The plausibility transition model for sensemaking.

When people make plausibility judgments about an assertion, an event, or a piece of evidence, they are gauging whether it makes sense that the event could transpire as it did. Therefore, we can treat plausibility judgments as a part of sensemaking. In this paper, we review the research literature, presenting the different ways that plausibility has been defined and measured. Then we describe the naturalistic research that allowed us to model how plausibility judgments are engaged during the sensemaking process. The model is based on an analysis of 23 cases in which people tried to make sense of complex situations. The model describes the user's attempts to construct a narrative as a state transition string, relying on plausibility judgments for each transition point. The model has implications for measurement and for training.

Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines.

The National Lung Screening Trial established the benefits of low-dose computed tomography for lung cancer screening (LCS) to identify lung cancer at earlier stages. In February 2021, the US Preventive Services Task Force (USPSTF) revised the eligibility recommendations to increase the number of high-risk individuals eligible for LCS and, in effect, expand screening eligibility for vulnerable populations. One strategy for facilitating LCS is to implement targeted screening in geographic areas with the greatest need. In Philadelphia, although neighborhood smoking rates have been defined, it is not known which neighborhoods have the greatest number of people eligible for LCS. In this study, the authors estimate eligibility for LCS within Philadelphia neighborhoods using both previous and current USPSTF guidelines. They used the Public Health Management Corporation's Household Health Survey from 2010, 2012, and 2015 to identify the number of people within ever-smoker groups (current every day, current occasional, and former smokers) by neighborhood in Philadelphia. Using the 2015 National Health Interview Survey (NHIS) Cancer Supplement, they identified the percentages within ever-smoker groups that were LCS eligible using the previous and current USPSTF guidelines. Finally, they applied the percentages eligible for the ever-smoker groups from the NHIS to the numbers in these groups within Philadelphia neighborhoods. They found that the number of Philadelphians eligible for LCS increased from 41,946 to 89,231 after the revised USPSTF guidelines. The current USPSTF guidelines increased eligibility for LCS within all Philadelphia neighborhoods, with the greatest increases in the River Wards planning district. Local providers should use these results to prioritize LCS services within neighborhoods with greatest eligibility.

Risk Factors of Recurrent Falls Among Older Adults Admitted to the Trauma Surgery Department.

Falls affect more than 29 million American adults ages ≥65 years annually. Many older adults experience recurrent falls requiring medical attention. These recurrent falls may be prevented through screening and intervention. In 2014 to 2015, records for 199 older adult patients admitted from a major urban teaching hospital's emergency department were queried. Open-ended variables from clinicians' notes were coded to supplement existing closed-ended variables. Of the 199 patients, 52 (26.1%) experienced one or more recurrent falls within 365 days after their initial fall. Half (50.0%) of all recurrent falls occurred within the first 90 days following discharge. A large proportion of recurrent falls among older adults appear to occur within a few months and are statistically related to identifiable risk factors. Prevention and intervention strategies, delivered either during treatment for an initial fall or upon discharge from an inpatient admission, may reduce the incidence of recurrent falls among this population.

Mechanical ventilation in disaster situations: A new paradigm using the AGILITIES Score System.

BACKGROUND: The failure of life-critical systems such as mechanical ventilators in the wake of a pandemic or a disaster may result in death, and therefore, state and federal government agencies must have precautions in place to ensure availability, reliability, and predictability through comprehensive preparedness and response plans. METHODS: All 50 state emergency preparedness response plans were extensively examined for the attention given to the critically injured and ill patient population during a pandemic or mass casualty event. Public health authorities of each state were contacted as well. RESULTS: Nine of 51 state plans (17.6 percent) included a plan or committee for mechanical ventilation triage and management in a pandemic influenza event. All 51 state plans relied on the Centers for Disease Control and Prevention Flu Surge 2.0 spreadsheet to provide estimates for their influenza planning. In the absence of more specific guidance, the authors have developed and provided guidelines recommended for ventilator triage and the implementation of the AGILITIES Score in the event of a pandemic, mass casualty event, or other catastrophic disaster. CONCLUSIONS: The authors present and describe the AGILITIES Score Ventilator Triage System and provide related guidelines to be adopted uniformly by government agencies and hospitals. This scoring system and the set of guidelines are to be used in disaster settings, such as Hurricane Katrina, and are based on three key factors: relative health, duration of time on mechanical ventilation, and patients' use of resources during a disaster. For any event requiring large numbers of ventilators for patients, the United States is woefully unprepared. The deficiencies in this aspect of preparedness include (1) lack of accountability for physical ventilators, (2) lack of understanding with which healthcare professionals can safely operate these ventilators, (3) lack of understanding from where additional ventilator resources exist, and (4) a triage strategy to provide ventilator support to those patients with the greatest chances of survival.

Do Employees From Less-Healthy Communities Use More Care and Cost More? Seeking to Establish a Business Case for Investment in Community Health.

INTRODUCTION: Few studies have examined the impact of community health on employers. We explored whether employed adults and their adult dependents living in less-healthy communities in the greater Philadelphia region used more care and incurred higher costs to employers than employees from healthier communities. METHODS: We used a multi-employer database to identify adult employees and dependents with continuous employment and mapped them to 31 zip code regions. We calculated community health scores at the regional level, by using metrics similar to the Robert Wood Johnson Foundation (RWJF) County Health Rankings but with local data. We used descriptive analyses and multilevel linear modeling to explore relationships between community health and 3 outcome variables: emergency department (ED) use, hospital use, and paid claims. Business leaders reviewed findings and offered insights on preparedness to invest in community health improvement. RESULTS: Poorer community health was associated with high use of ED services, after controlling for age and sex. After including a summary measure of racial composition at the zip code region level, the relationship between community health and ED use became nonsignificant. No significant relationships between community health and hospitalizations or paid claims were identified. Business leaders expressed interest in further understanding health needs of communities where their employees live. CONCLUSION: The health of communities in which adult employees and dependents live was associated with ED use, but similar relationships were not seen for hospitalizations or paid claims. This finding suggests a need for more primary care access. Despite limited quantitative evidence, business leaders expressed interest in guidance on investing in community health improvement.

The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA.

Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

Macrocognition: From Theory to Toolbox.

We trace several trajectories-the evolution of field-based decision making models in the mid-1980s to the formation of the Naturalistic Decision Making movement in 1989, then the further broadening of NDM into Macrocognition in 2003, and finally the transition from macrocognitive models into a set of methods and tools to boost cognitive performance.

Impact of a multi-trigger intervention on seasonal patterns of asthma symptoms in inner city children.

OBJECTIVES: Peaks in childhood asthma symptoms and asthma morbidity occur universally in the fall and late winter/early spring. This study examines whether there is a time of the year best suited to implement environmental interventions to attenuate this pattern. METHODS: From September 2006 to June 2010, mid-Atlantic inner-city children asthmatics with 1 asthma-related hospitalization (IP) or 2 emergency (ED) visits the year prior to enrollment received 5 in-home self-management education sessions which included multi-trigger avoidance techniques and supplies. Children's daily asthma symptoms were recorded for 12 months by caregivers. RESULTS: One-hundred and thirty-six children (48%) completed 12 months of symptoms diaries. Symptom days were reduced by 4.5 days at 12 months follow-up (p < 0.001). Symptom severity improved with a decreased severity score of 29.0 to 7.9 at month 12 (p < 0.001). Sixty-one percent of patients with ≥2 ED visits at baseline dropped to 0-1visits (p < 0.001). Eighty percent of patients with ≥1 IP visits dropped to 0 visits at 12 months (p < 0.001). Patients who received intervention in the summer months had half the average monthly symptoms score (10.8) as those who received intervention in the spring months (20.8). When controlling for environment and morbidity, the summer enrolled group had a significantly lower (p = 0.021) symptom score than those in other seasons. CONCLUSION: Home self-management/environmental interventions for this cohort appear to have the greatest effect for those receiving the intervention in the summer and fall. The largest impact occurs in the summer cohort. Further studies with a control group are necessary to confirm these findings.

Influencing preferences for different types of causal explanation of complex events.

OBJECTIVE: We examined preferences for different forms of causal explanations for indeterminate situations. Background: Klein and Hoffman distinguished several forms of causal explanations for indeterminate, complex situations: single-cause explanations, lists of causes, and explanations that interrelate several causes. What governs our preferences for single-cause (simple) versus multiple- cause (complex) explanations? METHOD: In three experiments, we examined the effect of target audience, explanatory context, participant nationality, and explanation type. All participants were college students. Participants were given two scenarios, one regarding the U.S. economic collapse in 2007 to 2008 and the other about the sudden success of the U.S. military in Iraq in 2007. The participants were asked to assess various types of causal explanations for each of the scenarios, with reference to one or more purposes or audience for the explanations. RESULTS: Participants preferred simple explanations for presentation to less sophisticated audiences. Malaysian students of Chinese ethnicity preferred complex explanations more than did American students. The form of presentation made a difference: Participants preferred complex to simple explanations when given a chance to compare the two, but the preference for simple explanations increased when there was no chance for compari- son, and the difference between Americans and Malaysians disappeared. CONCLUSIONS: Preferences for explanation forms can vary with the context and with the audience, and they depend on the nature of the alternatives that are provided. APPLICATION: Guidance for decision-aiding technology and training systems that provide explanations need to involve consideration of the form and depth of the accounts provided as well as the intended audience.

Diabetes self-management education: miles to go.

This meta-analysis assessed how successfully Diabetes Self-Management Education (DSME) interventions help people with type 2 diabetes achieve and maintain healthy blood glucose levels. We included 52 DSME programs with 9,631 participants that reported post-intervention A1c levels in randomized controlled trials. The training conditions resulted in significant reductions in A1c levels compared to control conditions. However, the impact of intervention was modest shifting of only 7.23% more participants from diabetic to pre-diabetic or normal status, relative to the control condition. Most intervention participants did not achieve healthy A1c levels. Further, few DSME studies assessed long-term maintenance of A1c gains. Past trends suggest that gains are difficult to sustain over time. Our results suggested that interventions delivered by nurses were more successful than those delivered by non-nursing personnel. We suggest that DSME programs might do better by going beyond procedural interventions. Most DSME programs relied heavily on rules and procedures to guide decisions about diet, exercise, and weight loss. Future DSME may need to include cognitive self-monitoring, diagnosis, and planning skills to help patients detect anomalies, identify possible causes, generate corrective action, and avoid future barriers to maintaining healthy A1c levels. Finally, comprehensive descriptions of DSME programs would advance future efforts.

Treatment of attention-deficit hyperactivity disorder: patterns of evolving care during the first treatment episode.

OBJECTIVE: This study sought to better understand factors associated with different patterns of treatment among children starting treatment for attention-deficit hyperactivity disorder (ADHD). METHODS: Factors associated with service utilization and pharmacy claims data for 2,077 Medicaid-enrolled children aged six to 12 who started treatment for ADHD between October 2006 and December 2007 in a large mid-Atlantic state were investigated by using logistic regressions and Cox proportional hazard models. RESULTS: A total of 45% of children started ADHD treatment with a psychosocial intervention alone, 41% of children started treatment with medication alone, and 14% of children started treatment with a combination of both treatments. By the end of the treatment episode, 42% of children who initiated treatment with psychosocial interventions alone had added medication. Within six months of starting treatment, approximately 40% of children had discontinued treatment. Among those who continued receiving treatment, a majority received medication, either alone or with a psychosocial intervention. Treatment with a psychosocial intervention was significantly more likely to be initiated among nonwhite versus white children and among younger versus older children. Younger versus older children and African-American versus Caucasian children were significantly more likely to drop out of treatment sooner. CONCLUSIONS: During the first episode of treatment for ADHD, the interventions children received frequently changed, suggesting dissatisfaction with initial treatment. Further research is needed to better understand what underlies the patterns of evolving care so that all families seeking care for children with ADHD may receive preferred and effective treatment.

The Child Asthma Link Line: a coalition-initiated, telephone-based, care coordination intervention for childhood asthma.

BACKGROUND: Childhood asthma is a complex chronic disease that poses significant challenges regarding management, and there is evidence of disparities in care. Many medical, psychosocial, and health system factors contribute to recognized poor control of this most prevalent illness among children, with resultant excessive use of emergency departments and hospitalizations for care. Recent national guidelines emphasize the need for community-based initiatives to address these critical issues. To address health system fragmentation and impact asthma outcomes, the Philadelphia Allies Against Asthma coalition developed and implemented the Child Asthma Link Line, a telephone-based care coordination and system integration program, which has been in operation since 2001. This study evaluates the effectiveness of the Child Asthma Link Line integration model to improve asthma management by measuring utilization markers of morbidity. METHODS: Medicaid Managed Care Organization claims data for 59 children who received the Link Line intervention in 2003 are compared to a matched sample of 236 children who did not receive the Link Line intervention. Children in the two study groups are ages 3 through 12 years and matched on 2003 emergency department visits, age, gender, and race/ethnicity. Primary outcome variables analyzed in this study are emergency department visits, hospitalizations, and office visit claims from the follow-up year (2004). RESULTS: Link Line intervention children were significantly less likely to have follow-up hospitalizations than matched sample children (p = .02). Children enrolled in the Link Line were also more likely to attend outpatient office visits in the follow-up year (p = .045). In addition, Link Line children with multiple emergency department visits in 2003 were significantly less likely to have an emergency department visit in 2004 (p = .046). CONCLUSION: This coalition-developed, telephone-based, system-level intervention had a significant impact on childhood asthma morbidity as measured by utilization endpoints of follow-up hospitalizations and emergency department visits. Telephone-based care coordination and service integration may be a viable and economic way to impact childhood asthma and other chronic diseases.

Mechanical ventilation in disaster situations: a new paradigm using the AGILITIES Score System.

BACKGROUND: The failure of life-critical systems such as mechanical ventilators in the wake of a pandemic or a disaster may result in death, and therefore, state and federal government agencies must have precautions in place to ensure availability, reliability, and predictability through comprehensive preparedness and response plans. METHODS: All 50 state emergency preparedness response plans were extensively examined for the attention given to the critically injured and ill patient population during a pandemic or mass casualty event. Public health authorities of each state were contacted as well. RESULTS: Nine of 51 state plans (17.6 percent) included a plan or committee for mechanical ventilation triage and management in a pandemic influenza event. All 51 state plans relied on the Centers for Disease Control and Prevention Flu Surge 2.0 spreadsheet to provide estimates for their influenza planning. In the absence of more specific guidance, the authors have developed and provided guidelines recommended for ventilator triage and the implementation of the AGILITIES Score in the event of a pandemic, mass casualty event, or other catastrophic disaster. CONCLUSIONS: The authors present and describe the AGILITIES Score Ventilator Triage System and provide related guidelines to be adopted uniformly by government agencies and hospitals. This scoring system and the set ofguidelines are to be used iA disaster settings, such as Hurricane Katrina, and are based on three key factors: relative health, duration of time on mechanical ventilation, and patients' use of resources during a disaster. For any event requiring large numbers of ventilators for patients, the United States is woefully unprepared. The deficiencies in this aspect of preparedness include (1) lack of accountability for physical ventilators, (2) lack of understanding with which healthcare professionals can safely operate these ventilators, (3) lack of understanding from where additional ventilator resources exist, and (4) a triage strategy to provide ventilator support to those patients with the greatest chances of survival.

Conditions for intuitive expertise: a failure to disagree.

This article reports on an effort to explore the differences between two approaches to intuition and expertise that are often viewed as conflicting: heuristics and biases (HB) and naturalistic decision making (NDM). Starting from the obvious fact that professional intuition is sometimes marvelous and sometimes flawed, the authors attempt to map the boundary conditions that separate true intuitive skill from overconfident and biased impressions. They conclude that evaluating the likely quality of an intuitive judgment requires an assessment of the predictability of the environment in which the judgment is made and of the individual's opportunity to learn the regularities of that environment. Subjective experience is not a reliable indicator of judgment accuracy.

A medication therapy management program's impact on low-density lipoprotein cholesterol goal attainment in Medicare Part D patients with diabetes.

OBJECTIVES: To determine a medication therapy management (MTM) service's impact on (1) Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and (2) use and cost expenditures. DESIGN: Nonequivalent group, quasiexperimental study. SETTING: Florida, January 1, 2006, through September 30, 2007. PARTICIPANTS: 2,114 Florida Health Care Plans Medicare Part D enrollees with diabetes. INTERVENTION: Intervention group participated in the MTM program during the HEDIS measurement year. MAIN OUTCOME MEASURES: Presence of low-density lipoprotein cholesterol (LDL-C) screening, LDL-C values, and LDL-C control (<100 mg/dL). The use measure was the total number of 30-day medication equivalents. Cost measures were (1) total Medicare Part D drug cost, (2) enrollees' out-of-pocket Part D medication costs, and (3) total medication copayments. Statistical analyses included chi-square, independent and paired t tests, and analysis of variance with post hoc comparisons. RESULTS: Of 2, 114 enrollees eligible for comprehensive diabetes care (CDC) according to HEDIS guidelines, 255 participated in the MTM intervention group and 56 patients were MTM eligible but opted out of the program or could not be reached for medication review during 2008 (MTM nonparticipants). A higher proportion of patients in the MTM participant group had LDL-C levels less than 100 mg/dL (69.0%) compared with those in the MTM nonparticipant (50.0%) and CDC only (54.1%) groups (chi2 = 20.9(3), P < 0.001). The two control groups' average LDL-C (90.8 and 93.6 mg/dL) was significantly higher than the intervention group (83.4 mg/dL, P < 0.001). Overall, per member per month use and drug costs differed from 2007 to 2008 and enrollees in the MTM participant group had greater percentage cost reductions. CONCLUSION: Enrollees who were eligible for MTM services but did not receive them had poorer clinical, use, and cost outcomes compared with the MTM intervention group. Pharmacists collaborating with physicians through a MTM program can improve quality of metrics for chronic diseases and reduce medication costs.

Impact of a stroke unit on length of hospital stay and in-hospital case fatality.

BACKGROUND AND PURPOSE: Randomized trials have demonstrated reduced morbidity and mortality with stroke unit care; however, the effect on length of stay, and hence the economic benefit, is less well-defined. In 2001, a multidisciplinary stroke unit was opened at our institution. We observed whether a stroke unit reduces length of stay and in-hospital case fatality when compared to admission to a general neurology/medical ward. METHODS: A retrospective study of 2 cohorts in the Foothills Medical Center in Calgary was conducted using administrative databases. We compared a cohort of stroke patients managed on general neurology/medical wards before 2001, with a similar cohort of stroke patients managed on a stroke unit after 2003. The length of stay was dichotomized after being centered to 7 days and the Charlson Index was dichotomized for analysis. Multivariable logistic regression was used to compare the length of stay and case fatality in 2 cohorts, adjusted for age, gender, and patient comorbid conditions defined by the Charlson Index. RESULTS: Average length of stay for patients on a stroke unit (n=2461) was 15 days vs 19 days for patients managed on general neurology/medical wards (n=1567). The proportion of patients with length of stay >7 days on general neurology/medical wards was 53.8% vs 44.4% on the stroke unit (difference 9.4%; P<0.0001). The adjusted odds of a length of stay >7 days was reduced by 30% (P<0.0001) on a stroke unit compared to general neurology/medical wards. Overall in-hospital case fatality was reduced by 4.5% with stroke unit care. CONCLUSIONS: We observed a reduced length of stay and reduced in-hospital case-fatality in a stroke unit compared to general neurology/medical wards.

Naturalistic decision making.

OBJECTIVE: This article describes the origins and contributions of the naturalistic decision making (NDM) research approach. BACKGROUND: NDM research emerged in the 1980s to study how people make decisions in real-world settings. METHOD: The findings and methods used by NDM researchers are presented along with their implications. RESULTS: The NDM framework emphasizes the role of experience in enabling people to rapidly categorize situations to make effective decisions. CONCLUSION: The NDM focus on field settings and its interest in complex conditions provide insights for human factors practitioners about ways to improve performance. APPLICATION: The NDM approach has been used to improve performance through revisions of military doctrine, training that is focused on decision requirements, and the development of information technologies to support decision making and related cognitive functions.