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1.
JAMA ; 2020 Feb 16.
Artículo en Inglés | MEDLINE | ID: mdl-32062674

RESUMEN

Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Design, Setting, and Participants: Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. Main Outcomes and Measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Conclusions and Relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

2.
J Emerg Med ; 57(5): 629-636, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31594745

RESUMEN

BACKGROUND: Many patients presenting to emergency departments (EDs) do not have primary care and risk being lost to follow-up. Technology has been used successfully in surgical populations for wound care follow-up yet this is not well studied in ED populations. OBJECTIVE: We aimed to conduct a pilot study demonstrating "smartphone" application-based follow-up after wound care in the ED. METHODS: We enrolled participants in 2 urban EDs using a smartphone application called Mobile Post-Operative Wound Evaluator (mPOWEr) and defined participation as photographic submission at any time during the study period. We collected demographic data, frequency of use of mPOWEr, number of photographs uploaded, and timing of uploads. RESULTS: We approached patients for study enrollment, and 67 patients (28%) were not enrolled because they had no access to a smartphone. Seventy-one patients (30%) declined to enroll, leaving 100 (42%) successfully enrolled. Smartphone ownership was more common among patients <40 years of age (81% vs. 64%, p = 0.004), more common among white patients than nonwhite patients (75% vs. 15%, p = 0.046), more common among patients approached at the university medical center than the trauma center (84% vs. 66%, p = 0.003), and among patients with commercial or other insurance than those with Medicare or Medicaid (92% vs. 54%, p < 0.001). Of those enrolled, 58% submitted a photograph. CONCLUSIONS: Patients presenting for wound care to the ED will participate in smartphone-based app communication for wound care follow-up and are satisfied with this option. Disparities in smartphone access must be considered when using this follow-up method.

3.
BMC Med ; 17(1): 149, 2019 07 31.
Artículo en Inglés | MEDLINE | ID: mdl-31362721

RESUMEN

BACKGROUND: Persons with human immunodeficiency virus (HIV) have higher risks for myocardial infarction (MI) than the general population. This is driven in part by higher type 2 MI (T2MI, due to coronary supply-demand mismatch) rates among persons with HIV (PWH). In the general population, T2MI has higher mortality than type 1 MI (T1MI, spontaneous and generally due to plaque rupture and thrombosis). PWH have a greater burden of comorbidities and may therefore have an even greater excess risk for complication and death in the setting of T2MI. However, mortality patterns after T1MI and T2MI in HIV are unknown. METHODS: We analyzed mortality after MI among PWH enrolled in the multicenter, US-based Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort (N = 28,186). Incident MIs occurring between January 1, 1996, and December 31, 2014, were centrally adjudicated and classified as T1MI or T2MI. We first compared mortality following T1MI vs. T2MI among PWH. Cox survival analyses and Bayesian model averaging were then used to evaluate pre-MI covariates associated with mortality following T1MI and T2MI. RESULTS: Among the 596 out of 28,186 PWH who experienced MI (2.1%; 293 T1MI and 303 T2MI), mortality rates were significantly greater after T2MI (22.2/100 person-years; 1-, 3-, and 5-year mortality 39%, 52%, and 62%) than T1MI (8.2/100 person-years; 1-, 3-, and 5-year mortality 15%, 22%, and 30%). Significant mortality predictors after T1MI were higher HIV viral load, renal dysfunction, and older age. Significant predictors of mortality after T2MI were low body-mass index (BMI) and detectable HIV viral load. CONCLUSIONS: Mortality is high following MI for PWH and substantially greater after T2MI than T1MI. Predictors of death after MI differed by type of MI, reinforcing the different clinical scenarios associated with each MI type and the importance of considering MI types separately.


Asunto(s)
Infecciones por VIH/mortalidad , Infarto del Miocardio/mortalidad , Síndrome de Inmunodeficiencia Adquirida/complicaciones , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Síndrome de Inmunodeficiencia Adquirida/mortalidad , Adulto , Anciano , Estudios de Cohortes , Redes Comunitarias , Comorbilidad , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/epidemiología , Placa Aterosclerótica/complicaciones , Placa Aterosclerótica/epidemiología , Placa Aterosclerótica/mortalidad , Estados Unidos/epidemiología
4.
Surg Infect (Larchmt) ; 20(7): 530-534, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31464572

RESUMEN

Background: A landscape analysis of mobile health (mHealth) applications and published literature related to their use in surgical site infection (SSI) detection and surveillance was conducted by the Assessing Surgical Site Infection Surveillance Technologies (ASSIST) investigators. Methods: The literature review focused on post-discharge SSI detection or tracking by caregivers or patients using mHealth technology. This report is unique in its review across both commercial and research-based mHealth apps. Apps designed for long-term wound tracking and those focused on care coordination and scheduling were excluded. A structured evaluation framework was used to assess the operational, technical, and policy features of the apps. Results: Of the 10 apps evaluated, only two were in full clinical use. A variety of data were captured by the apps including wound photographs (eight apps), wound measurements (three apps), dressing assessments (two apps), physical activity metrics (three apps), medication adherence (three apps) as well as structured surveys, signs, and symptoms. Free-text responses were permitted by at least two apps. The extent of integration with the native electronic health record system was variable. Conclusion: The examination of rapidly evolving technologies is challenged by lack of standard evaluative methods, such as those more commonly used in clinical research. This review is unique in its application of a structured evaluation framework across both commercial and research-based mHealth apps.


Asunto(s)
Pruebas Diagnósticas de Rutina/métodos , Pruebas Diagnósticas de Rutina/normas , Monitoreo Epidemiológico , Infección de la Herida Quirúrgica/diagnóstico por imagen , Telemedicina/métodos , Humanos , Procesamiento de Imagen Asistida por Computador , Datos de Salud Generados por el Paciente , Periodo Posoperatorio
5.
Surg Infect (Larchmt) ; 20(7): 546-554, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31453753

RESUMEN

Background: There has been tremendous growth in the amount of new surgical site infection (SSI) data generated. Key challenges exist in understanding the data for robust clinical decision-support. Limitations of traditional methodologies to handle these data led to the emergence of artificial intelligence (AI). This article emphasizes the capabilities of AI to identify patterns of SSI data. Method: Artificial intelligence comprises various subfields that present potential solutions to identify patterns of SSI data. Discussions on opportunities, challenges, and limitations of applying these methods to derive accurate SSI prediction are provided. Results: Four main challenges in dealing with SSI data were defined: (1) complexities in using SSI data, (2) disease knowledge, (3) decision support, and (4) heterogeneity. The implications of some of the recent advances in AI methods to optimize clinical effectiveness were discussed. Conclusions: Artificial intelligence has the potential to provide insight in detecting and decision-support of SSI. As we turn SSI data into intelligence about the disease, we increase the possibility of improving surgical practice with the promise of a future optimized for the highest quality patient care.


Asunto(s)
Inteligencia Artificial , Monitoreo Epidemiológico , Procesamiento de Imagen Asistida por Computador/métodos , Infección de la Herida Quirúrgica/diagnóstico por imagen , Toma de Decisiones , Manejo de la Enfermedad , Humanos
6.
Surg Infect (Larchmt) ; 20(7): 555-565, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31424335

RESUMEN

Background: Emerging technologies such as smartphones and wearable sensors have enabled the paradigm shift to new patient-centered healthcare, together with recent mobile health (mHealth) app development. One such promising healthcare app is incision monitoring based on patient-taken incision images. In this review, challenges and potential solution strategies are investigated for surgical site infection (SSI) detection and evaluation using surgical site images taken at home. Methods: Potential image quality issues, feature extraction, and surgical site image analysis challenges are discussed. Recent image analysis and machine learning solutions are reviewed to extract meaningful representations as image markers for incision monitoring. Discussions on opportunities and challenges of applying these methods to derive accurate SSI prediction are provided. Conclusions: Interactive image acquisition as well as customized image analysis and machine learning methods for SSI monitoring will play critical roles in developing sustainable mHealth apps to achieve the expected outcomes of patient-taken incision images for effective out-of-clinic patient-centered healthcare with substantially reduced cost.


Asunto(s)
Procesamiento Automatizado de Datos/métodos , Procesamiento de Imagen Asistida por Computador/métodos , Datos de Salud Generados por el Paciente , Infección de la Herida Quirúrgica/diagnóstico por imagen , Telemedicina/métodos , Procesamiento Automatizado de Datos/tendencias , Humanos , Procesamiento de Imagen Asistida por Computador/tendencias , Telemedicina/tendencias
7.
Surg Infect (Larchmt) ; 20(7): 566-570, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31429637

RESUMEN

Background: The implementation of health information technology interventions is at the forefront of most hospital institutional policy agendas. Despite the availability of numerous apps and mobile platforms focusing on specific areas in healthcare the widespread integration into clinical practice can be a complex process. Here we present guidelines and methodology that we have learned in the implementation process of new technology and an overview of some of the current barriers and enablers specific to implementation of post-surgical site surveillance technology. Methods: Analysis of the experience of successful information technology (IT) implementation in different healthcare systems reveals that, despite differences among patient groups, care providers, and hospitals, there are common barriers and enablers to implementation of health IT. Results: The process of implementation in organizations and among individuals can be most successful by identifying barriers and enablers within three key stakeholder groups: (1) patients; (2) care providers/clinicians; and (3) manager/administration within healthcare systems. This can be achieved by specific engagement and co-design processes establishing clear benefits, sufficient incentives, and adequate support for clinicians as well as payer-provider relationships, marketplace competition and privacy legislation. Conclusions: The successful implementation of such programs requires appropriate strategic planning to address the needs of three specific components: patients, care provider, and policymakers/healthcare management understanding and acceptance.


Asunto(s)
Procesamiento Automatizado de Datos/métodos , Informática Médica/métodos , Datos de Salud Generados por el Paciente , Telemedicina/métodos , Procesamiento Automatizado de Datos/organización & administración , Guías como Asunto , Humanos , Informática Médica/organización & administración
8.
Surg Infect (Larchmt) ; 20(7): 535-540, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31429644

RESUMEN

Background: As the use of patient-owned devices, including smartphones and tablets, to manage day-to-day activities grows, so does healthcare industry's interest to better leverage technology to engage patients. For surgical care, a unique opportunity exists to capture patient-generated health data (PGHD) including photographs. As part of a broader initiative to evaluate PGHD for surgical site infection (SSI) surveillance, we sought evidence regarding patient involvement and experience with PGHD for SSI monitoring and surveillance. Methods: Through a scoping review of the literature and semi-structured stakeholder interviews we gathered evidence on what is currently known about patient perspectives of and experiences with mobile health (mHealth) interventions for post-operative recovery. We presented findings to and discussed with the ASSIST PGHD Stakeholder Advisory Group (PSAG) to generate priorities for further examination. Results: Our scoping review yielded 34 studies that addressed post-discharge use of PGHD for monitoring and surveillance of SSI. Of these, 16 studies addressed at least one outcome regarding patient experience; the most commonly measured outcome was patient satisfaction. Only three studies reported on patient involvement in the development of PGHD tools and interventions. We conducted interviews (n = 24) representing a range of stakeholder perspectives. Interviewees stressed the importance of patient involvement in tool and program design, noting patient involvement ensures the "work" that patients do in their daily lives to manage their health and healthcare is recognized. Discussion of evidence with the ASSIST PSAG resulted in formal recommendations for direct involvement of patients and caregivers for future work. Conclusions: While mHealth initiatives to advance post-operative management offer the ability to improve patient engagement, work is needed to ensure the patient voice is reflected. Active engagement with patients and caregivers in the development of new technology, the design of new workflows, and the conduct of research and evaluation ensures that the patient experiences and values are incorporated.


Asunto(s)
Pruebas Diagnósticas de Rutina/métodos , Monitoreo Epidemiológico , Participación del Paciente/métodos , Infección de la Herida Quirúrgica/diagnóstico por imagen , Telemedicina/métodos , Procesamiento Automatizado de Datos/métodos , Humanos , Datos de Salud Generados por el Paciente
9.
Surg Infect (Larchmt) ; 20(7): 571-576, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31397635

RESUMEN

Background: The patient's history of present illness provides an important part of the data with which clinicians diagnose and treat. Once surgical patients are discharged, the ability to incorporate direct observation requires coordinating patient and provider for a clinical visit. Mobile technologies offer the ability to gather and organize the patient's history, supplement that history with photographs and other clinical observations, and convey those data accurately and rapidly to the entire clinical team. Methods: We review our experience with patient-generated health data in surgical site infection, draw parallels with similar work in other domains, and identify principles we have found useful. Results: Health information system implementations require substantial changes in provider workflow. Shared expectations between the patient and the surgical team, an incremental approach to change in clinical processes, and an emphasis on clinical utility all support successful implementation. Conclusions: The data collection and rapid information exchange afforded by monitoring post-operative, post-discharge patients using mobile technologies can support the expectations of both patients and providers and may provide a novel data source for public health surveillance of surgical site infection. Both uses of these data require careful attention to introducing changes in clinical workflow.


Asunto(s)
Manejo de la Enfermedad , Sistemas de Información en Salud/tendencias , Difusión de la Información/métodos , Datos de Salud Generados por el Paciente , Infección de la Herida Quirúrgica/diagnóstico por imagen , Flujo de Trabajo , Humanos
10.
J Pain Symptom Manage ; 58(5): 857-863.e1, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31349036

RESUMEN

CONTEXT: Advance care planning (ACP) is difficult in the setting of a life-threatening trauma but may be equally important in this context, especially with increasing numbers of trauma victims being elderly or having multimorbidity. OBJECTIVES: Identify predictors of absent ACP documentation in the electronic health records of patients with underlying chronic illness who died of traumatic injury. METHODS: We used death records and electronic health records to identify decedents with chronic life-limiting illness who died of traumatic injury between 2010 and 2015 and to evaluate factors associated with documentation of living wills, durable powers of attorney, or physician orders for life-sustaining treatment. RESULTS: Only 22% of decedents had ACP documentation at time of injury. Among those without preinjury ACP documentation, 4% completed ACP documentation after injury. In multipredictor analyses, patients were less likely to have ACP documentation at the time of injury if they were younger (P < 0.001), had fewer chronic illnesses (P = 0.002), and had fewer nonsurgical hospitalizations (P = 0.042) in the year before injury. Among patients without ACP documentation before injury, those with fewer postinjury nonsurgical hospitalizations were less likely to complete ACP documentation after injury (P = 0.019). CONCLUSIONS: Our findings suggest that patient characteristics play an important role in the completion of ACP among patients with chronic life-limiting illness and who died from sudden severe injury. Interventions to improve ACP completion by patients with serious chronic conditions have the potential for increasing goal-concordant care in the event of traumatic injury.

11.
Surg Infect (Larchmt) ; 20(7): 588-591, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31347988

RESUMEN

Background: Patients increasingly use mobile devices to send text messages and photographic data to surgeons. There is potential to harness this patient-generated health data (PGHD) for clinical and public health surveillance of surgical site infection (SSI). Leveraging PGHD collected via remote monitoring in the post-operative period has the potential to produce important benefits for patients, surgeons, care teams, and infection surveillance and prevention. Methods: We conducted a health technology assessment (HTA), drawing heavily on stakeholder engagement to better understand current and potential uses of PGHD in post-operative care. Stakeholder engagement activities included assembling an advisory board composed of stakeholder experts, interviewing key informants, and seeking out stakeholder guidance to synthesize evidence from interviews, literature review, and technical app review in order to develop recommendations on the use of PGHD in SSI surveillance. Results: We conducted a review of the published literature, a technical/market scan of available apps for capturing post-operative PGHD, and two rounds of key informant interviews with stakeholders. In addition, we held a day-long workshop to solicit stakeholder feedback on initial findings of the project and to guide additional work. These activities culminated in an HTA report that provides guidance and recommendations on the use of PGHD in SSI surveillance, including practice, research, and public health surveillance, and identifies open issues on post-operative use of PGHD for which additional evidence and experience are needed to optimize application of those data for clinical and public health purposes. Conclusion: Stakeholders, individuals with direct experience, or interest in a given topic are critical to the HTA process. They provide insight to guide the work conducted, ensure that the topics addressed are relevant and important, and that products of the work are accessible and meaningful to the individuals who will be most impacted.


Asunto(s)
Monitoreo Epidemiológico , Investigación sobre Servicios de Salud/métodos , Investigación sobre Servicios de Salud/organización & administración , Datos de Salud Generados por el Paciente , Participación del Paciente/métodos , Infección de la Herida Quirúrgica/diagnóstico por imagen , Procesamiento Automatizado de Datos , Humanos , Periodo Posoperatorio , Participación de los Interesados
12.
JAMA Surg ; 154(2): 117-124, 2019 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-30422236

RESUMEN

Importance: Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients' electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice. Objective: To determine how wound photography affects surgeons' abilities to diagnose SSIs in a pragmatic setting. Design, Setting, and Participants: This prospective study compared surgeons' paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016. Intervention: Surgeons reviewed online clinical vignettes with or without wound photography. Main Outcomes and Measures: Surgeons' diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs. Results: A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons' assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P < .001) but they were more likely to undertriage patients when vignettes included a wound photograph, regardless of whether they correctly identified an SSI. Conclusions and Relevance: In a practical simulation, wound photography increased specificity and surgeon confidence, but worsened sensitivity for detection of SSIs. Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions. Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality.


Asunto(s)
Competencia Clínica/normas , Fotograbar , Cirujanos/normas , Infección de la Herida Quirúrgica/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Estudios Prospectivos , Consulta Remota/métodos , Sensibilidad y Especificidad
13.
J Gen Intern Med ; 33(10): 1661-1668, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29845470

RESUMEN

BACKGROUND: Patient-provider sexual risk behavior discussions occur infrequently but may be facilitated by high-quality sexual risk screening tools. OBJECTIVE: To develop the Sexual Risk Behavior Inventory (SRBI), a brief computer-administered patient-reported measure. DESIGN: Qualitative item development/quantitative instrument validation. PARTICIPANTS: We developed SRBI items based on patient interviews (n = 128) at four geographically diverse US primary care clinics. Patients were diverse in gender identity, sex, sexual orientation, age, race/ethnicity, and HIV status. We compared sexual risk behavior identified by the SRBI and the Risk Assessment Battery (RAB) among patients (n = 422). APPROACH: We constructed an item pool based on validated measures of sexual risk, developed an in-depth interview guide based on pool content, and used interviews to elicit new sexual risk concepts. We coded concepts, matched them to item pool content, and developed new content where needed. A provider team evaluated item clinical relevance. We conducted cognitive interviews to assess item comprehensibility. We administered the SRBI and the RAB to patients. KEY RESULTS: Common, clinically relevant concepts in the SRBI included number of sex partners; partner HIV status; partner use of antiretroviral medication (ART)/pre-exposure prophylaxis (PrEP); and recent sex without barrier protection, direction of anal sex, and concern regarding HIV/STI exposure. While 90% reported inconsistent condom use on the RAB, same-day SRBI administration revealed that for over one third, all their partners were on ART/PrEP. CONCLUSION: The SRBI is a brief, skip-patterned, clinically relevant measure that ascertains sexual risk behavior across sex, sexual orientation, gender identity, partner HIV serostatus, and partner treatment status, furnishing providers with context to determine gradations of risk for HIV/STI.


Asunto(s)
Medición de Resultados Informados por el Paciente , Atención Primaria de Salud/métodos , Asunción de Riesgos , Conducta Sexual/estadística & datos numéricos , Adulto , Terapia Antirretroviral Altamente Activa/estadística & datos numéricos , Diagnóstico por Computador/métodos , Femenino , Identidad de Género , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Medición de Riesgo/métodos , Parejas Sexuales , Terminología como Asunto , Estados Unidos/epidemiología , Sexo Inseguro/estadística & datos numéricos
14.
J Pain ; 19(9): 996-1005, 2018 09.
Artículo en Inglés | MEDLINE | ID: mdl-29605691

RESUMEN

The objective of this study was to develop and pilot test a chronic pain empowerment and self-management platform, derived from acceptance and commitment therapy, in a pain specialty setting. A controlled, sequential, nonrandomized study design was used to accommodate intervention development and to test the efficacy of the PainTracker Self-Manager (PTSM) intervention (Web-based educational modules and outcome tracking combined with tailored patient coaching sessions and provider guidance). Generalized estimating equations evaluated changes over time (baseline, 3 months, 6 months) in pain self-efficacy (primary outcome), chronic pain acceptance (activity engagement and pain willingness), perceived efficacy in patient-provider interactions, pain intensity and interference, and overall satisfaction with pain treatment (secondary outcomes) between intervention (n = 48) and usual care control groups (n = 51). The full study sample (N = 99) showed greater improvements over time (significant Group × Time interactions) in pain self-efficacy and satisfaction with pain treatment. Among study completers (n = 82), greater improvement in activity engagement as well as pain intensity and interference were also observed. These preliminary findings support the efficacy of the PTSM intervention in a pain specialty setting. Further research is needed to refine and expand the PTSM intervention and to test it in a randomized trial in primary care settings. PERSPECTIVE: We developed a Web-based patient empowerment platform that combined acceptance and commitment therapy-based educational modules and tailored coaching sessions with longitudinal tracking of treatments and patient-reported outcomes, named PTSM. Pilot controlled trial results provide preliminary support for its efficacy in improving pain self-efficacy, activity engagement, pain intensity and interference, and satisfaction with pain treatment.


Asunto(s)
Terapia de Aceptación y Compromiso/métodos , Dolor Crónico , Manejo del Dolor/métodos , Educación del Paciente como Asunto/métodos , Automanejo/métodos , Adolescente , Adulto , Anciano , Femenino , Humanos , Internet , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Proyectos Piloto , Adulto Joven
15.
J Pain Symptom Manage ; 54(2): 176-185.e1, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28495487

RESUMEN

CONTEXT: Little is known about psychiatric illness and utilization of end-of-life care. OBJECTIVES: We hypothesized that preexisting psychiatric illness would increase hospital utilization at end of life among patients with chronic medical illness due to increased severity of illness and care fragmentation. METHODS: We reviewed electronic health records to identify decedents with one or more of eight chronic medical conditions based on International Classification of Diseases-9 codes. We used International Classification of Diseases-9 codes and prescription information to identify preexisting psychiatric illness. Regression models compared hospital utilization among patients with and without psychiatric illness. Path analyses examined the effect of severity of illness and care fragmentation. RESULTS: Eleven percent of 16,214 patients with medical illness had preexisting psychiatric illness, which was associated with increased risk of death in nursing homes (P = 0.002) and decreased risk of death in hospitals (P < 0.001). In the last 30 days of life, psychiatric illness was associated with reduced inpatient and intensive care unit utilization but increased emergency department utilization. Path analyses confirmed an association between psychiatric illness and increased hospital utilization mediated by severity of illness and care fragmentation, but a stronger direct effect of psychiatric illness decreasing hospitalizations. CONCLUSION: Our findings differ from the increased hospital utilization for patients with psychiatric illness in circumstances other than end-of-life care. Path analyses confirmed hypothesized associations between psychiatric illness and increased utilization mediated by severity of illness and care fragmentation but identified more powerful direct effects decreasing hospital use. Further investigation should examine whether this effect represents a disparity in access to preferred care.


Asunto(s)
Enfermedad Crónica/mortalidad , Enfermedad Crónica/terapia , Trastornos Mentales/complicaciones , Cuidados Paliativos/estadística & datos numéricos , Cuidado Terminal/estadística & datos numéricos , Enfermedad Crónica/psicología , Estudios de Cohortes , Cuidados Críticos/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Hospitalización , Humanos , Masculino , Trastornos Mentales/mortalidad , Trastornos Mentales/terapia , Persona de Mediana Edad , Cuidados Paliativos/psicología , Análisis de Regresión , Factores de Riesgo , Índice de Severidad de la Enfermedad , Cuidado Terminal/psicología
17.
AIDS Behav ; 21(11): 3111-3121, 2017 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-28205041

RESUMEN

We compared same-day provider medical record documentation and interventions addressing depression and risk behaviors before and after delivering point-of-care patient-reported outcomes (PROs) feedback for patients who self-reported clinically relevant levels of depression or risk behaviors. During the study period (1 January 2006-15 October 2010), 2289 PRO assessments were completed by HIV-infected patients. Comparing the 8 months before versus after feedback implementation, providers were more likely to document depression (74% before vs. 87% after feedback, p = 0.02) in patients with moderate-to-severe depression (n = 317 assessments), at-risk alcohol use (41 vs. 64%, p = 0.04, n = 155) and substance use (60 vs. 80%, p = 0.004, n = 212). Providers were less likely to incorrectly document good adherence among patients with inadequate adherence after feedback (42 vs. 24%, p = 0.02, n = 205). While PRO feedback of depression and adherence were followed by increased provider intervention, other domains were not. Further investigation of factors associated with the gap between awareness and intervention are needed in order to bridge this divide.


Asunto(s)
Fármacos Anti-VIH/administración & dosificación , Recolección de Datos/métodos , Infecciones por VIH/tratamiento farmacológico , Internet , Medición de Resultados Informados por el Paciente , Sistemas de Atención de Punto , Asunción de Riesgos , Adulto , Consumo de Bebidas Alcohólicas/epidemiología , Depresión/epidemiología , Documentación , Femenino , Humanos , Masculino , Cumplimiento de la Medicación , Persona de Mediana Edad , Trastornos Relacionados con Sustancias/epidemiología , Resultado del Tratamiento
18.
JAMA Cardiol ; 2(3): 260-267, 2017 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-28052152

RESUMEN

Importance: The Second Universal Definition of Myocardial Infarction (MI) divides MIs into different types. Type 1 MIs result spontaneously from instability of atherosclerotic plaque, whereas type 2 MIs occur in the setting of a mismatch between oxygen demand and supply, as with severe hypotension. Type 2 MIs are uncommon in the general population, but their frequency in human immunodeficiency virus (HIV)-infected individuals is unknown. Objectives: To characterize MIs, including type; identify causes of type 2 MIs; and compare demographic and clinical characteristics among HIV-infected individuals with type 1 vs type 2 MIs. Design, Setting, and Participants: This longitudinal study identified potential MIs among patients with HIV receiving clinical care at 6 US sites from January 1, 1996, to March 1, 2014, using diagnoses and cardiac biomarkers recorded in the centralized data repository. Sites assembled deidentified packets, including physician notes and electrocardiograms, procedures, and clinical laboratory tests. Two physician experts adjudicated each event, categorizing each definite or probable MI as type 1 or type 2 and identifying the causes of type 2 MI. Main Outcomes and Measures: The number and proportion of type 1 vs type 2 MIs, demographic and clinical characteristics among those with type 1 vs type 2 MIs, and the causes of type 2 MIs. Results: Among 571 patients (median age, 49 years [interquartile range, 43-55 years]; 430 men and 141 women) with definite or probable MIs, 288 MIs (50.4%) were type 2 and 283 (49.6%) were type 1. In analyses of type 1 MIs, 79 patients who underwent cardiac interventions, such as coronary artery bypass graft surgery, were also included, totaling 362 patients. Sepsis or bacteremia (100 [34.7%]) and recent use of cocaine or other illicit drugs (39 [13.5%]) were the most common causes of type 2 MIs. A higher proportion of patients with type 2 MIs were younger than 40 years (47 of 288 [16.3%] vs 32 of 362 [8.8%]) and had lower current CD4 cell counts (median, 230 vs 383 cells/µL), lipid levels (mean [SD] total cholesterol level, 167 [63] vs 190 [54] mg/dL, and mean (SD) Framingham risk scores (8% [7%] vs 10% [8%]) than those with type 1 MIs or who underwent cardiac interventions. Conclusions and Relevance: Approximately half of all MIs among HIV-infected individuals were type 2 MIs caused by heterogeneous clinical conditions, including sepsis or bacteremia and recent use of cocaine or other illicit drugs. Demographic characteristics and cardiovascular risk factors among those with type 1 and type 2 MIs differed, suggesting the need to specifically consider type among HIV-infected individuals to further understand MI outcomes and to guide prevention and treatment.


Asunto(s)
Electrocardiografía , Infecciones por VIH/complicaciones , VIH , Infarto del Miocardio/diagnóstico , Medición de Riesgo , Adulto , Angiografía Coronaria , Femenino , Estudios de Seguimiento , Infecciones por VIH/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiología
19.
J Am Coll Surg ; 224(1): 8-15.e1, 2017 01.
Artículo en Inglés | MEDLINE | ID: mdl-27746223

RESUMEN

BACKGROUND: Postoperative surgical site infections (SSI) are common and costly. Most occur post discharge, and can result in potentially preventable readmission or unnecessary urgent evaluation. Mobile health approaches incorporating patient-generated wound photos are being implemented in an attempt to optimize triage and management. We assessed how adding wound photos to existing data sources modifies provider decision making. STUDY DESIGN: We used a web-based simulation survey using a convenience sample of providers with expertise in surgical infections. Participants viewed a range of scenarios, including surgical history, physical exam, and description of wound appearance. All participants reported SSI diagnosis, diagnostic confidence, and management recommendations (main outcomes) first without, and then with, accompanying wound photos. At each step, participants ranked the most important features contributing to their decision. RESULTS: Eighty-three participants completed a median of 5 scenarios (interquartile range 4 to 7). Most participants were physicians in academic surgical specialties (n = 70 [84%]). The addition of photos improved overall diagnostic accuracy from 67% to 76% (p < 0.001), and increased specificity from 77% to 92% (p < 0.001), but did not significantly increase sensitivity (55% to 65%; p = 0.16). Photos increased mean confidence in diagnosis from 5.9 of 10 to 7.4 of 10 (p < 0.001). Overtreatment recommendations decreased from 48% to 16% (p < 0.001), and undertreatment did not change (28% to 23%; p = 0.20) with the addition of photos. CONCLUSIONS: The addition of wound photos to existing data as available via chart review and telephone consultation with patients significantly improved diagnostic accuracy and confidence, and prevented proposed overtreatment in scenarios without SSI. Post-discharge mobile health technologies have the potential to facilitate patient-centered care, decrease costs, and improve clinical outcomes.


Asunto(s)
Fotograbar , Cuidados Posoperatorios/métodos , Infección de la Herida Quirúrgica/diagnóstico , Telemedicina/métodos , Adulto , Toma de Decisiones Clínicas/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente , Sensibilidad y Especificidad , Infección de la Herida Quirúrgica/terapia
20.
Int J Med Inform ; 97: 68-75, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-27919397

RESUMEN

BACKGROUND: Variations in the functionality, content and form of electronic medical record systems (EMRs) challenge national roll-out of these systems as part of a national strategy to monitor HIV response. To enforce the EMRs minimum requirements for delivery of quality HIV services, the Kenya Ministry of Health (MoH) developed EMRs standards and guidelines. The standards guided the recommendation of EMRs that met a preset threshold for national roll-out. METHODS: Using a standards-based checklist, six review teams formed by the MoH EMRs Technical Working Group rated a total of 17 unique EMRs in 28 heath facilities selected by individual owners for their optimal EMR implementation. EMRs with an aggregate score of ≥60% against checklist criteria were identified by the MoH as suitable for upgrading and rollout to Kenyan public health facilities. RESULTS: In Kenya, existing EMRs scored highly in health information and reporting (mean score=71.8%), followed by security, system features, core clinical information, and order entry criteria (mean score=58.1%-55.9%), and lowest against clinical decision support (mean score=17.6%) and interoperability criteria (mean score=14.3%). Four EMRs met the 60.0% threshold: OpenMRS, IQ-Care, C-PAD and Funsoft. On the basis of the review, the MoH provided EMRs upgrade plans to owners of all the 17 systems reviewed. CONCLUSION: The standards-based review in Kenya represents an effort to determine level of conformance to the EMRs standards and prioritize EMRs for enhancement and rollout. The results support concentrated use of resources towards development of the four recommended EMRs. Further review should be conducted to determine the effect of the EMR-specific upgrade plans on the other 13 EMRs that participated in the review exercise.


Asunto(s)
Registros Electrónicos de Salud/normas , Salud Pública , Instituciones de Salud , Humanos , Kenia
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