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1.
J Grad Med Educ ; 13(5): 717-721, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34721802

RESUMO

Background: Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. Objective: To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. Methods: This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015-2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. Results: Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am-6am (2.6 vs 1.7, P < .001) and 6am-12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). Conclusions: Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (<6 hours), overall sleep duration and alertness did not significantly differ between rotations.


Assuntos
Internato e Residência , Tolerância ao Trabalho Programado , Cuidados Críticos , Humanos , Sono , Vigília
2.
Ann Intern Med ; 2021 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-34781715

RESUMO

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

4.
JCO Clin Cancer Inform ; 5: 1134-1140, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34767436

RESUMO

PURPOSE: Patients with cancer are at greater risk of developing severe symptoms from COVID-19 than the general population. We developed and tested an automated text-based remote symptom-monitoring program to facilitate early detection of worsening symptoms and rapid assessment for patients with cancer and suspected or confirmed COVID-19. METHODS: We conducted a feasibility study of Cancer COVID Watch, an automated COVID-19 symptom-monitoring program with oncology nurse practitioner (NP)-led triage among patients with cancer between April 23 and June 30, 2020. Twenty-six patients with cancer and suspected or confirmed COVID-19 were enrolled. Enrolled patients received twice daily automated text messages over 14 days that asked "How are you feeling compared to 12 hours ago? Better, worse, or the same?" and, if worse, "Is it harder than usual for you to breathe?" Patients who responded worse and yes were contacted within 1 hour by an oncology NP. RESULTS: Mean age of patients was 62.5 years. Seventeen (65%) were female, 10 (38%) Black, and 15 (58%) White. Twenty-five (96%) patients responded to ≥ 1 symptom check-in, and overall response rate was 78%. Four (15%) patients were escalated to the triage line: one was advised to present to the emergency department (ED), and three were managed in the outpatient setting. Median time from escalation to triage call was 11.5 minutes. Four (15%) patients presented to the ED without first escalating their care via our program. Participant satisfaction was high (Net Promoter Score: 100, n = 4). CONCLUSION: Implementation of an intensive remote symptom monitoring and rapid NP triage program for outpatients with cancer and suspected or confirmed COVID-19 infection is possible. Similar tools may facilitate more rapid triage for patients with cancer in future pandemics.


Assuntos
COVID-19 , Neoplasias , Envio de Mensagens de Texto , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias/diagnóstico , SARS-CoV-2 , Triagem
5.
Acad Med ; 2021 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-34753860

RESUMO

PURPOSE: Most of what is known about resident burnout and wellness comes from cross-sectional snapshot surveys. The purpose of this study was to elicit qualitative perspectives on wellness from a cohort of internal residents over time using ecological momentary assessment. METHOD: Drawing on principles of ecological momentary assessment, 13 different open-ended survey prompts were delivered between October and March during the 2019-2020 academic year. Participants were 88 randomly selected internal medicine residents from 4 internal medicine training programs in the Northeast. RESULTS: The response rate was 95%. Three main themes regarding wellness were self, program/education environment, and medical/structural system. A fourth theme, the desire to provide quality patient care, cut across all other themes. The patient care theme repeatedly stressed residents' desire to spend more time with patients. The self theme primarily reflected messages about personal emotions and the need for work-life balance and wellness. The program/education environment theme reflected the value of learning, teamwork and community, and program culture. The medical/structural system theme showed that residents' experiences were shaped by the efficiency of their days, and largely a product of their schedules and administrative support. Closing advice to future trainees was optimistic and reassuring. CONCLUSIONS: While findings support much of what has been learned via single-occasion survey snapshots, an ecological momentary assessment design allowed a deeper dive into contextual associations. The results affirm the primacy of patient care and also highlight the value of teamwork and culture. Peers and program leaders are heavily influential in setting the tone for the learning experience, whether for the day or with a more enduring message of respect and support. There is opportunity to maximize high- or higher-value learning experiences for residents and find solutions to reduce and reframe the perceived "low-value administrative work" that is part of care coordination.

7.
JAMA Netw Open ; 4(10): e2127799, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34665240

RESUMO

Importance: Mortality across US counties varies considerably, from 252 to 1847 deaths per 100 000 people in 2018. Although patient satisfaction with health care is associated with patient- and facility-level health outcomes, the association between health care satisfaction and community-level health outcomes is not known. Objective: To examine the association between online ratings of health care facilities and mortality across US counties and to identify language specific to 1-star (lowest rating) and 5-star (highest rating) reviews in counties with high vs low mortality. Design, Setting, and Participants: This retrospective population-based cross-sectional study examined reviews and ratings of 95 120 essential health care facilities across 1301 US counties. Counties that had at least 1 essential health care facility with reviews available on Yelp, an online review platform, were included. Essential health care was defined according to the 10 essential health benefits covered by Affordable Care Act insurance plans. Main Outcomes and Measures: The mean rating of essential health care facilities was calculated by county from January 1, 2015, to December 31, 2019. Ratings were on a scale of 1 to 5 stars, with 1 being the worst rating and 5 the best. County-level composite measures of health behaviors, clinical care, social and economic factors, and physical environment were obtained from the University of Wisconsin School of Medicine and Public Health County Health Rankings database. The 2018 age-adjusted mortality by county was obtained from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiological Research database. Multiple linear regression analysis was used to estimate the association between mean facility rating and mortality, adjusting for county health ranking variables. Words with frequencies of use that were significantly different across 1-star and 5-star reviews in counties with high vs low mortality were identified. Results: The 95 120 facilities meeting inclusion criteria were distributed across 1301 of 3142 US counties (41.4%). At the county level, a 1-point increase in mean rating was associated with a mean (SE) age-adjusted decrease of 18.05 (3.68) deaths per 100 000 people (P < .001). Words specific to 1-star reviews in high-mortality counties included told, rude, and wait, and words specific to 5-star reviews in low-mortality counties included Dr, pain, and professional. Conclusions and Relevance: This study found that, at the county level, higher online ratings of essential health care facilities were associated with lower mortality. Equivalent online ratings did not necessarily reflect equivalent experiences of care across counties with different mortality levels, as evidenced by variations in the frequency of use of key words in reviews. These findings suggest that online ratings and reviews may provide insight into unequal experiences of essential health care.

9.
Implement Sci ; 16(1): 90, 2021 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-34563227

RESUMO

BACKGROUND: Serious illness conversations (SICs) are an evidence-based approach to eliciting patients' values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics ("nudges") that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion-either alone or in combination with clinician nudges that additionally compare performance relative to peers-may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. METHODS: We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. DISCUSSION: This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021. FUNDING: National Cancer Institute P50CA244690.


Assuntos
Neoplasias , Assistência Terminal , Comunicação , Economia Comportamental , Feminino , Humanos , Neoplasias/terapia , Cuidados Paliativos
10.
J Am Heart Assoc ; 10(19): e020596, 2021 10 05.
Artigo em Inglês | MEDLINE | ID: mdl-34558301

RESUMO

Background Online platforms are used to manage aspects of our lives including health outside clinical settings. Little is known about the effectiveness of using online platforms to manage hypertension. We assessed effects of tweeting/retweeting cardiovascular health content by individuals with poorly controlled hypertension on systolic blood pressure (SBP) and patient activation. Methods and Results We conducted this 2-arm randomized controlled trial. Eligibility included diagnosis of hypertension; SBP >140 mm Hg; and an existing Twitter account or willingness to create one to follow study Twitter account. Intervention arm was asked to tweet/retweet health content 2×/week using a specific hashtag for study duration (6 months). The main measures include primary outcome change in SBP; secondary outcome point change in Patient Activation Measure (PAM). We remotely recruited and enrolled 611 participants, mean age 52 (SD, 11.7). Mean baseline SBP for the intervention group was 155.8 and for control was 155.6. At 6 months, mean SBP for intervention group was 137.6 and for control was 135.7. Mean change in SBP from baseline to 6 months for the intervention group was -18.5 and for control was -19.8 (P=0.48). Mean PAM at baseline for the intervention group was 70.3 for control was 72.7. At 6 months, mean PAM scores were 71.1 (intervention) and 75.6 (control). Mean change in PAM score for the intervention group was 0.0 and for control was 3.3 (P=0.12). Conclusions Recruiting and engaging patients and collecting outcome measures remotely are feasible using Twitter. Encouraging patients with poorly controlled hypertension to tweet or retweet health content on Twitter did not improve SBP or PAM score at 6 months. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02622256.

11.
J Grad Med Educ ; 13(4): 515-525, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34434512

RESUMO

Background: The COVID-19 pandemic forced numerous unprecedented systemic changes within residency programs and hospital systems. Objective: We explored how the COVID-19 pandemic, and associated changes in clinical and educational experiences, were related to internal medicine residents' well-being in the early months of the pandemic. Methods: Across 4 internal medicine residency programs in the Northeast United States that have previously participated in the iCOMPARE study, all 394 residents were invited to participate in a study with open-ended survey prompts about well-being approximately every 2 weeks in academic year 2019-2020. In March and April 2020, survey prompts were refocused to COVID-19. Content analysis revealed themes in residents' open-ended responses to 4 prompts. Results: One hundred and eighty-six residents expressed interest, and 88 were randomly selected (47%). There were 4 main themes: (1) in early days of the pandemic, internal medicine residents reported fear and anxiety about uncertainty and lack of personal protective equipment; (2) residents adapted and soon were able to reflect, rest, and pursue personal wellness; (3) communication from programs and health systems was inconsistent early in the pandemic but improved in clarity and frequency; (4) residents appreciated the changes programs had made, including shorter shifts, removal of pre-rounding, and telemedicine. Conclusions: COVID-19 introduced many challenges to internal medicine residency programs and to resident well-being. Programs made structural changes to clinical schedules, educational/conference options, and communication that boosted resident well-being. Many residents hoped these changes would continue regardless of the pandemic's course.


Assuntos
COVID-19 , Internato e Residência , Ansiedade , Humanos , Pandemias , SARS-CoV-2
12.
Implement Sci ; 16(1): 72, 2021 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-34266468

RESUMO

BACKGROUND: Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS: A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION: This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.


Assuntos
Neoplasias , Tabaco , Economia Comportamental , Humanos , Neoplasias/terapia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Fumaça , Uso de Tabaco
13.
Healthc (Amst) ; 9(3): 100568, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34293616

RESUMO

The Covid-19 pandemic required rapid scale of telemedicine as well as other digital workflows to maintain access to care while reducing infection risk. Both patients and clinicians who hadn't used telemedicine before were suddenly faced with a multi-step setup process to log into a virtual meeting. Unlike in-person examination rooms, locking a virtual meeting room was more error-prone and posed a risk of multiple patients joining the same online session. There was administrative burden on the practice staff who were generating and manually sending links to patients, and educating patients on device set up was time-consuming and unsustainable. A solution had to be deployed rapidly system-wide, without the usual roll out across months. Our answer was to design and implement a novel EHR-integrated web application called the Switchboard, in just two weeks. The Switchboard leverages a commercial, cloud-based video meeting platform and facilitates an end-to-end virtual care encounter workflow, from pre-visit reminders to post-visit SMS text message-based measurement of patient experience, with tools to extend contact-less workflows to in-person appointments. Over the first 11 months of the pandemic, the in-house platform has been adopted across 6 hospitals and >200 practices, scaled to 8,800 clinicians who at their peak conducted an average of 30,000 telemedicine appointments/week, and enabled over 10,000-20,000 text messages/day to be exchanged through the platform. Furthermore, it enabled our organization to convert from an average of 75% of telehealth visits being conducted via telephone to 75% conducted via video within weeks.


Assuntos
COVID-19 , Telemedicina , Humanos , Pandemias , SARS-CoV-2 , Fatores de Tempo
14.
J Med Internet Res ; 23(6): e29395, 2021 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-34106074

RESUMO

BACKGROUND: In 2020, the number of internet users surpassed 4.6 billion. Individuals who create and share digital data can leave a trail of information about their habits and preferences that collectively generate a digital footprint. Studies have shown that digital footprints can reveal important information regarding an individual's health status, ranging from diet and exercise to depression. Uses of digital applications have accelerated during the COVID-19 pandemic where public health organizations have utilized technology to reduce the burden of transmission, ultimately leading to policy discussions about digital health privacy. Though US consumers report feeling concerned about the way their personal data is used, they continue to use digital technologies. OBJECTIVE: This study aimed to understand the extent to which consumers recognize possible health applications of their digital data and identify their most salient concerns around digital health privacy. METHODS: We conducted semistructured interviews with a diverse national sample of US adults from November 2018 to January 2019. Participants were recruited from the Ipsos KnowledgePanel, a nationally representative panel. Participants were asked to reflect on their own use of digital technology, rate various sources of digital information, and consider several hypothetical scenarios with varying sources and health-related applications of personal digital information. RESULTS: The final cohort included a diverse national sample of 45 US consumers. Participants were generally unaware what consumer digital data might reveal about their health. They also revealed limited knowledge of current data collection and aggregation practices. When responding to specific scenarios with health-related applications of data, they had difficulty weighing the benefits and harms but expressed a desire for privacy protection. They saw benefits in using digital data to improve health, but wanted limits to health programs' use of consumer digital data. CONCLUSIONS: Current privacy restrictions on health-related data are premised on the notion that these data are derived only from medical encounters. Given that an increasing amount of health-related data is derived from digital footprints in consumer settings, our findings suggest the need for greater transparency of data collection and uses, and broader health privacy protections.


Assuntos
Comportamento do Consumidor/estatística & dados numéricos , Informação de Saúde ao Consumidor/estatística & dados numéricos , Coleta de Dados/ética , Conjuntos de Dados como Assunto/provisão & distribuição , Entrevistas como Assunto , Privacidade/psicologia , Pesquisa Qualitativa , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
15.
JAMA Netw Open ; 4(6): e2112842, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34137829

RESUMO

Importance: Black patients hospitalized with COVID-19 may have worse outcomes than White patients because of excess individual risk or because Black patients are disproportionately cared for in hospitals with worse outcomes for all. Objectives: To examine differences in COVID-19 hospital mortality rates between Black and White patients and to assess whether the mortality rates reflect differences in patient characteristics by race or by the hospitals to which Black and White patients are admitted. Design, Setting, and Participants: This cohort study assessed Medicare beneficiaries admitted with a diagnosis of COVID-19 to 1188 US hospitals from January 1, 2020, through September 21, 2020. Exposure: Hospital admission for a diagnosis of COVID-19. Main Outcomes and Measures: The primary composite outcome was inpatient death or discharge to hospice within 30 days of admission. We estimated the association of patient-level characteristics (including age, sex, zip code-level income, comorbidities, admission from a nursing facility, and days since January 1, 2020) with differences in mortality or discharge to hospice among Black and White patients. To examine the association with the hospital itself, we adjusted for the specific hospitals to which patients were admitted. We used simulation modeling to estimate the mortality among Black patients had they instead been admitted to the hospitals where White patients were admitted. Results: Of the 44 217 Medicare beneficiaries included in the study, 24 281 (55%) were women; mean (SD) age was 76.3 (10.5) years; 33 459 participants (76%) were White, and 10 758 (24%) were Black. Overall, 2634 (8%) White patients and 1100 (10%) Black patients died as inpatients, and 1670 (5%) White patients and 350 (3%) Black patients were discharged to hospice within 30 days of hospitalization, for a total mortality-equivalent rate of 12.86% for White patients and 13.48% for Black patients. Black patients had similar odds of dying or being discharged to hospice (odds ratio [OR], 1.06; 95% CI, 0.99-1.12) in an unadjusted comparison with White patients. After adjustment for clinical and sociodemographic patient characteristics, Black patients were more likely to die or be discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19). This difference became indistinguishable when adjustment was made for the hospitals where care was delivered (odds ratio, 1.02; 95% CI, 0.94-1.10). In simulations, if Black patients in this sample were instead admitted to the same hospitals as White patients in the same distribution, their rate of mortality or discharge to hospice would decline from the observed rate of 13.48% to the simulated rate of 12.23% (95% CI for difference, 1.20%-1.30%). Conclusions and Relevance: This cohort study found that Black patients hospitalized with COVID-19 had higher rates of hospital mortality or discharge to hospice than White patients after adjustment for the personal characteristics of those patients. However, those differences were explained by differences in the hospitals to which Black and White patients were admitted.


Assuntos
Afro-Americanos/estatística & dados numéricos , COVID-19/etnologia , COVID-19/mortalidade , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Mortalidade Hospitalar/etnologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais , Humanos , Masculino , Medicare , SARS-CoV-2 , Estados Unidos/epidemiologia
16.
J Clin Med ; 10(9)2021 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-34063729

RESUMO

OBJECTIVE: Patients requiring hospital care for COVID-19 may be stable for discharge soon after admission. This study sought to describe patient characteristics associated with short-stay hospitalization for COVID-19. METHODS: We performed a retrospective cohort study of patients with COVID-19 admitted to five United States hospitals from March to December 2020. We used multivariable logistic regression to identify patient characteristics associated with short hospital length-of-stay. RESULTS: Of 3103 patients, 648 (20.9%) were hospitalized for less than 48 h. These patients were significantly less likely to have an age greater than 60, diabetes, chronic kidney disease; emergency department vital sign abnormalities, or abnormal initial diagnostic testing. For patients with no significant risk factors, the adjusted probability of short-stay hospitalization was 62.4% (95% CI 58.9-69.6). CONCLUSION: Identification of candidates for early hospital discharge may allow hospitals to streamline throughput using protocols that optimize the efficiency of hospital care and coordinate post-discharge monitoring.

18.
BMJ ; 373: n1022, 2021 05 18.
Artigo em Inglês | MEDLINE | ID: mdl-34006604

RESUMO

OBJECTIVE: To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965. DESIGN: Pragmatic randomized controlled trial. SETTING: 43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020. PARTICIPANTS: Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period. INTERVENTIONS: This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content). MAIN OUTCOME MEASURES: Proportion of patients who completed HCV testing within four months. RESULTS: 21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001). CONCLUSIONS: Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages. TRIAL REGISTRATION: ClinicalTrials.gov NCT03712553.


Assuntos
Controle Comportamental/métodos , Relações Comunidade-Instituição , Hepatite C/diagnóstico , Programas de Rastreamento/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Idoso , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Motivação , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Portais do Paciente , Pennsylvania , Serviços Postais , Atenção Primária à Saúde/estatística & dados numéricos , Resultado do Tratamento
19.
JAMA Netw Open ; 4(5): e2110918, 2021 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-34009347

RESUMO

Importance: Curbing COVID-19 transmission is currently the greatest global public health challenge. Consumer digital tools used to collect data, such as the Apple-Google digital contact tracing program, offer opportunities to reduce COVID-19 transmission but introduce privacy concerns. Objective: To assess uses of consumer digital information for COVID-19 control that US adults find acceptable and the factors associated with higher or lower approval of use of this information. Design, Setting, and Participants: This cross-sectional survey study obtained data from a nationally representative sample of 6284 US adults recruited by email from the web-based Ipsos KnowledgePanel in July 2020. Respondents evaluated scenarios reflecting uses of digital data for COVID-19 control (case identification, digital contact tracing, policy setting, and enforcement of quarantines). Main Outcomes and Measures: Levels of support for use of personal digital data in 9 scenarios to mitigate the spread of COVID-19 infection, rated on a Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Multivariable linear regression models were fitted for each scenario and included factors hypothesized to be associated with views about digital data use for COVID-19 mitigation measures. Black and Hispanic survey respondents were oversampled; thus, poststratification weights were used so that results are representative of the general US population. Results: Of 6284 individuals invited to participate in the study, 3547 responded, for a completion rate of 56%. A total of 1762 participants (52%) were female, 715 (21%) identified as Black, 790 (23%) identified as Hispanic, and 1224 (36%) were 60 years or older; mean (SD) age was 51.7 (16.6) years. Approval of scenarios was low, ranging from 28% to 43% (52%-67% when neutral responses were included). Differences were found based on digital data source (smartphone vs social media: coefficient, 0.29 [95% CI, 0.23-0.35]; P < .001; smart thermometer vs social media: coefficient, 0.09 [95% CI, 0.03-0.16]; P = .004). County COVID-19 rates (coefficient, -0.02; 95% CI, -0.16 to 0.13 for quartile 4 compared with quartile 1) and prior family diagnosis of COVID-19 (coefficient, 0.00; 95% CI, -0.25 to 0.25) were not associated with support. Compared with self-described liberal individuals, conservative (coefficient, -0.81; 95% CI, -0.96 to -0.66; P < .001) and moderate (coefficient, -0.52; 95% CI, -0.67 to -0.38; P < .001) individuals were less likely to support the scenarios. Similarly, large political differences were observed in support of the Apple-Google digital contact tracing program, with less support from conservative (coefficient, -0.99; 95% CI, -1.11 to -0.87; P < .001) and moderate (coefficient, -0.59; 95% CI, -0.69 to -0.48; P < .001) individuals compared with liberal individuals. Respondents from racial/ethnic minority groups were more supportive of the scenarios than were White, non-Hispanic respondents. For example, compared with White respondents, Black respondents were more supportive of the Apple-Google contact tracing program (coefficient, 0.20; 95% CI, 0.07-0.32; P = .002). Conclusions and Relevance: In this survey study of US adults, many were averse to their information being used on digital platforms to mitigate transmission of COVID-19. These findings suggest that in current and future pandemics, public health departments should use multiple strategies to gain public trust and accelerate adoption of tools such as digital contact tracing applications.


Assuntos
Atitude , COVID-19/prevenção & controle , Busca de Comunicante , Tecnologia Digital , Pandemias , Privacidade , Opinião Pública , Adulto , Idoso , Atitude/etnologia , Controle de Doenças Transmissíveis/métodos , Estudos Transversais , Coleta de Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários , Política , SARS-CoV-2 , Smartphone , Mídias Sociais , Inquéritos e Questionários , Telemedicina , Estados Unidos
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