy and 6.5% (355) underwent wedge resection. Lobectomy was associated with improved OS compared with wedge resection for patients with occult pN1 disease (median OS, 70.0 months [95% CI, 66.6-77.4] vs 36.4 months [95% CI, 24.2-45.6]; P < .001) but not for pN2 disease (median OS, 48.2.1 months [95% CI, 43.8-52.9] vs 43.7 months [95% CI, 31.2-62.4]; P = 0.24). On inverse probability treatment weighting-adjusted multivariable analysis, adjusting for demographics, comorbidities, margin status, and pathologic T and N stage, lobectomy remained associated with improved survival (adjusted hazard ratio, 0.73; 95% CI, 0.60-0.89; P = .0016). CONCLUSIONS: Lobectomy is associated with improved survival in clinical stage Ia non-small cell lung cancer patients with occult lymph node disease. These data may aid the decision for completion lobectomy for patients with unanticipated N1 lymph node upstaging.

Effect of In-Person vs Video Training and Access to All Functions vs a Limited Subset of Functions on Portal Use Among Inpatients: A Randomized Clinical Trial.

Importance: Inpatient portals provide patients with clinical data and information about their care and have the potential to influence patient engagement and experience. Although significant resources have been devoted to implementing these portals, evaluation of their effects has been limited. Objective: To assess the effects of patient training and portal functionality on use of an inpatient portal and on patient satisfaction and involvement with care. Design, Setting, and Participants: This randomized clinical trial was conducted from December 15, 2016, to August 31, 2019, at 6 noncancer hospitals that were part of a single health care system. Patients who were at least 18 years of age, identified English as their preferred language, were not involuntarily confined or detained, and agreed to be provided a tablet to access the inpatient portal during their stay were eligible for participation. Data were analyzed from May 1, 2019, to March 15, 2021. Interventions: A 2 × 2 factorial intervention design was used to compare 2 levels of a training intervention (touch intervention, consisting of in-person training vs built-in video tutorial) and 2 levels of portal function availability (tech intervention) within an inpatient portal (all functions operational vs a limited subset of functions). Main Outcomes and Measures: The primary outcomes were inpatient portal use, measured by frequency and comprehensiveness of use, and patients' satisfaction and involvement with their care. Results: Of 2892 participants, 1641 were women (56.7%) with a median age of 47.0 (95% CI, 46.0-48.0) years. Most patients were White (2221 [76.8%]). The median Charlson Comorbidity Index was 1 (95% CI, 1-1) and the median length of stay was 6 (95% CI, 6-7) days. Notably, the in-person training intervention was found to significantly increase inpatient portal use (incidence rate ratio, 1.34 [95% CI, 1.25-1.44]) compared with the video tutorial. Patients who received in-person training had significantly higher odds of being comprehensive portal users than those who received the video tutorial (odds ratio, 20.75 [95% CI, 16.49-26.10]). Among patients who received the full-tech intervention, those who also received the in-person intervention used the portal more frequently (incidence rate ratio, 1.36 [95% CI, 1.25-1.48]) and more comprehensively (odds ratio, 22.52; [95% CI, 17.13-29.62]) than those who received the video tutorial. Patients who received in-person training had higher odds (OR, 2.01 [95% CI, 1.16-3.50]) of reporting being satisfied in the 6-month postdischarge survey. Similarly, patients who received the full-tech intervention had higher odds (OR, 2.06 [95%CI, 1.42-2.99]) of reporting being satisfied in the 6-month postdischarge survey. Conclusions and Relevance: Providing in-person training or robust portal functionality increased inpatient engagement with the portal during the hospital stay. The effects of the training intervention suggest that providing personalized training to support use of this health information technology can be a powerful approach to increase patient engagement via portals. Trial Registration: ClinicalTrials.gov Identifier: NCT02943109.

Improving Provisioning of an Inpatient Portal: Perspectives from Nursing Staff.

BACKGROUND: Inpatient portals are recognized to provide benefits for both patients and providers, yet the process of provisioning tablets to patients by staff has been difficult for many hospitals. OBJECTIVE: Our study aimed to identify and describe practices important for provisioning an inpatient portal from the perspectives of nursing staff and provide insight to enable hospitals to address challenges related to provisioning workflow for the inpatient portal accessible on a tablet. METHODS: Qualitative interviews were conducted with 210 nursing staff members across 26 inpatient units in six hospitals within The Ohio State University Wexner Medical Center (OSUWMC) following the introduction of tablets providing access to an inpatient portal, MyChart Bedside (MCB). Interviews asked questions focused on nursing staffs' experiences relative to MCB tablet provisioning. Verbatim interview transcripts were coded using thematic analysis to identify factors associated with tablet provisioning. Unit provisioning performance was established using data stored in the OSUWMC electronic health record about provisioning status. Provisioning rates were divided into tertiles to create three levels of provisioning performance: (1) higher; (2) average; and (3) lower. RESULTS: Three themes emerged as critical strategies contributing to MCB tablet provisioning success on higher-performing units: (1) establishing a feasible process for MCB provisioning; (2) having persistent unit-level MCB tablet champions; and (3) having unit managers actively promote MCB tablets. These strategies were described differently by staff from the higher-performing units when compared with characterizations of the provisioning process by staff from lower-performing units. CONCLUSION: As inpatient portals are recognized as a powerful tool that can increase patients' access to information and enhance their care experience, implementing the strategies we identified may help hospitals' efforts to improve provisioning and increase their patients' engagement in their health care.

Expenditures and Healthcare Utilization of Patients Receiving Care at a Specialized Primary Care Clinic Designed with and for Autistic Adults.

BACKGROUND: We previously found that autistic adults who received care through a primary care embedded specialized clinic, called the Center for Autism Services and Transition (CAST), had higher satisfaction, continuity of care, and preventive care use than national samples of autistic adults. OBJECTIVE: Examine the impact of CAST on healthcare utilization and expenditures. DESIGN: Retrospective study of medical billing data. SAMPLE: CAST patients (N = 490) were propensity score matched to Medicare-enrolled autistic adults (N = 980) and privately insured autistic adults (N = 980) using demographic characteristics. The median age of subjects was 21 years, 79% were male, and the median duration of observation was 2.2 years. MAIN MEASURES: We quantified expenditures and utilization for primary care; emergency department (ED) visits; inpatient hospitalizations; mental health admissions; and outpatient visits. KEY RESULTS: CAST patients had the highest primary care utilization and expenditures. However, CAST patients had significantly lower expenditures than Medicare-enrolled autistic adults for mental health admissions ($1074 vs $1903), outpatient visits ($1671 vs $2979), and total expenditures ($5893 vs $6987), as well as 57% fewer inpatient hospitalizations. Compared to privately insured autistic adults, CAST patients had significantly lower expenditures for mental health admissions ($1074 vs $1362), inpatient hospitalizations ($3851 vs $4513), and outpatient visits ($1671 vs $6070), as well as 16% fewer inpatient hospitalizations, 24% fewer ED visits, and 50% fewer outpatient visits. On average, CAST patients had more ED visits, mental health admissions, and outpatient visits than Medicare-enrolled autistic adults and more mental health admissions than privately insured autistic adults. CONCLUSIONS: Although CAST patients had greater primary care utilization and expenditures, our findings suggest embedding specialized clinics within broader primary care settings could be an alternative to current standards of care and may reduce expenditures and healthcare utilization in other areas, particularly relative to standard care for privately insured autistic adults.

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction.

At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches. METHODS: This retrospective cohort study identified 145 women who underwent autologous breast reconstruction from 2015 to 2017. Three groups were included: historical control patients (n = 46) and enhanced recovery patients that received multimodal pain management including a postoperative transversalis abdominis plane block with either a continuous local anesthetic catheter (n = 60) or a single-shot of liposomal bupivacaine (n = 39). The primary outcome was pain scores in the first three postoperative days. Secondary outcomes were opioid consumption in oral morphine equivalents and length of stay. RESULTS: Postoperative pain scores were similar across all three groups until postoperative day 3. Length of stay was significantly shorter in both of the enhanced recovery cohorts (3.0 [3.0, 4.0]) compared with control patients (4.0 [4.0, 5.0], P < 0.001). Likewise, average total oral morphine equivalents consumption was significantly reduced in enhanced recovery patients (continuous catheter 215.9 (95% CI, 165.4-266.3); liposomal bupivacaine 211.0 (95% CI, 154.8-267.2); control 518.4 (95% CI 454.2-582.7), P < 0.001). Neither length of stay (P = 0.953), nor oral morphine equivalents consumption (P = 0.883) differed by type of regional analgesia. CONCLUSION: Compared with control patients, both approaches to regional transversalis abdominis plane block analgesia as part of an opiate-sparing enhanced recovery pain management strategy were successful, but neither superior to the other.

Characteristics associated with healthcare independence among autistic adults.

Background: Healthcare independence refers to someone's ability to assume responsibility for their own health and complete tasks like taking medication as prescribed or scheduling healthcare appointments. Prior studies have shown that autistic people tend to need more support with healthcare tasks than people with other chronic conditions. We sought to identify modifiable and non-modifiable factors linked with healthcare independence among autistic adults. Method: We conducted a cross-sectional survey to examine how executive functioning skills, restrictive and repetitive behaviors, gender, education, and age were linked with healthcare independence among this population. Participants included: (a) autistic adults (n=19) who are their own legal guardian, who participated via self-report; and (b) family members of autistic adults with a legal guardian (n=11), who provided proxy-reports. Results: Findings differed between self- and proxy-reports. Among autistic adults who self-reported, difficulties in executive functioning were strongly linked with less healthcare independence. Among proxy-reports, greater restrictive and repetitive behaviors were strongly linked with less healthcare independence. According to the proxy-reports, having not completed high school, being older during the healthcare transition, and being male were all independently linked with less healthcare independence. Conclusions: Interventions aimed at supporting executive functioning, providing opportunities to increase independence with healthcare tasks, and reducing the extent to which restrictive and repetitive behaviors interfere with daily activities may be viable options for supporting healthcare independence among autistic adults. Our findings are an important first step for future initiatives to better identify individuals who need additional care coordination, supports, or services to maximize healthcare independence.

Applying Human Factors Engineering to Address the Telemetry Alarm Problem in a Large Medical Center.

OBJECTIVE: Address the alarm problem by redesigning, reorganizing, and reprioritizing to better discriminate alarm sounds and displays in a hospital. BACKGROUND: Alarms in hospitals are frequently misunderstood, disregarded, and overridden. METHOD: Discovery-oriented, intervention, and translational studies were conducted. Study objectives and measures varied, but had the shared goals of increasing positive predictive value (PPV) of critical alarms by reducing low-PPV alarms in the background, prioritizing alarms, redesigning alarm sounds to increase information content, and transparently conveying who initiated alarms. An alarm ontology was iteratively generated and refined until consensus was achieved. RESULTS: The ontology distinguishes five levels of urgency that incorporate likely PPV, three categories for who initiates the alarm (hospital staff, patient, or machine), whether it is clinical or technical, and clinical functions. CONCLUSION: This unique collaboration allowed us to make progress on the alarm problem by making unintuitive leaps, avoiding common missteps, and refuting conventional healthcare approaches. APPLICATION: Hospitals can consistently redesign, reorganize, reprioritize, and better discriminate alarms by priority, PPV, and content to reduce nurse response times.

"It was surprisingly equivalent to the appointment I had in person": Advantages and disadvantages of synchronous telehealth for delivering primary care for autistic adults.

LAY ABSTRACT: Autistic adults face many barriers to receiving quality primary health care like clinics that are far away and sensory sensitivities. Real-time telehealth visits, called "virtual visits," are live video chats between the patient and provider. Virtual visits may minimize barriers to care for autistic adults. We wanted to describe advantages and disadvantages of using virtual visits for delivering primary health care for autistic adults. We interviewed 7 autistic adults and 12 caregivers of autistic adults who receive primary care through one clinic. Autistic adults and caregivers said advantages to virtual visits were that (1) patients were more comfortable at home, (2) patients could get health care while avoiding physical contact with other people during the pandemic, and (3) virtual visits were similar to or better than in-person visits. The disadvantages included that (1) there could be technology problems like grainy video, (2) the doctor could not physically examine the patient (e.g. look in ears), and (3) patients sometimes participated less in the virtual visit than they would in person. Virtual visits may be beneficial for autistic adults by eliminating travel to the clinic and avoiding stressful sensory stimuli. We recognize that virtual visits may not work for all patients or in all situations. However, our study shows that primary care virtual visits may be beneficial for autistic adults during and beyond the pandemic.