Glaucoma Detection through a Novel Hyperspectral Imaging Band Selection and Vision Transformer Integration.

Conventional diagnostic methods for glaucoma primarily rely on non-dynamic fundus images and often analyze features such as the optic cup-to-disc ratio and abnormalities in specific retinal locations like the macula and fovea. However, hyperspectral imaging techniques focus on detecting alterations in oxygen saturation within retinal vessels, offering a potentially more comprehensive approach to diagnosis. This study explores the diagnostic potential of hyperspectral imaging for glaucoma by introducing a novel hyperspectral imaging conversion technique. Digital fundus images are transformed into hyperspectral representations, allowing for a detailed analysis of spectral variations. Spectral regions exhibiting differences are identified through spectral analysis, and images are reconstructed from these specific regions. The Vision Transformer (ViT) algorithm is then employed for classification and comparison across selected spectral bands. Fundus images are used to identify differences in lesions, utilizing a dataset of 1291 images. This study evaluates the classification performance of models using various spectral bands, revealing that the 610-780 nm band outperforms others with an accuracy, precision, recall, F1-score, and AUC-ROC all approximately at 0.9007, indicating its superior effectiveness for the task. The RGB model also shows strong performance, while other bands exhibit lower recall and overall metrics. This research highlights the disparities between machine learning algorithms and traditional clinical approaches in fundus image analysis. The findings suggest that hyperspectral imaging, coupled with advanced computational techniques such as the ViT algorithm, could significantly enhance glaucoma diagnosis. This understanding offers insights into the potential transformation of glaucoma diagnostics through the integration of hyperspectral imaging and innovative computational methodologies.

A Secondary Data Analysis of Technology Access as a Determinant of Health and Impediment in Social Needs Screening and Referral Processes.

Introduction: Although health systems increasingly integrate social needs screening and referrals into routine care, the effectiveness of these interventions and for whom they work remains unclear. Methods: Patients (N=4,608) seen in the emergency department were screened for social needs (e.g., transportation, housing, food) and offered an opportunity to receive outreach from community service specialists. Results: Among 453 patients with 1 or more social needs who requested assistance, outreach specialists connected with 95 (21.0%). Patients preferred to be contacted through their telephone (n=21, 60.2%), email (n=126, 28.0%), someone else's telephone (n=30, 6.7%), or first by telephone followed by email (n=23, 5.1%). Preferred contact method varied by patient age; endorsement of unmet transportation, housing, and utility needs; receipt of service outreach; and differences in emergency department utilization from the 6 months before the index visit to the 6 months after. Conclusions: Because limited access to a stable telephone or internet connection may prevent patients from connecting with resource referrals, social needs interventions may not benefit the most underserved populations who are at the highest risk of negative health outcomes. Future research should investigate whether communication preferences are an important indicator of needs and how to adapt social needs screening and referral processes so that they are more accessible to populations who may experience more frequent disruptions in methods utilized for digital communication.

Noninvasive cardiac radioablation for ventricular tachycardia: dosimetric comparison between linear accelerator- and robotic CyberKnife-based radiosurgery systems.

BACKGROUND: Few dosimetric comparisons have been published between linear accelerator (LA)-based systems and CyberKnife (CK)-based robotic radiosurgery systems for cardiac radio-ablation in ventricular tachycardia. This study aimed to compare the dosimetry of noninvasive cardiac radio-ablation deliverable on LA with that on CK. METHODS: Thirteen patients who underwent noninvasive cardiac radio-ablation by LA were included. The prescribed dose was 25 Gy in 1 fraction, and the average planning target volume was 49.8 ± 31.0 cm3 (range, 14.4-93.7 cm3). CK plans were generated for comparison. RESULTS: Both the CK and LA plans accomplished appropriate dose coverage and normal tissue sparing. Compared with the LA plans, the CK plans achieved significantly lower gradient indices (3.12 ± 0.71 vs. 3.48 ± 0.55, p = 0.031) and gradient measures (1.00 ± 0.29 cm vs. 1.17 ± 0.29 cm, p < 0.001). They had similar equivalent conformity indices (CK vs. LA: 0.84 ± 0.08 vs. 0.87 ± 0.07, p = 0.093) and maximum doses 2 cm from the planning target volume (PTV) in any direction (CK vs. LA: 50.8 ± 9.9% vs. 53.1 ± 5.3%, p = 0.423). The dosimetric advantages of CK were more prominent in patients with a PTV of ≤ 50 cm3 or a spherical PTV. In patients with a PTV of > 50 cm3 or a non-spherical PTV, the LA and CK plans were similar regarding dosimetric parameters. CK plans involved more beams (232.2 ± 110.8 beams vs. 10.0 ± 1.7 arcs) and longer treatment times (119.2 ± 43.3 min vs. 22.4 ± 1.6 min, p = 0.007). CONCLUSIONS: Both CK and LA are ideal modalities for noninvasive cardiac radio-ablation. Upfront treatment should be considered based on clinical intent.

Detection of Hydroxychloroquine Retinopathy via Hyperspectral and Deep Learning through Ophthalmoscope Images.

Hydroxychloroquine, also known as quinine, is primarily utilized to manage various autoimmune diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's syndrome. However, this drug has side effects, including diarrhea, blurred vision, headache, skin itching, poor appetite, and gastrointestinal discomfort. Blurred vision is caused by irreversible retinal damages and can only be mitigated by reducing hydroxychloroquine dosage or discontinuing the drug under a physician's supervision. In this study, color fundus images were utilized to identify differences in lesions caused by hydroxychloroquine. A total of 176 color fundus images were captured from a cohort of 91 participants, comprising 25 patients diagnosed with hydroxychloroquine retinopathy and 66 individuals without any retinopathy. The mean age of the participants was 75.67 ± 7.76. Following the selection of a specific region of interest within each image, hyperspectral conversion technology was employed to obtain the spectrum of the sampled image. Spectral analysis was then conducted to discern differences between normal and hydroxychloroquine-induced lesions that are imperceptible to the human eye on the color fundus images. We implemented a deep learning model to detect lesions, leveraging four artificial neural networks (ResNet50, Inception_v3, GoogLeNet, and EfficientNet). The overall accuracy of ResNet50 reached 93% for the original images (ORIs) and 96% for the hyperspectral images (HSIs). The overall accuracy of Inception_v3 was 87% for ORIs and 91% for HSI, and that of GoogLeNet was 88% for ORIs and 91% for HSIs. Finally, EfficientNet achieved an overall accuracy of 94% for ORIs and 97% for HSIs.

Evaluation and Comparison of Real-World Databases for Conducting Research in Patients With Colorectal Cancer.

PURPOSE: Evaluating whether patient populations in clinico-genomic oncology databases are comparable with whom in other databases without genomic component is important. METHODS: Four databases were compared for colorectal cancer (CRC) cases and stage IV CRC cases: American Association for Cancer Research Project Genomics Evidence Neoplasia Information Exchange Biopharma Collaborative (GENIE-BPC), The Cancer Genome Atlas (TCGA), SEER-Medicare, and MarketScan Commercial and Medicare Supplemental claims databases. These databases were also compared with the SEER registry database which serves as national benchmarks. Demographics, clinical characteristics, and overall survival were compared in patients with newly diagnosed CRC and patients with stage IV CRC across databases. Treatment patterns were further compared in patients with stage IV CRC. RESULTS: A total of 65,976 patients with CRC and 13,985 patients with stage IV CRC were identified. GENIE-BPC had the youngest patient population (mean age [years]: CRC, 54.1; stage IV CRC, 52.7). SEER-Medicare had the oldest patient population (CRC, 77.7; stage IV CRC, 77.3). Most patients were male and of White race across databases. GENIE-BPC had the highest proportion of patients with stage IV CRC (48.4% v other databases 13.8%-25.4%) and patients receiving treatments (95.7% v 37.6%-59.1%). Infusional fluorouracil, leucovorin, and oxaliplatin with or without bevacizumab was the most common regimen across databases accounting for 47.3%-78.5% of patients receiving first line of therapy. The median survival from diagnosis was 36, 94, 44 months (CRC) and 23, 36, 15 months (stage IV CRC) for patients in GENIE-BPC after left truncation, TCGA, and SEER-Medicare databases, respectively. CONCLUSION: Compared with other databases, GENIE-BPC had the youngest patients with CRC with the most advanced disease and the largest proportion of patients receiving treatment. Investigators should consider adjustments when extrapolating results from clinico-genomic databases to the general CRC population.

Optical Identification of Diabetic Retinopathy Using Hyperspectral Imaging.

The severity of diabetic retinopathy (DR) is directly correlated to changes in both the oxygen utilization rate of retinal tissue as well as the blood oxygen saturation of both arteries and veins. Therefore, the current stage of DR in a patient can be identified by analyzing the oxygen content in blood vessels through fundus images. This enables medical professionals to make accurate and prompt judgments regarding the patient's condition. However, in order to use this method to implement supplementary medical treatment, blood vessels under fundus images need to be determined first, and arteries and veins then need to be differentiated from one another. Therefore, the entire study was split into three sections. After first removing the background from the fundus images using image processing, the blood vessels in the images were then separated from the background. Second, the method of hyperspectral imaging (HSI) was utilized in order to construct the spectral data. The HSI algorithm was utilized in order to perform analysis and simulations on the overall reflection spectrum of the retinal image. Thirdly, principal component analysis (PCA) was performed in order to both simplify the data and acquire the major principal components score plot for retinopathy in arteries and veins at all stages. In the final step, arteries and veins in the original fundus images were separated using the principal components score plots for each stage. As retinopathy progresses, the difference in reflectance between the arteries and veins gradually decreases. This results in a more difficult differentiation of PCA results in later stages, along with decreased precision and sensitivity. As a consequence of this, the precision and sensitivity of the HSI method in DR patients who are in the normal stage and those who are in the proliferative DR (PDR) stage are the highest and lowest, respectively. On the other hand, the indicator values are comparable between the background DR (BDR) and pre-proliferative DR (PPDR) stages due to the fact that both stages exhibit comparable clinical-pathological severity characteristics. The results indicate that the sensitivity values of arteries are 82.4%, 77.5%, 78.1%, and 72.9% in the normal, BDR, PPDR, and PDR, while for veins, these values are 88.5%, 85.4%, 81.4%, and 75.1% in the normal, BDR, PPDR, and PDR, respectively.

Indications of food insecurity in the content of telephone calls to a community referral system.

BACKGROUND: Food insecurity is a social determinant of health that impacts more than 10% of U.S. households every year. Many unexpected events make food-insecure people and those with unmet food needs seek information and help from both formal (e.g., community organizations) and informal (e.g., family/friends) resources. Food-related information seeking through telephone calls to a community referral system-211 network-has been used as a proxy for food insecurity but the context of these calls has not been characterized and the validity of this proxy measure is unknown. OBJECTIVE: To investigate the content of food-related telephone calls to 211 and explore the indications of food insecurity during these calls. METHODS: We conducted a secondary qualitative analysis on the transcripts of food-related calls to Utah's 211. From February to March 2022, 25 calls were sampled based on the location of callers to ensure the representation of rural residents. 13 calls from metropolitan and 12 calls from nonmetropolitan ZIP Codes were included. Using a purposive sampling approach, we also made sure that the sample varied with regard to race and ethnicity. Calls were transcribed and de-identified by our community partner-Utah's 211 and were analyzed using a thematic analysis approach by our research team. RESULTS: Three themes emerged from the qualitative analysis including referral to 211, reasons for food-related calls, and reasons for unmet food needs. Results highlight the complex social environment around 211 food-related callers, lack of knowledge about available food resources, and indications of food insecurity in calls. CONCLUSION: Information seeking for food-related resources through 211 is a problem-solving source for people living in a complex social environment. Indications of food insecurity through these calls validate the use of these calls as a proxy measure for food insecurity. Interventions should be designed to increase awareness about the available resources and address the co-existing social needs with food insecurity.

Comparative effectiveness of pegfilgrastim biosimilars vs originator for prevention of febrile neutropenia: A retrospective cohort study.

BACKGROUND: Real-world evidence on the comparative effectiveness of pegfilgrastim biosimilars compared with the originator product is limited. OBJECTIVE: To compare the risk of febrile neutropenia (FN) among users of pegfilgrastim biosimilars (pegfilgrastim-jmdb and pegfilgrastim-cbqv) and the originator product. METHODS: A retrospective cohort study was conducted using 2019 IBM MarketScan databases to assess comparative effectiveness of pegfilgrastim originator and biosimilars for prevention of FN among patients receiving myelosuppressive chemotherapy. Patients with cancer, including breast, lung, colorectal, esophageal and gastric, pancreatic, prostate, ovarian, and non-Hodgkin lymphomas, initiating myelosuppressive chemotherapy courses were selected. We further selected patients who used pegfilgrastim originator and biosimilars within 3 days of chemotherapy completion. FN-associated hospitalizations were measured by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. After 1:1 propensity score matching, we used equivalence (with a margin of 6%) hypothesis tests to compare FN-related hospitalization risk in the first cycle and across all cycles between biosimilars and originator users. RESULTS: A total of 2,045 patients were included, of which 445 (21.8%) used pegfilgrastim-jmdb, 636 (31.1%) used pegfilgrastim-cbqv, and 964 (47.1%) used pegfilgrastim originator. After matching, 13 out of 445 originator users and 17 out of 445 pegfilgrastim-jmdb users developed FN after the first chemotherapy cycle (risk difference was 0.9%; P < 0.001 for equivalence test indicating statistical equivalence). After matching, 14 out of 633 originator users and 16 out of 633 pegfilgrastim-cbqv users developed FN (risk difference was 0.32%; P < 0.001 for equivalence test indicating statistical equivalence). Results across all cycles (including the first cycle) were consistent with that in the first cycle. CONCLUSIONS: In this real-world study of patients with cancer receiving myelosuppressive chemotherapy, there was no difference in FN risk between patients receiving pegfilgrastim originator and biosimilars in the first cycle and across all cycles. These results add further to the current evidence on pegfilgrastim biosimilars and support wider adoption of pegfilgrastim biosimilars among payers, providers, and patients. Future studies assessing the tolerability, side effects, and other safety issues of pegfilgrastim biosimilars are needed.

Feasibility and usefulness of the going home toolkit, an mhealth app, during hospital discharge: patient and clinician perspectives.

Feasibility and Usefulness of the Going Home Toolkit, an mHealth App, during Hospital Discharge: Patient and Clinician Perspectives. Objective Communication gaps during discharge planning contribute to post-discharge outcomes. mHealth Apps may allow health systems to provide resources to fill patients' needs. The study's purpose was to elicit feedback regarding The Going Home Toolkit (GHT), an App that aims to facilitate patient communication about discharge needs. Participants Twenty patients hospitalized within the past year, and seven case managers involved in discharge processes from an academic health sciences center. Methods Using tablets installed with the GHT prototype, remote engagement studio interviews were used to observe GHT use and perceptions about usefulness and feasibility. Results Patients successfully used the GHT to identify resources that they may not have known otherwise. Clinicians reported the GHT would support patient engagement during discharge. However, patients liked being able to search for resources, while clinicians focused on offering a list of information. This can be described as a pull vs. push approach to accessing resources. Participants recognized the GHT's unique focus on cognitive processes related to self-management vs. knowledge transfer. Conclusions The GHT represents a valuable tool for facilitating anticipatory planning and procurement of resources post-discharge. Future work should focus on refining the user interface and user experience of the app and creating seamless links to community resources.

Patient out-of-pocket and payer costs for pegfilgrastim originator vs biosimilars as primary prophylaxis of febrile neutropenia in the first cycle among a commercially insured population.

BACKGROUND: It is unknown whether using pegfilgrastim biosimilars is cost saving in a real-world setting. OBJECTIVE: To compare medical costs including pegfilgrastim drug costs and febrile neutropenia (FN) treatment and management costs between pegfilgrastim biosimilars (pegfilgrastim-jmdb, pegfilgrastim-cbqv) and originator users for primary prophylaxis of febrile neutropenia. METHODS: A retrospective cohort study using 2019 IBM MarketScan Commercial and Medicare Supplemental databases was conducted in adult patients with cancer initiating myelosuppressive chemotherapy courses. At least 2 diagnoses of the same cancer (at least 7 days apart) were required within 30 days of the chemotherapy initiation date. Pegfilgrastim (excluding on-body injector) costs included drug costs only (excluding administration fees). FN-related costs included all FN-related health care utilizations that were defined as having neutropenia, fever, or infection diagnosis. Per-patient per-cycle (PPPC) out-of-pocket (OOP) costs, health plan costs, and total costs were compared between originator (excluding on-body injector) and biosimilars users in the first cycle. A generalized linear model and a 2-part model were used. RESULTS: A total of 1,930 patients were included, of whom 884 (45.8%) used pegfilgrastim originator, 427 (22.1%) used pegfilgrastim-jmdb, and 619 (32.1%) used pegfilgrastim-cbqv. Adjusted PPPC OOP pegfilgrastim costs in the first cycle were significantly lower for the biosimilars vs the originator ($182 for pegfilgrastim-jmdb and $159 for pegfilgrastim-cbqv vs $299 for originator, P < 0.0001 for both comparisons). However, there was no difference in health plan costs ($5,783 for pegfilgrastim-jmdb and $5,845 for pegfilgrastim-cbqv vs $5,618 for originator) and total costs. In addition, no difference was observed for adjusted PPPC FN treatment and management OOP costs, health plan costs, and total costs in the first cycle. FN treatment OOP costs were $192 for originator, $197 for pegfilgrastim-jmdb (P = 0.958), and $240 for pegfilgrastim-cbqv (P = 0.680). FN treatment health plan costs were $2,804 for originator, $2,970 for pegfilgrastim-jmdb (P = 0.692), and $2,745 for pegfilgrastim-cbqv (P = 0.879). CONCLUSIONS: In a commercially insured population, using pegfilgrastim biosimilars in the first cycle for primary prophylaxis of FN led to cost savings for patients but not payers. No difference in FN-related costs was observed.

Uncontrolled Extensions of Clinical Trials and the Use of External Controls-Scoping Opportunities and Methods.

Increased interest in real-world evidence (RWE) for clinical and regulatory decision making and the need to evaluate long-term benefits and risks of pharmaceutical products raise the importance of understanding the use of external controls (ECs) for uncontrolled extensions of randomized controlled trials (RCTs). We searched clinicaltrials.gov from 2009 to 2019 for uncontrolled extensions and assessed the use of ECs in the trial protocol registry and PubMed. We present characteristics of identified uncontrolled extensions, their adoption of ECs, and a qualitative appraisal of published uncontrolled extensions with ECs according to good pharmacoepidemiologic practice. The number of uncontrolled extensions increased slightly across the study period, resulting in a total of 1,115 studies. Most originated from phase III RCTs (62.2%) and specified safety outcomes (61.9% among those with specified outcomes). Most uncontrolled extensions incorporated no control group with only 7 out of 1,115 (0.6%) employing ECs. For those studies with ECs, all involved treatments for rare conditions and assessment of effectiveness. Attempts to balance comparison groups varied from none mentioned to propensity score matching. We noted consistent deficiencies in outcome ascertainment methods and approaches to address attrition bias. The contrast of the large and growing number of uncontrolled extensions with the small number of studies that utilized ECs showed clear opportunities for enhancement in design, measurement, and analysis of uncontrolled extensions to allow causal inferences on long-term treatment effects. As extensions continue to expand within RWE regulatory frameworks, development of guidelines for use of EC with uncontrolled extensions is needed.

Trends in Use of Granulocyte Colony-Stimulating Factor Following Introduction of Biosimilars Among Adults With Cancer and Commercial or Medicare Insurance From 2014 to 2019.

Importance: The introduction of biosimilars and novel delivery devices between 2014 and 2019 may have changed the utilization of granulocyte colony-stimulating factors (G-CSF). Objective: To assess utilization trends of G-CSFs for primary prophylaxis of febrile neutropenia (FN) among patients with cancer receiving myelosuppressive chemotherapy with commercial or Medicare insurance. Design, Setting, and Participants: This cross-sectional study assessed G-CSF utilization trends overall and stratified by regimen febrile neutropenia risk level. Associations between patient characteristics and G-CSF use were evaluated. Patients with cancer, including breast, lung, colorectal, esophageal and gastric, pancreatic, prostate, ovarian, and non-Hodgkin lymphomas, initiating myelosuppressive chemotherapy courses were included from the 2014 to 2019 commercial insurance and 2014 to 2018 Medicare fee-for-service claims databases. Data were analyzed from March to June 2021. Exposures: Year of chemotherapy initiation. Main Outcomes and Measures: The main outcomes were use and trends of G-CSFs for primary prophylaxis, from completion to 3 days after in the first chemotherapy cycle. Results: In total, 86 731 chemotherapy courses (mean [SD] age, 57.7 [11.5] years; 57 838 [66.7%] women and 28 893 [33.3%] men) were identified from 82 410 patients in the commercial insurance database and 32 398 chemotherapy courses (mean [SD] age, 71.8 [8.3] years; 18 468 [57.0%] women and 13 930 [43.0%] men) were identified from 30 279 patients in the Medicare database. Among the commercially insured population, 39 639 patients (45.7%) received G-CSFs, and 12 562 patients (38.8%) received G-CSFs among Medicare insured patients. Overall G-CSF use increased significantly throughout the study period in both populations, from 45.1% (95% CI, 44.4%-45.7%) of patients in 2014 to 47.5% (95% CI, 46.5%-48.5%) of patients in 2019 (P = .001) in the commercially insured population and from 36.0% (95% CI, 34.2%-38.0%) of patients in 2014 to 39.1% (95% CI, 38.1%-40.1%) of patients in 2018 (P < .001) in the Medicare population. The greatest increases in G-CSF use were observed among patients with high FN risk, from 75.0% (95% CI, 74.1%-76.0%) of patients to 83.2% (95% CI, 82.0%-84.2%) of patients (P < .001) among the commercially insured population and 75.3% (95% CI, 71.8%-78.6%) of patients to 86.2% (95% CI, 84.7%-87.6%) of patients (P < .001) among the Medicare population. Use of G-CSFs decreased in the commercially insured population among patients with intermediate FN risk (from 27.5% [95% CI, 26.4%-28.5%] of patients to 20.4% [95% CI, 19.1%-21.7%] of patients; P < .001) or low FN risk (from 19.3% [95% CI, 18.3%-20.4%] of patients to 16.3% [95% CI, 14.7%-18.0%] of patients; P < .001) and remained stable in the Medicare population (intermediate risk: from 26.4% [95% CI, 23.8%-29.2%] of patients to 28.4% [95% CI, 27.0%-29.8%] of patients; P = .35; low risk: from 19.6% [95% CI, 17.0%-22.4%] of patients to 20.9% [95% CI, 19.6%-22.3%] of patients; P = .58). Factors associated with increased odds of G-CSF use included older age (commercial insurance: adjusted odds ratio [aOR], 1.50 [95% CI, 1.41-1.59]; Medicare: aOR, 1.36 [95% CI, 1.08-1.71]), receiving a regimen with high FN risk (commercial insurance: aOR, 16.01 [95% CI, 15.17-16.90]; Medicare: aOR, 17.17 [95% CI, 15.76-18.71]), and history of neutropenia (commercial insurance: 3.90 (3.67-4.15); Medicare: 3.82 (3.50-4.18). Conclusions and Relevance: This cross-sectional study found that utilization of G-CSFs increased among patients with cancer with high FN risk in both a commercially and Medicare-insured population, but 14% to 17% of patients still did not receive preventive treatment.

Interpreting convolutional neural network for real-time volatile organic compounds detection and classification using optical emission spectroscopy of plasma.

This study presents the investigation of optical emission spectroscopy of plasma using interpretable convolutional neural network (CNN) for real-time volatile organic compounds (VOCs) classification. A microplasma-generation platform was developed to efficiently collect 64 k spectra from various types of VOCs at different concentrations, as training and testing sets for machine learning. A CNN model was trained to classify VOCs with accuracy of 99.9%. To interpret the CNN model and its predictions, the spectral processing mechanism of the CNN was visualized by feature maps and the critical spectral features were identified by gradient-weighted class activation mapping. Such approaches brought insights on how CNN analyzes the spectra and enables the CNN operation to be explainable. Finally, the CNN model was incorporated with the microplasma platform to demonstrate the application of real-time VOC monitoring. The type of VOCs can be identified and reported via messages within 10 s once the microplasma is ignited. We believe that using CNN brings a novel route for plasma spectroscopy analysis for VOC classification and impacts the fields of plasma, spectroscopy, and environmental monitoring.

A Comparison of the Survival, Place of Death, and Medical Utilization of Terminal Patients Receiving Hospital-Based and Community-Based Palliative Home Care: A Retrospective and Propensity Score Matching Cohort Study.

Evidence shows that community-based palliative home care (PHC) provision enhances continuous care and improves patient outcomes. This study compared patient survival, place of death, and medical utilization in community- versus hospital-based PHC. A retrospective cohort study was conducted of patients aged over 18 referred to either community- or hospital-based PHC from May to December 2018 at a tertiary hospital and surrounding communities in Southern Taiwan. A descriptive analysis, Chi-square test, t-test, and Log-rank test were used for the data analysis of 131 hospital-based PHC patients and 43 community-based PHC patients, with 42 paired patient datasets analyzed after propensity score matching. More nurse visits (p = 0.02), fewer emergency-room visits (p = 0.01), and a shorter waiting time to access PHC (p = 0.02) were found in the community group. There was no difference in the duration of survival and hospitalization between groups. Most hospital-based patients (57%) died in hospice wards, while most community-based patients died at home (52%). Community-based PHC is comparable to hospital-based PHC in Taiwan. Although it has fewer staffing and training requirements, it is an alternative for terminal patients to meet the growing end-of-life care demand.

Exploring experiences of COVID-19-positive individuals from social media posts.

AIMS: This study aimed to explore the experience of individuals who claimed to be COVID-19 positive via their Twitter feeds. BACKGROUND: Public social media data are valuable to understanding people's experiences of public health phenomena. To improve care to those with COVID-19, this study explored themes from Twitter feeds, generated by individuals who self-identified as COVID-19 positive. DESIGN: This study utilized a descriptive design for text analysis for social media data. METHODS: This study analysed social media text retrieved by tweets of individuals in the United States who self-reported being COVID-19 positive and posted on Twitter in English between April 2, 2020, and April 24, 2020. In extracting embedded topics from tweets, we applied topic modelling approach based on latent Dirichlet allocation and visualized the results via LDAvis, a related web-based interactive visualization tool. RESULTS: Three themes were mined from 721 eligible tweets: (i) recognizing the seriousness of the condition in COVID-19 pandemic; (ii) having symptoms of being COVID-19 positive; and (iii) sharing the journey of being COVID-19 positive. CONCLUSION: Leveraging the knowledge and context of study themes, we present experiences that may better reflect patient needs while experiencing COVID-19. The findings offer more descriptive support for public health nursing and other translational public health efforts during a global pandemic.

Developing the Resilience Framework for Nursing and Healthcare.

Despite four decades of resilience research, resilience remains a poor fit for practice as a scientific construct. Using the literature, we explored the concepts attributed to the development of resilience, identifying those that mitigate symptoms of distress caused by adversity and facilitate coping in seven classes of illness: transplants, cancer, mental illness, episodic illness, chronic and painful illness, unexpected events, and illness within a dyadic relationship. We identified protective, compensatory, and challenge-related coping-concept strategies that healthcare workers and patients use during the adversity experience. Healthcare-worker assessment and selection of appropriate coping concepts enable the individual to control their distress, resulting in attainment of equanimity and the state of resilience, permitting the resilient individual to work toward recovery, recalibration, and readjustment. We inductively developed and linked these conceptual components into a dynamic framework, The Resilience Framework for Nursing and Healthcare, making it widely applicable for healthcare across a variety of patients.

Three-Year, Postintervention, Follow-up Comparison of Health Care Resource Utilization and Costs in the Lifestyle Interventions and Independence for Elders (LIFE) Study.

BACKGROUND: The Lifestyle Interventions and Independence for Elders (LIFE) Study physical activity (PA) intervention was found to be cost-effective compared to health education (HE). However, long-term effects postintervention are unknown. METHOD: This was a secondary analysis of LIFE Study data linked to Medicare claims data (2014-2016). Participants were linked via Social Security Numbers to Medicare claims data. Utilization and cost variables were analyzed using generalized linear models with negative binomial and Tweedie distributions. Unadjusted means and 95% confidence intervals were compared by year and overall stratified. Each model compared PA versus HE and adjusted for other baseline characteristics and stratified by study site. Additional models were stratified by baseline physical functioning assessment scores. RESULTS: Of the 1,635 LIFE Study participants, 804 (53.5%) were linked to Medicare claims with an average of 33 months of follow-up time during the 3-year data linkage period. Mean outpatient (6.6 vs 6.8), inpatient (0.40 vs 0.40), and other utilization metrics were similar between PA and HE groups. Costs were also similar for each group and each type of service, for example, outpatient: $2,070 versus $2,093 and inpatient: $4,704 versus $4,792. Regression results indicated no statistically significant differences between PA and HE groups. CONCLUSIONS: While the LIFE Study demonstrated that PA reduced mobility disability in older adults and was cost-effective, it did not appear to affect long-term health care utilization costs posttrial. These findings suggest that it remains challenging to affect long-term health care costs using PA interventions effects.

Readmissions after Pancreatic Surgery in Patients with Pancreatic Cancer: Does Hospital Variation Exist for Quality Measurement?

BACKGROUND: The appropriateness of using readmission rate after pancreatic surgery among pancreatic cancer patients as a quality metric to evaluate hospital performance has been widely discussed in the literature. OBJECTIVES: The present study reported readmission rate using Nationwide Readmissions Database (NRD), examined the reasons and risk factors for readmissions, and evaluated the appropriateness of using it as a quality metric. METHOD: We analyzed 3,619 patient discharge records in 2014. The outcome of interest was all-cause 30-day readmission. Reasons for readmission were grouped into clinical associated categories. Hierarchical regression model was used for examining the relationship between risk factors and readmission. RESULTS: The 30-day readmission rate was 20.95%. The most common reason for readmission was surgery-related complication. In descriptive analyses, age, certain comorbidities, number of chronic conditions, mortality risk, severity of illness, living at large metropolitan area, resident of the state where patients received initial care, postoperative complication, length of stay, discharge location, and receiving care at the hospitals in large metropolitan area were predictive of readmission. In multivariable analysis, age, depression, peripheral vascular disorder, mortality risk, and discharge location were independently associated with readmission. The intraclass correlation coefficient was 0.41 for hierarchical regression model. CONCLUSIONS: Readmission after pancreatic surgery remains an important issue. Our study found the majority of variation in readmissions is accounted for by patient factors whereas there was little between hospital variation. This finding does not support the use of readmission rate after pancreatic surgery as a quality metric.

Updating the Cost Effectiveness of Oral Anticoagulants for Patients with Atrial Fibrillation Based on Varying Stroke and Bleed Risk Profiles.

BACKGROUND: Previous investigations into the cost effectiveness of direct oral anticoagulants only considered individual stroke risk but not bleed risk even though bleeding is an important and potentially fatal side effect for anticoagulated patients. OBJECTIVE: This study aimed to evaluate the cost effectiveness of dabigatran, rivaroxaban, apixaban, and edoxaban vs warfarin in patients with atrial fibrillation with varying stroke/bleed risk profiles over a lifetime horizon. METHODS: A Markov micro-simulation was adapted to examine the lifetime costs and quality-adjusted survival of five anticoagulants from a US private payer's perspective. The study hypothetical cohort consisted of 10,000 patients with atrial fibrillation with age, CHA2DS2-VASc, and HAS-BLED scores similar to a commercially insured patient with atrial fibrillation cohort. Model input parameters including the efficacy and safety of each strategy, utilities, and cost were estimated from public sources, published literature, and analysis conducted in the IBM MarketScan database. Lifetime cost, quality-adjusted life-years, and incremental cost-effectiveness ratios were assessed for each treatment strategy. Subgroup analyses stratified by age, stroke risk score alone, bleed risk score alone and both were performed. Uncertainty was assessed by a deterministic sensitivity analysis and a probabilistic sensitivity analysis. RESULTS: The base-case analysis suggested dabigatran was the optimal treatment with an incremental cost-effectiveness ratio of $35,055 per quality-adjusted life-year relative to warfarin. Subgroup analyses stratified by age, stroke risk score, and bleed risk score alone were largely consistent with the base-case analysis. Subgroup analyses stratified by both stroke and bleed risk score showed edoxaban was the preferred treatment in patients with a low stroke and a low or medium bleed risk, and patients with a high stroke and low bleed risk. Apixaban was the preferred treatment in patients with a medium stroke and high bleed risk. Results of the deterministic sensitivity analysis indicate the model results were most sensitive to the drug cost and hazard ratio for stroke and bleeding event. Results of the probability sensitivity analysis showed dabigatran is cost effective vs. other treatments in 32.8% and 42.4% of iterations at a willingness to pay of $50,000/quality-adjusted life-year and a willingness to pay of $100,000/quality-adjusted life year, respectively. CONCLUSIONS: From a US private payer's perspective, dabigatran appears cost effective compared with other anticoagulants. This study indicated risk stratification especially considering both stroke and bleed risk simultaneously is important not only in clinical practice but also in health technology assessment exercises among patients with atrial fibrillation.

Implementing a Social Determinants Screening and Referral Infrastructure During Routine Emergency Department Visits, Utah, 2017-2018.

PURPOSE AND OBJECTIVES: Emergency departments see a disproportionate share of low-income and uninsured patients. We developed and evaluated a process for identifying social needs among emergency department patients, for facilitating access to community-based resources, and for integrating clinical and community-based data. INTERVENTION APPROACH: We leveraged an academic-community partnership to develop a social needs screening tool and referral process. EVALUATION METHODS: In a 25-day feasibility trial incorporating rapid improvement cycles, emergency department staff screened 210 patients for social needs. Observational and interview notes were analyzed, and data were linked from patient screenings, the United Way of Salt Lake 2-1-1 consumer information system, and electronic health records. RESULTS: Domains uncovered during pilot testing included screening based on appearance or insurance; discomfort asking stigmatizing questions; and lack of clarity regarding the screening's purpose. During the trial, 61% (n = 129) of patients reported 1 or more need, 52% (n = 67) of whom wanted follow-up. Of the 65 patients with complete data who wanted referrals, 49% (n = 32) were ultimately reached by 2-1-1, which provided an average of 4 community referrals (eg, pharmacy programs, utility assistance). Service usage 3 months before versus 3 months after emergency department index dates demonstrated that patients with social needs experienced a significant increase in emergency department use compared with those without needs (1.07 vs 1.36, P = .03), while patients with no needs experienced increases in primary care visits compared with those patients with unmet needs (0.24 vs 0.56, P = .03). IMPLICATIONS FOR PUBLIC HEALTH: We demonstrated the ability to systematically screen and refer for emergency department patients' unmet social needs by using existing resources and to link screening results, service referral details, and health service data. However, our experiences demonstrate that widespread implementation efforts should thoughtfully address staff perceptions and patient communication challenges.