Why may patients with spinal cord injury be overlooked for obesity screening in the Veterans Health Administration? Qualitative research of the perspectives of patients and healthcare providers.

PURPOSE: We sought to describe factors influencing reduced rates of obesity screening for patients with spinal cord injury (SCI) in the United States Veterans Health Administration (VA) and to foster potential solutions. MATERIALS AND METHODS: Semi-structured interviews with healthcare providers and patients with SCI who were recruited nationally from diverse VAs. We performed rapid qualitative analysis using content analysis of interview data. RESULTS: There were 36 providers and 37 patients. We identified provider, patient, and system level barriers to obesity screening for individuals with SCI. Overarching barriers involved provider and patient perceptions that obesity screening is a low priority compared to other health conditions, and body mass index is of low utility. Other obesity screening barriers were related to measuring weight (i.e., insufficient equipment, unknown wheelchair weight, staffing shortages, measurement errors, reduced access to annual screening, insufficient time, patient preference not to be weighed) and measuring height (i.e., insufficient guidance and equipment to this population, measurement errors). CONCLUSIONS: Barriers to obesity screenings exist for patients with SCI receiving care in VA. Healthcare provider and patient interviews suggest possible solutions, including standardizing height and weight measurement processes, ensuring equipment availability in clinics, clarifying guidelines, and offering support to providers and patients.IMPLICATIONS FOR REHABILITATIONIndividuals with spinal cord injury (SCI) have higher rates of obesity, but are often overlooked for annual obesity screening, even in clinic settings designed to care for individuals with SCI.Results may help tailor guidelines/education for healthcare and rehabilitation providers offering them guidance for improving obesity screening for individuals with SCI by standardizing weight and height measurement and documentation. To facilitate this, findings highlight the need for resources, such as ensuring clinics have necessary equipment, and increasing patient access to support and equipment.Improving the provision of obesity screening for individuals with SCI is necessary to improve health outcomes and patient satisfaction with care.

Interaction between increasing body mass index and spinal cord injury to the probability of developing a diagnosis of nonalcoholic fatty liver disease.

Background: The prevalence of obesity and comorbidities is high in the population with spinal cord injury (SCI). We sought to determine the effect of SCI on the functional form of the relationship between body mass index (BMI) and risk of developing nonalcoholic fatty liver disease (NAFLD), and assess whether SCI-specific mapping of BMI to risk of developing NAFLD is needed. Methods: Longitudinal cohort study comparing Veterans Health Administration patients with a diagnosis of SCI to a 1:2 matched control group without SCI. The relationship between BMI and development of NAFLD at any time was assessed with propensity score matched Cox regression models; NAFLD development at 10-year with a propensity score matched logistic model. The positive predictive value of developing NAFLD at 10 years was calculated for BMI 19-45 kg/m2. Results: 14,890 individuals with SCI met study inclusion criteria, and 29,780 Non-SCI individuals in matched control group. Overall, 9.2% in SCI group and 7.3% in Non-SCI group developed NAFLD during the study period. A logistic model assessing the relationship between BMI and the probability of developing a diagnosis of NAFLD demonstrated that the probability of developing disease increased as BMI increased in both cohorts. The probability was significantly higher in the SCI cohort at each BMI threshold (p < 0.01), and increased at a higher rate compared with the Non-SCI cohort as BMI increased 19-45 kg/m2. Positive predictive value for developing a diagnosis of NAFLD was higher in the SCI group for any given BMI threshold from 19 kg/m2 to BMI 45 kg/m2. Conclusions: The probability of developing NAFLD is greater in individuals with SCI than without SCI, at every BMI level 19 kg/m2 to 45 kg/m2. Individuals with SCI may warrant a higher level of suspicion and closer screening for NAFLD. The association of SCI and BMI is not linear.

Simplifying Hospital Quality Comparisons for Vascular Surgery Using Center-Level Frailty Burden Rather Than Comorbidities.

BACKGROUND: Failure to rescue (FtR), or inpatient death following complication, is a publicly reported hospital quality measure. Previous work has demonstrated significant variation in the proportion of frail patients across hospitals. However, frailty is not incorporated into risk-adjustment algorithms for hospital quality comparisons and risk adjustment is made by comorbidity scores. Our aim was to assess the impact of frailty on FtR quality measurement and as a means of risk adjustment. METHODS: Patients undergoing open or endovascular aneurysm repair or lower extremity bypass in the Vascular Quality Initiative (VQI) at centers performing ≥ 25 vascular procedures annually (2003-2019) were included. Multivariable logistic regression evaluated in-hospital death using scaled hierarchical modeling clustering at the center level. Center FtR observed/expected ratios were compared with expected values adjusted for either standard comorbidity profiles or frailty as measured by the VQI Risk Analysis Index. Centers were divided into quartiles using VQI-linked American Hospital Association data to describe the hospital characteristics of centers whose ranks changed. RESULTS: A total of 63,143 patients (213 centers) were included; 1,630 patients (2.58%) were classified as FtR. After accounting for center-level variability, frailty was associated with FtR [scaled odds ratio 1.9 (1.8-2.0), P < 0.001]. The comorbidity-centric and frailty-based models performed similarly in predicting FtR with C-statistics of 0.85 (0.84-0.86) and 0.82 (0.82-0.84), respectively. Overall changes in ranking based on observed/expected ratios were not statistically significant (P = 0.48). High and low performing centers had similar ranking using comorbidity-centric and frailty-based methods; however, centers in the middle of the performance spectrum saw more variability in ranking alterations. Forty nine (23%) of hospitals improved their ranking by five or more positions when using frailty versus comorbidity risk adjustment. The centers in Quartile 4, those who performed the highest number of vascular procedures annually, experience on average a significant improvement in hospital ranking when frailty was used for risk adjustment, whereas centers performing the fewest number of vascular procedures and the lowest proportion of vascular surgery cases annually (Quartile 1) saw a significant worsening of ranking position (all P < 0.05). However, total number of surgical procedures annually, total hospital beds, for-profit status, and teaching hospital status were not significantly associated with changes in rank. CONCLUSIONS: A simple frailty-adjusted model has similar predictive abilities as a comorbidity-focused model for predicting a common quality metric that influences reimbursement. In addition to distilling the risk-adjustment algorithm to a few variables, frailty can be assessed preoperatively to develop quality improvement efforts for rescuing frail patients. Centers treating a greater proportion of frail patients and those who perform higher volumes of vascular surgery benefit from a risk adjustment strategy based on frailty.

Insurance churn after adult traumatic injury: A national evaluation among a large private insurance database.

BACKGROUND: Traumatic injury leads to significant disability, with injured patients often requiring substantial health care resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact health care access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury. METHODS: Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using Injury Severity Score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS, <9), moderate (ISS, 9-15), severe (ISS, 16-24), and very severe (ISS, >24) injuries. Kaplan-Meier analysis was used to compare time with insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn. RESULTS: Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared with patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured. CONCLUSION: Increasing severity of traumatic injury is associated with higher levels of health coverage churn among the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury. LEVEL OF EVIDENCE: Economic and Value Based Evaluations; Level III.

The impact of the COVID-19 pandemic on individuals living with spinal cord injury: A qualitative study.

PURPOSE/OBJECTIVE: To explore the impact of the COVID-19 pandemic as experienced and reported by individuals living with a spinal cord injury (SCI). RESEARCH METHOD/DESIGN: Descriptive qualitative design using in-depth semistructured interviews with individuals with SCI (n = 33) followed by thematic analysis. RESULTS: Three main themes described impacts of the COVID-19 pandemic. (a) Impact on health care use; subthemes elaborated that this was attributable to in-person health care facility restrictions or individual decisions to delay care. Individuals with SCI experienced lapses in primary and SCI-specialty care, rehabilitation/therapy services, and home care, but some made use of telehealth services. (b) Impact on weight and/or weight management lifestyle behaviors; subthemes discussed that engagement in physical activity declined because of fitness center closures, recreational activity cancellations, and safety precautions limiting community-based and outdoor activities. The pandemic disrupted participants' independence in purchasing and making preferred food selections which impacted healthy eating. Participants ate due to boredom, at nonmealtimes, and consumed unhealthy foods during the pandemic. (c) Impact on psychosocial factors; included subthemes noting reduced social interactions, social participation, and ability to pursue pastimes with family, friends, and groups they belonged to. The pandemic also triggered emotional reactions such as worry, fear, doubt, demotivation, and feelings of social isolation. CONCLUSIONS: Our findings highlight the magnitude of consequences faced by individuals with SCI when restrictions to health care, healthy lifestyle endeavors, and social participation occurred during the COVID-19 pandemic. Findings may inform SCI health care providers on what is needed in response to future public health or natural disaster crises. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Physical and emotional consequences of excess weight as experienced by individuals with spinal cord injuries.

CONTEXT/OBJECTIVE: Excess weight has the potential to carry a substantial physical and emotional burden. A better understanding of perceived consequences of excess weight may facilitate the development of patient-centered programs and interventions to promote weight management efforts in persons with spinal cord injury (SCI). The study objective was to describe consequences of excess weight from the personal perspectives of individuals with SCI. DESIGN: Descriptive qualitative design using in-depth semi-structured interviews and thematic analysis. SETTING: Veterans Health Administration (VHA) SCI System of Care. PARTICIPANTS: Individuals with SCI (n-33). OUTCOME MEASURES: Key themes from thematic analysis. RESULTS: Participants were male (61%), ranged from 29 to 84 years of age, and about half had tetraplegia (55%). Five themes were identified that demonstrate negative consequences of excess weight experienced by individuals with SCI, including: (1) physical health conditions (including chronic conditions and SCI secondary conditions), (2) physical symptoms (such as pain, discomfort, and fatigue), (3) movement challenges, (4) appearance-related concerns, and (5) emotional impacts. CONCLUSIONS: Carrying excess weight is concerning to individuals with SCI and in terms of consequences such onset or exacerbation of chronic conditions, SCI secondary conditions, physical symptoms, e.g. pain, movement impairment (including hampered mobility, difficult transfers and self-care), image/appearance concerns (e.g. body image, clothing misfit), and negative emotions (e.g. unhappy, sad, depressed). Our findings may inform SCI healthcare providers about the consequences of excess weight as experienced by individuals with SCI, highlighting what matters most to persons with SCI and guiding a patient-centered approach to weight management in this population.

Preventive Health Screening in Veterans Undergoing Bariatric Surgery.

INTRODUCTION: Individuals with obesity are vulnerable to low rates of preventive health screening. Veterans with obesity seeking bariatric surgery are also hypothesized to have gaps in preventive health screening. Evaluation in a multidisciplinary bariatric surgery clinic is a point of interaction with the healthcare system that could facilitate improvements in screening. METHODS: This is a retrospective cohort study of 381 consecutive patients undergoing bariatric surgery at a Veterans Affairs Hospital from January 2010 to October 2021. Age- and sex-appropriate health screening rates were determined at initial referral to a multidisciplinary bariatric surgery clinic and at the time of surgery. Rates of guideline concordance at both time points were compared using McNemar's test. Univariate and multivariate analyses were performed to identify the risk factors for nonconcordance. RESULTS: Concordance with all recommended screening was low at initial referral and significantly improved by time of surgery (39.1%‒63.8%; p<0.001). Screening rates significantly improved for HIV (p<0.001), cervical cancer (p=0.03), and colon cancer (p<0.001). Increases in BMI (p=0.005) and the number of indicated screening tests (p=0.029) were associated with reduced odds of concordance at initial referral. Smoking history (p=0.012) and increasing distance to the nearest Veterans Affairs Medical Center (p=0.039) were associated with reduced odds of change from nonconcordance at initial referral to concordance at the time of surgery. CONCLUSIONS: Rates of preventive health screening in Veterans with obesity are low. A multidisciplinary bariatric surgery clinic is an opportunity to improve preventive health screening in Veterans referred for bariatric surgery.

Kidney Stone Events Following Parathyroidectomy vs Nonoperative Management for Primary Hyperparathyroidism.

CONTEXT: Primary hyperparathyroidism (PHPT) is associated with an increased risk of kidney stones. Few studies account for PHPT severity or stone risk when comparing stone events after parathyroidectomy vs nonoperative management. OBJECTIVE: Compare the incidence of kidney stone events in PHPT patients treated with parathyroidectomy vs nonoperative management. DESIGN: Longitudinal cohort study with propensity score inverse probability weighting and multivariable Cox proportional hazards regression. SETTING: Veterans Health Administration integrated health care system. PATIENTS: A total of 44 978 patients with > 2 years follow-up after PHPT diagnosis (2000-2018); 5244 patients (11.7%) were treated with parathyroidectomy. MAIN OUTCOMES MEASURE: Clinically significant kidney stone event. RESULTS: The cohort had a mean age of 66.0 years, was 87.8% male, and 66.4% White. Patients treated with parathyroidectomy had higher mean serum calcium (11.2 vs 10.8mg/dL) and were more likely to have a history of kidney stone events. Among patients with baseline history of kidney stones, the unadjusted incidence of ≥ 1 kidney stone event was 30.5% in patients managed with parathyroidectomy (mean follow-up, 5.6 years) compared with 18.0% in those managed nonoperatively (mean follow-up, 5.0 years). Patients treated with parathyroidectomy had a higher adjusted hazard of recurrent kidney stone events (hazard ratio [HR], 1.98; 95% CI, 1.56-2.51); however, this association declined over time (parathyroidectomy × time: HR, 0.80; 95% CI, 0.73-0.87). CONCLUSION: In this predominantly male cohort with PHPT, patients treated with parathyroidectomy continued to be at higher risk of kidney stone events in the immediate years after treatment than patients managed nonoperatively, although the adjusted risk of stone events declined with time, suggesting a benefit to surgical treatment.

Rates, Variability, and Predictors of Screening for Obesity: Are Individuals with Spinal Cord Injury Being Overlooked?

INTRODUCTION: Individuals with spinal cord injury (SCI) are vulnerable to obesity. Annual obesity screening using body mass index (BMI) is the standard of care mandated by US Veterans Health Administration (VHA) guidelines. Our objective was to determine the rates, variability, and predictors of guideline-concordant annual screening for obesity, given potential challenges of height and weight measurements in individuals with SCI. METHODS: This is a cross-sectional retrospective study using US national VA databases. We identified all VHA patients with chronic SCI in the fiscal year (FY) 2019, their treating facility and frequency of recorded height and weight. We applied mixed-effects logistic regression models to assess associations between annual BMI screening and patient- and facility-level characteristics. RESULTS: Of 20,978 individuals with chronic SCI in VHA in FY19, guideline-concordant annual BMI screening was lacking in 37.9%. Accounting for facility-level factors (geographic region, SCI facility type, volume of patients with SCI treated at the facility), a mixed-effects logistic regression model demonstrated that lack of annual obesity screening was significantly associated with older patient age (p < 0.001) and fewer outpatient encounters (p < 0.001) but not other patient-level factors such as sex, race, level of injury, or rurality. The rate of obesity screening among different facilities within VHA varied widely from 11.1% to 75.7%. CONCLUSION: A large proportion of persons with SCI receiving care in VHA do not receive guideline-concordant annual obesity screening, an especially acute problem in some facilities. Older patients with fewer outpatient encounters are more likely to be missed. To inform the design of interventions to improve identification and documentation of obesity, further study is needed to assess potential barriers to obesity screening in the population with SCI.

Perspectives on Home Time and Its Association With Quality of Life After Inpatient Surgery Among US Veterans.

Importance: Home time, defined as time spent at home after hospital discharge, is emerging as a novel, patient-oriented outcome in stroke recovery and end-of-life care. Longer home time is associated with lower mortality and higher patient satisfaction. However, a knowledge gap exists in the measurement and understanding of home time in the population undergoing surgery. Objectives: To examine the association between postoperative home time and quality of life (QoL), functional status, and decisional regret and to identify themes regarding the meaning of time spent at home after surgery. Design, Setting, and Participants: This mixed-methods study including a survey and qualitative interviews used an explanatory sequential design involving 152 quantitative surveys followed by in-depth interviews with 12 participants from February 26, 2020, to December 17, 2020. US veterans older than 65 years who underwent inpatient surgery at a single-center veterans hospital within the prior 6 to 12 months were studied. Exposures: Quality of life, measured by the Veterans RAND 12-item Health Survey and 19-item Control, Autonomy, Self-realization, and Pleasure scale; functional status, measured by activities of daily living (ADL) and instrumental ADL scales; and regret, measured by the Decision Regret Scale. Main Outcomes and Measures: Home time, standardized as percentage of total time spent at home from the time of surgery to the time of survey administration. Associations between home time and QoL, function, and decisional regret in the survey data were analyzed using Spearman correlation in the overall cohort and in operative stress score subcohorts (1-2 [low] vs 3-5 [high]) in a stratified analysis. The 12 semistructured interviews were analyzed to elicit patients' perspectives on home time in postoperative recovery. Qualitative data were coded and analyzed using content and thematic analysis and integrated with quantitative data in joint displays. Results: A total of 152 patients (mean [SD] age, 72.3 [4.4] years; 146 [96.0%] male) were surveyed, and 12 patients (mean [SD] age, 72.3 [4.8] years; 11 [91.7%] male) were interviewed. The median time to survey completion was 307 days (IQR, 265-344 days). The median home time was 97.8% (IQR, 94.6%-98.6%; range, 22.2%-99.5%). Increased home time was associated with better physical health-related QoL in the Veterans RAND 12-item Health Survey (r = 0.33; 95% CI, 0.18-0.47; P < .001) and higher ADL scores (r = 0.21; 95% CI, 0.06-0.36; P = .008) and instrumental ADL functional scores (r = 0.21; 95% CI, 0.04-0.37; P = .009). Decisional regret was inversely associated with home time in only the high operative stress score subcohort (r = -0.22; 95% CI, -0.47 to -0.04; P = .047). Home was perceived as a safe and familiar environment that accelerated recovery through nurturing support of loved ones. Conclusions and Relevance: In this mixed-methods study including a survey and qualitative interviews, increased home time in the first year after major surgery was associated with improved daily function and physical QoL among US veterans. Interviewees considered the transition to home to be an indicator of recovery, suggesting that home time may be a promising, patient-oriented quality outcome measure for surgical recovery that warrants further study.

Engagement and Adherence with a Web-Based Prehabilitation Program for Patients Awaiting Abdominal Colorectal Surgery.

BACKGROUND: Understanding the drivers of patient engagement and adherence is critical to developing and implementing preoperative optimization programs. The aim of this project is to determine whether existing health beliefs are associated with engagement and adherence in a home-based online prehabilitation program. METHODS: Patients undergoing abdominal colorectal operations were enrolled in an online nutrition and exercise program. We collected baseline health beliefs and mindsets, daily exercises, and weekly diet recalls. Multivariable binary logistic regression predicted engagement, multivariable ordinary least squares regression predicted diet adherence, and generalized linear models with a binomial distribution predicted engagement and exercise adherence. RESULTS: Of the 227 patients who agreed to participate, 75% activated their accounts; of those, 75% used the program. Engagement with the program was unrelated to health beliefs or mindsets. Positive diet-related health beliefs and a growth mindset were associated with positive diet behaviors and inversely associated with negative diet behaviors. Exercise-related health beliefs and mindsets were not associated with exercise adherence. Patients enrolled within 4 weeks of surgery used the program more than those enrolled more than 4 weeks from surgery. CONCLUSIONS: This app-based prehabilitation program demonstrated moderate acceptability, engagement, and adherence. Addressing health beliefs and mindsets may be an effective way of increasing adherence to diet recommendations. To increase adherence to exercise recommendations, further assessment of potential barriers is critical. While an online platform is a highly promising scalable strategy, more customization and user engagement are necessary to make it an effective way of delivering a preoperative health behavior change intervention.

Gender Disparity in Surgical Society Leadership and Annual Meeting Programs.

INTRODUCTION: Prior work suggests women surgical role models attract more female medical students into surgical training. We investigate recent trends of women in surgical society leadership and national conference moderator and plenary speaker roles. METHODS: Gender distribution was surveyed at 15 major surgical societies and 14 conferences from 2014 to 2018 using publicly reported data. Roles were categorized as leadership (executive council), moderator, or plenary speaker. Data were cross-checked from online profiles and by contacting societies. Logistic regression with Huber-White clustering by society was utilized to evaluate proportions of women in each role over time and determine associations between the proportion of women in executive leadership, and scientific session moderators and plenary speakers. RESULTS: The proportion of leadership positions held by women increased slightly from 2014 to 2018 (20.6%-26.6%, P = 0.23), as did the proportion of moderators (26.2%-30.6%, P = 0.027) and plenary speakers (26.2%-30.9%, P = 0.058). The proportion of women in each role varied significantly across societies (all P < 0.001): leaders (range 0.0%-52.0%), moderators (12.5%-58.8%), and plenary speakers (11.3%-60.0%). Three patterns of change were observed: eight societies (53.3%) demonstrated increases in representation of women over time, four societies (26.6%) showed stable moderate-to-good gender balance, and three societies (20.0%) had consistent underrepresentation of women. CONCLUSION: There is significant variability in the representation of women at the leadership level of national surgical societies and participating at national surgical conferences as moderators and plenary speakers. Over the past 5 years some societies have achieved advances in gender equity, but many societies still have substantial room for improvement.

Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures.

INTRODUCTION: Pain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures. METHODS: We retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups' average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24-48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity. RESULTS: We identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression-with and without sensitivity analysis-did not show an effect of IVL on any outcomes. CONCLUSION: IVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL's opioid-sparing effects for patients with rib fractures.

Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke?

BACKGROUND: Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design. METHODS/DESIGN: We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects. DISCUSSION: Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.

Impact of 12 step mutual help groups on drug use disorder patients across six clinical trials.

BACKGROUND: 12 step mutual help groups are widely accessed by people with drug use disorder but infrequently subjected to rigorous evaluation. Pooling randomized trials containing a condition in which mutual help group attendance is actively facilitated presents an opportunity to assess the effectiveness of 12 step groups in large, diverse samples of drug use disorder patients. METHODS: Data from six federally-funded randomized trials were pooled (n = 1730) and subjected to two-stage instrumental variables modelling, and, fixed and random effects regression models. All trials included a 12 step group facilitation condition and employed the Addiction Severity Index as a core measure. RESULTS: The ability of 12 step facilitation to increase mutual help group participation among drug use disorder patients was minimal, limiting ability to employ two-stage instrumental variable models that correct for selection bias. However, traditional fixed and random effect regression models found that greater 12 step mutual help group attendance by drug use disorder patients predicted reduced use of and problems with illicit drugs and also with alcohol. CONCLUSION: Facilitating significant and lasting involvement in 12 step groups may be more challenging for drug use disorder patients than for alcohol use disorder patients, which has important implications for clinical work and for effectiveness evaluations. Though selection bias could explain part of the results of traditional regression models, the finding that participation in 12 step mutual help groups predicts lower illicit drug and alcohol use and problems in a large, diverse, sample of drug use disorder patients is encouraging.

Assessment of the Risk Analysis Index for Prediction of Mortality, Major Complications, and Length of Stay in Patients who Underwent Vascular Surgery.

BACKGROUND: Frailty is a risk factor for adverse postoperative outcomes. We aimed to test the performance of a prospectively validated frailty measure, the Risk Analysis Index (RAI) in patients who underwent vascular surgery and delineate the additive impact of procedure complexity on surgical outcomes. METHODS: We queried the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program database to identify 6 major elective vascular procedure categories (carotid revascularization, abdominal aortic aneurysm [AAA] repair, suprainguinal revascularization, infrainguinal revascularization, thoracic aortic aneurysm [TAA] repair, and thoracoabdominal aortic aneurysm [TAAA] repair). We trained and tested logistic regression models for 30-day mortality, major complications, and prolonged length of stay (LOS). The first model, "RAI," used the RAI alone; "RAI-Procedure (RAI-P)" included procedure category (e.g., AAA repair) and procedure approach (e.g., endovascular); "RAI-Procedure Complexity (RAI-PC)" added outpatient versus inpatient surgery, general anesthesia use, work relative value units (RVUs), and operative time. RESULTS: The RAI model was a good predictor of mortality for vascular procedures overall (C-statistic: 0.72). The C-statistic increased with the RAI-P (0.78), which further improved minimally, with the RAI-PC (0.79). When stratified by procedure category, the RAI predicted mortality well for infrainguinal (0.79) and suprainguinal (0.74) procedures, moderately well for AAA repairs (0.69) and carotid revascularizations (0.70), and poorly for TAAs (0.62) and TAAAs (0.54). For carotid, infrainguinal, and suprainguinal procedures, procedure complexity (RAI-PC) had little impact on model discrimination for mortality, did improve discrimination for AAAs (0.84), TAAs (0.73), and TAAAs (0.80). Although the RAI model was not a good predictor for major complications or LOS, discrimination improved for both with the RAI-PC model. CONCLUSIONS: Frailty as measured by the RAI was a good predictor of mortality overall after vascular surgery procedures. Although the RAI was not a strong predictor of major complications or prolonged LOS, the models improved with the addition of procedure characteristics like procedure category and approach.

Comparison of Surgeon Assessment to Frailty Measurement in Abdominal Aortic Aneurysm Repair.

BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR) allows us to intervene on patients otherwise considered poor candidates for open repair. Despite its importance in determining operative approach, no comparison has been made between the subjective "eyeball test" and an objective measurement of preoperative frailty for EVAR patients. MATERIALS AND METHODS: Patients undergoing elective EVAR were identified in the Vascular Quality Initiative (VQI) database (2003-2017). Patients were classified "unfit" based on a surgeon-reported variable. Frailty was defined using the VQI-derived Risk Analysis Index, which includes sex, age, BMI, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. The association between fitness and/or frailty and adverse outcomes was determined by logistic regression. RESULTS: A total of 11,694 patients undergoing elective EVAR were included of which only 18.1% were "unfit," whereas 34.6% were "frail" and overall 43.6% "unfit or frail." Patients deemed "unfit" or "frail" had significantly increased odds of mortality, complications, and nonhome discharge (P < 0.001), and both frailty and unfitness generated negative predictive values for these outcomes greater than 93%. In adjusted logistic regression, the addition of objective frailty significantly improved model performance in predicting nonhome discharge (C-statistic 0.65 versus 0.71, P < 0.001) and complications (0.59 versus 0.61, P = 0.01), but similarly predicted mortality (0.74 versus 0.73, P = 0.99). CONCLUSIONS: Preoperative frailty assessment provides a useful objective measure of risk stratification as an adjunct to a physician's clinical intuition. The addition of frailty expands the pool of high-risk patients who are more likely to experience adverse postoperative events after elective EVAR and may benefit from uniquely tailored perioperative interventions.

Early Use of Anti-influenza Medications in Hospitalized Children With Tracheostomy.

BACKGROUND: Early administration of anti-influenza medications is recommended for all children hospitalized with influenza. We investigated whether early use of anti-influenza medications is associated with improved outcomes in children with tracheostomy hospitalized with influenza. METHODS: We performed a multicenter retrospective cohort study through the Pediatric Health Information System database for patients aged 30 days to 19 years who were discharged between October 1, 2007, and September 30, 2015 with diagnostic codes for both influenza and tracheostomy. Our primary predictor was receipt of anti-influenza medications on hospital day 0 or 1. We used propensity score matching to adjust for confounding by indication. Primary outcomes were length of stay (LOS) and 30-day all-cause revisit rate (emergency department visit or hospital admission). RESULTS: Of 1436 discharges screened, 899 met inclusion criteria. The median admission age was 5 years (interquartile range: 2-10). The majority had multiple complex chronic conditions (median 3; interquartile range: 3-4) and technology dependence, such as gastrostomy tube (73.6%). After matching 772 unique admissions by propensity score, LOS was shorter for the cohort receiving early anti-influenza medications (6.4 vs 7.5 days; P = .01) without increase in revisit rate (27.5% vs 24.1%; P = .28). More than 80% in both cohorts received empirical antibiotics, and the duration of antibiotic therapy was similar (5.0 vs 5.6 days; P = .11). CONCLUSIONS: Early use of anti-influenza medications in children with tracheostomy hospitalized with influenza is associated with shorter LOS, but these children continue to receive antibiotics despite identification and treatment of their viral infections.

Factors Associated With Length of Stay and 30-Day Revisits in Pediatric Acute Pancreatitis.

OBJECTIVE: The objective of the study was to identify factors associated with length of stay (LOS) and 30-day hospital revisit for patients hospitalized with acute pancreatitis (AP). METHOD: Multicenter, retrospective cohort study using the Pediatric Health Information System database. Multilevel linear and logistic regression was used to identify factors independently associated with the primary outcome variables of LOS and 30-day hospital revisit in children aged 1 and 18 years discharged with a primary discharge diagnosis of AP from participating hospitals between 2008 and 2013. RESULTS: For the 7693 discharges, median LOS was 4 days (interquartile range 3-7 days) and 30-day revisit rate 17.6% (n = 1356). Discharges were primarily girls (55%), Caucasian (46%), and 6 years old or older (85%). On multilevel regression, factors independently associated with both longer LOS and higher revisit odds included malignant and gastrointestinal complex chronic conditions (CCCs) and total parenteral nutrition use while hospitalized. Male gender was associated with both lower LOS (adjusted length of stay = -0.6 days, 95% confidence interval [CI] = -0.8 to -0.4) and decreased revisit odds (aOR 0.85; 95% CI = 0.74 to 0.97). Hispanic ethnicity was associated with increased LOS (adjusted length of stay = +0.8 days, 95% CI = +0.5 to +1.1), but no change in revisit odds. CONCLUSIONS: Certain demographic and clinical factors, including gender, ethnicity, and type of CCC, were independently associated with LOS and risk of 30-day hospital revisit for pediatric AP. Children with malignant and gastrointestinal CCCs who require total parenteral nutrition are at highest risk for both longer LOS and hospital revisit when admitted with AP. These patient populations may benefit from intensive care coordination when hospitalized for AP.