Systematic Review of the Psychometric Performance of Generic Childhood Multi-attribute Utility Instruments.

BACKGROUND: Childhood multi-attribute utility instruments (MAUIs) can be used to measure health utilities in children (aged ≤ 18 years) for economic evaluation. Systematic review methods can generate a psychometric evidence base that informs their selection for application. Previous reviews focused on limited sets of MAUIs and psychometric properties, and only on evidence from studies that directly aimed to conduct psychometric assessments. OBJECTIVE: This study aimed to conduct a systematic review of psychometric evidence for generic childhood MAUIs and to meet three objectives: (1) create a comprehensive catalogue of evaluated psychometric evidence; (2) identify psychometric evidence gaps; and (3) summarise the psychometric assessment methods and performance by property. METHODS: A review protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; CRD42021295959); reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guideline. The searches covered seven academic databases, and included studies that provided psychometric evidence for one or more of the following generic childhood MAUIs designed to be accompanied by a preference-based value set (any language version): 16D, 17D, AHUM, AQoL-6D, CH-6D, CHSCS-PS, CHU9D, EQ-5D-Y-3L, EQ-5D-Y-5L, HUI2, HUI3, IQI, QWB, and TANDI; used data derived from general and/or clinical childhood populations and from children and/or proxy respondents; and were published in English. The review included 'direct studies' that aimed to assess psychometric properties and 'indirect studies' that generated psychometric evidence without this explicit aim. Eighteen properties were evaluated using a four-part criteria rating developed from established standards in the literature. Data syntheses identified psychometric evidence gaps and summarised the psychometric assessment methods/results by property. RESULTS: Overall, 372 studies were included, generating a catalogue of 2153 criteria rating outputs across 14 instruments covering all properties except predictive validity. The number of outputs varied markedly by instrument and property, ranging from 1 for IQI to 623 for HUI3, and from zero for predictive validity to 500 for known-group validity. The more recently developed instruments targeting preschool children (CHSCS-PS, IQI, TANDI) have greater evidence gaps (lack of any evidence) than longer established instruments such as EQ-5D-Y, HUI2/3, and CHU9D. The gaps were prominent for reliability (test-retest, inter-proxy-rater, inter-modal, internal consistency) and proxy-child agreement. The inclusion of indirect studies (n = 209 studies; n = 900 outputs) increased the number of properties with at least one output of acceptable performance. Common methodological issues in psychometric assessment were identified, e.g., lack of reference measures to help interpret associations and changes. No instrument consistently outperformed others across all properties. CONCLUSION: This review provides comprehensive evidence on the psychometric performance of generic childhood MAUIs. It assists analysts involved in cost-effectiveness-based evaluation to select instruments based on the application-specific minimum standards of scientific rigour. The identified evidence gaps and methodological issues also motivate and inform future psychometric studies and their methods, particularly those assessing reliability, proxy-child agreement, and MAUIs targeting preschool children.

Ethnic differences and inequities in paediatric healthcare utilisation in the UK: a scoping review.

BACKGROUND: Despite the increased policy attention on ethnic health inequities since the COVID-19 pandemic, research on ethnicity and healthcare utilisation in children has largely been overlooked. OBJECTIVES: This scoping review aimed to describe and appraise the quantitative evidence on ethnic differences (unequal) and inequities (unequal, unfair and disproportionate to healthcare needs) in paediatric healthcare utilisation in the UK 2001-2021. METHODS: We searched Embase, Medline and grey literature sources and mapped the number of studies that found differences and inequities by ethnic group and healthcare utilisation outcome. We summarised the distribution of studies across various methodological parameters. RESULTS: The majority of the 61 included studies (n=54, 89%) identified ethnic differences or inequities in paediatric healthcare utilisation, though inequities were examined in fewer than half of studies (n=27, 44%). These studies mostly focused on primary and preventive care, and depending on whether ethnicity data were aggregated or disaggregated, findings were sometimes conflicting. Emergency and outpatient care were understudied, as were health conditions besides mental health and infectious disease. Studies used a range of ethnicity classification systems and lacked the use of theoretical frameworks. Children's ethnicity was often the explanatory factor of interest while parent/caregiver ethnicity was largely overlooked. DISCUSSION: While the current evidence base can assist policy makers to identify inequities in paediatric healthcare utilisation among certain ethnic groups, we outline recommendations to improve the validity, generalisability and comparability of research to better understand and thereby act on ethnic inequities in paediatric healthcare.

The Effect of Exercise and Nutritional Interventions on Body Composition in Patients with Advanced or Metastatic Cancer: A Systematic Review.

Advanced and metastatic cancers significantly alter body composition, leading to decreased lean mass and variable effects on fat mass. These effects on body composition are associated with significant physical dysfunction and poor prognosis in patients with cancer. Whilst exercise and nutritional interventions are likely to be of benefit in counteracting these effects, relatively little is known about using such interventions in patients with advanced or metastatic cancer. Therefore, in this systematic review we examine the effect of exercise and combined exercise and nutritional interventions on lean mass and fat mass among patients diagnosed with advanced or metastatic cancer. Following PRISMA guidelines, we identified 20 articles from PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PEDro, SPORTDiscus, and REHABDATA. Overall, advanced or metastatic cancer populations comprising of mixed cancer types were most commonly examined (n = 8) with exercise or combined exercise and nutritional interventions being well-tolerated with few adverse effects. Both intervention approaches may preserve lean mass, while only combined interventions may lead to alterations in fat mass. However, further exercise and nutritional studies are needed to definitively understand their effects on body composition. As exercise and nutrition-related research continues in this understudied population, the knowledge gained will help guide supportive clinical treatments.

Granulocyte colony-stimulating factor as a cause of acute leucocytoclastic vasculitis with anti-Ro and anti-La antibodies.

Granulocyte colony-stimulating factor (G-CSF) administration is associated with a diverse range of cutaneous sequelae. Serious dermatological side effects of G-CSF include the development of Sweet's syndrome and exacerbations of pre-existing inflammatory disorders such as psoriasis. Here, we describe a report of acute leucocytoclastic vasculitis caused by G-CSF therapy associated with anti-Ro and anti-La antibodies in a patient with multiple myeloma. This case highlights the importance of having a high index of suspicion for acute leucocytoclastic vasculitis in patients with haematological malignancies undergoing G-CSF therapy.

Increased Alcohol-Related Mortality in Wisconsin Pre-COVID: A Two-Decade Trend.

INTRODUCTION: Alcohol-related mortality is increasing nationally, but state-specific trends still need to be explored. This paper reviews the patterning of alcohol-related deaths among Wisconsin residents in the 2 decades prior to the COVID-19 pandemic. METHODS: Data are from death certificates for state residents from 2000 through 2019. We used underlying cause of death codes (ICD-10) to classify deaths as 100% attributable to alcohol (ie, acute, chronic liver, and other chronic). Demographic characteristics were available for the most recent decedents (2015-2019). We assess trends in alcohol-related mortality and used chi-square tests to assess demographic differences compared to deaths from all other causes. RESULTS: The number of alcohol-related deaths more than doubled from 2000 through 2019 in Wisconsin, rising from 394 in 2000 to 857 in 2019. In the 5 most recent years (2015-2019), the populations with significantly higher rates of alcohol-related deaths included men, middle-aged adults, Black residents, and those of Hispanic descent. Education level also was significantly related to alcohol-attributable mortality, as those with the highest and lowest education levels were the least likely to die from this cause. DISCUSSION/CONCLUSIONS: Results of these analyses show that the number of deaths due to alcohol-related diseases has risen significantly since 2000, and this trend preceded the COVID-19 pandemic. These rising mortality rates deserve the attention of the medical and public health communities. Our findings show that, in recent years, Hispanic individuals, men, and middle-aged adults are at a higher risk for alcohol-related deaths. Stakeholders may wish to consider interventions targeted to these groups.

Inbreeding in Solanum carolinense alters floral attractants and rewards and adversely affects pollinator visitation.

PREMISE: Inbreeding depression is well documented in flowering plants and adversely affects a wide range of fitness-related traits. Recent work has begun to explore the effects of inbreeding on ecological interactions among plants and other organisms, including insect herbivores and pathogens. However, the effects of inbreeding on floral traits, floral scents, and pollinator visitation are less well studied. METHODS: Using inbred and outbred maternal families of horsenettle (Solanum carolinense, Solanaceae), we examined the effects of inbreeding on traits associated with pollinator attraction and floral rewards. Specifically, we measured corolla size, counted pollen grains per flower, and analyzed floral volatile emissions via gas chromatography and mass spectrometry. We also examined pollinator visitation to experimental arrays of flowering inbred and outbred plants under field conditions. RESULTS: Compared to those of outbred plants, flowers of inbred plants exhibited reduced corolla size and pollen production, as well as significantly reduced emission of the two most abundant volatile compounds in the floral blend. Furthermore, bumblebees-the main pollinators of horsenettle-discriminated against inbred flowers in the field: bees were more likely to make initial visits to flowers on outbred plants, visited outbred flowers more often overall, and spent more time on outbred flowers. CONCLUSIONS: These results show that inbreeding can (1) alter floral traits that are known to mediate pollinator attraction; (2) reduce the production of floral rewards (pollen is the sole reward in horsenettle); and (3) adversely affect pollinator visitation under field conditions.

The journey from precontemplation to action: Transitioning between electronic medical record systems.

BACKGROUND: Health care organizations, in response to federal programs, have sought to identify electronic medical record (EMR) strategies that align well with their visions for success. Little exists in the literature discussing the transition from one EMR strategy to another. PURPOSE: The analysis and planning process used by a major academic medical center in its journey to adopt a new strategy was described in this study. We use the transtheoretical model of change to frame the five phases through which the organization transitioned from a best-of-breed system to an enterprise system. METHODOLOGY/APPROACH: We explore the five phases of change from the perspective of a maturing approach to new technology adoption. Data collection included archival retrieval and review as well as interviews with key stakeholders. FINDINGS: Although there was always a focus on some enterprise capabilities such as computerized physician order entry, the emphasis on EMR selection tended to be driven by specialty requirements. Focusing on the patient across the continuum of care, as opposed to focusing on excessive requirements by clinical specialties, was essential in forming and deploying a vision for the new EMR. PRACTICE IMPLICATIONS: This research outlines a successful pathway used by an organization that had invested heavily in EMR technology and was faced with evaluating whether to continue that investment or start with a new platform. Rather than focusing on the technology alone, efforts to reframe the discussion to one that focused on the patient resulted in less resistance to change.

Solvolyses of benzoyl chlorides in weakly nucleophilic media.

Rate constants and activations parameters are reported for solvolyses of p-Z-substituted benzoyl chlorides (1, Z = OMe, Me, H, and Cl) in 97% w/w hexafluoroisopropanol-water (97H). Additional kinetic data are reported for solvolyses in acetic and formic acids. Plots of log k vs. σ(p) in 97H are consistent with previous research showing that a cationic reaction channel is dominant, even for solvolyses of 1, Z = NO(2). A benzoyl cation intermediate was trapped by Friedel-Crafts reaction with 1,3,5-trimethoxybenzene in hexafluoroisopropanol. The results are explained by an S(N)2-S(N)1 spectrum of mechanisms with variations in nucleophilic solvent assistance. Ab initio calculations of heterolytic bond dissociation energies of various chloro- and fluoro-substituted and other benzoyl chlorides are correlated with log k for solvolyses.

Lemierre's syndrome: methicillin-resistant Staphylococcus aureus (MRSA) finds a new home.

Lemierre's syndrome is septic thrombophlebitis of the internal jugular vein, arising as a complication of an oropharyngeal infection. This thrombophlebitis frequently results in septic emboli to organs such as the lungs. The causative agent in most previously described cases is Fusobacterium necrophorum, an anaerobic Gram-negative organism. We present the case of an 8-year-old previously healthy girl who came to the Emergency Department with a 5-day history of left-sided neck pain and was subsequently diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) Lemierre's syndrome. MRSA has not previously been described in Lemierre's syndrome in the Emergency Medicine literature. The clinical presentation, findings, and management of the syndrome are discussed. Regardless of etiology, once the diagnosis of Lemierre's syndrome is made, long-term broad-spectrum intravenous therapy will be necessary.

Integrating systems requires balancing act.

A Web-based patient record system at The Ohio State University Medical Center dramatically speeds up interactions with referring physicians.

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients.

BACKGROUND: Critically ill patients require rapid care, yet they are also at risk for morbidity from the potential complications of that care. Computerized physician order entry (CPOE) is advocated as a tool to reduce medical errors, improve the efficiency of healthcare delivery, and improve outcomes. Little is known regarding the essential attributes of CPOE in the intensive care unit (ICU). OBJECTIVE: To assess the effect of CPOE on ICU patient care. DESIGN: Retrospective before and after cohort study. SETTING: An academic ICU. PATIENTS: Patients admitted to the ICU during use of the initial CPOE application and those admitted after its modification. INTERVENTIONS: Comprehensive order interface redesign improving clarity, specificity, and efficiency. MEASUREMENTS: Orders for complex ICU care were compared between the two groups. In addition, the use of higher-efficiency CPOE order paths was tracked. RESULTS: Patients treated with both the initial and modified CPOE system were similar for all measured characteristics. With the modified CPOE system, there were significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management. There was also a significant increase in orders executed through ICU-specific order sets after system modifications. LIMITATIONS: This retrospective study cannot assess issues related to learner expertise and is meant to only suggest the importance of developing CPOE systems that are appropriate for specialty care environments. CONCLUSION: Appropriate CPOE applications can improve the efficiency of care for critically ill patients. The workflow requirements of individual units must be analyzed before technologies like CPOE can be properly developed and implemented.

Development of a Web-based event reporting system in an academic environment.

In pursuit of a strategy for patient safety and error reduction, The Ohio State University Health System developed and implemented a standardized voluntary event reporting system. The Web-based application is user friendly as well as context-sensitive and encompasses a broad range of errors, events, and near misses. A full organizational transformation was required to effectively implement the system, which involved process reengineering for event entry and for postentry automated workflows. This system serves as the foundation for efficient and consistent reporting processes, which are essential for encouraging a culture of commitment to patient safety.

Immediate benefits realized following implementation of physician order entry at an academic medical center.

OBJECTIVE: To evaluate the benefits of computerized physician order entry (POE) and electronic medication administration record (eMAR) on the delivery of health care. DESIGN: Inpatient nursing units in an academic health system were the setting for the study. The study comprised before-and-after comparisons between phase 1, pre-implementation of POE (pre-POE) and phase 2, post-implementation of POE (post-POE) and, within phase 2, a comparison of POE and the combination of POE plus eMAR. Length of stay and cost were compared pre- and post-POE for a period of 10 to 12 months across all services in the respective hospitals. MEASUREMENTS: Comparisons were made pre- and post-POE for the time intervals between initiation and completion of pharmacy (pre-POE, n=46; post-POE, n=70), radiology (pre-POE, n=11; post-POE, n=54), and laboratory orders (without POE, n=683; with POE, n=1,142); timeliness of countersignature of verbal order (University Hospitals [OSUH]: pre-POE, n=605; post-POE, n=19,225; James Cancer Hospital (James): pre-POE, n=478; post-POE, n=10,771); volume of nursing transcription errors (POE with manual MAR, n=888; POE with eMAR, n=396); length of stay and total cost (OSUH: pre-POE, n=8,228; post-POE, n=8,154; James: (pre-POE, n=6,471; post-POE, n=6,045). RESULTS: Statistically significant reductions were seen following the implementation of POE for medication turn-around times (64 percent, from 5:28 hr to 1:51 hr; p<0.001), radiology procedure completion times (43 percent, from 7:37 hr to 4:21 hr; p<0.05), and laboratory result reporting times (25 percent, from 31:3 min to 23:4 min; p=0.001). In addition, POE combined with eMAR eliminated all physician and nursing transcription errors. There were 43 and 26 percent improvements in order countersignature by physicians in OSUH and James, respectively. Severity-adjusted length of stay decreased in OSUH (pre-POE, 3.91 days; post-POE, 3.71 days; p=0.002), but not significantly in James (pre-POE, 3.68 days; post-POE, 3.61 days; p=0.356). Although total cost per admission decreased significantly in selected services, it did not change significantly across either institution (OSUH: pre-POE, 5,697 dollars; post-POE, 5,661 dollars; p=0.687; James: pre-POE, 6,427 dollars; post-POE, 6,518 dollars; p=0.502). CONCLUSION: Physician order entry and eMAR provided the framework for improvements in patient safety and in the timeliness of care. The significant cultural and workflow changes that accompany the implementation of POE did not adversely affect acuity-adjusted length of stay or total cost. The reductions in transcription errors, medication turn-around times, and timely reporting of results supports the view that POE and eMAR provide a good return on investment.

Key attributes of a successful physician order entry system implementation in a multi-hospital environment.

The benefits of computerized physician order entry have been widely recognized, although few institutions have successfully installed these systems. Obstacles to successful implementation are organizational as well as technical. In the spring of 2000, following a 4-year period of planning and customization, a 9-month pilot project, and a 14-month hiatus for year 2000, the Ohio State University Health System extensively implemented physician order entry across inpatient units. Implementation for specialty and community services is targeted for completion in 2002. On implemented units, all orders are processed through the system, with 80 percent being entered by physicians and the rest by nursing or other licensed care providers. The system is deployable across diverse clinical environments, focused on physicians as the primary users, and accepted by clinicians. These are the three criteria by which the authors measured the success of their implementation. They believe that the availability of specialty-specific order sets, the engagement of physician leadership, and a large-scale system implementation were key strategic factors that enabled physician-users to accept a physician order entry system despite significant changes in workflow.