Clinical guidelines for stroke management: chapter 7 of 8: discharge planning and transfer of care

The Stroke Foundation is a national charity that partners with the community to prevent, treat and beat stroke. We stand alongside stroke survivors and their families, healthcare professionals and researchers. We build community awareness and foster new thinking and innovative treatments. We support survivors on their journey to live the best possible life after stroke. We are the voice of stroke in Australia and we work to: • Raise awareness of the risk factors, signs of stroke and promote healthy lifestyles. • Improve treatment for stroke to save lives and reduce disability. • Improve life after stroke for survivors. • Encourage and facilitate stroke research. • Advocate for initiatives to prevent, treat and beat stroke. • Raise funds from the community, corporate sector and government to continue our mission. The Stroke Foundation has been developing stroke guidelines since 2002 and in 2017 released the fourth edition. In order for the Australian Government to ensure up-to-date, best-practice clinical advice is provided and maintained to healthcare professionals, the NHMRC requires clinical guidelines be kept current and relevant by reviewing and updating them at least every five years. As a result, the Stroke Foundation, in partnership with Cochrane Australia, have moved to a model of living guidelines, in which recommendations are continually reviewed and updated in response to new evidence. This approach was piloted in a three year project (July 2018 -June 2021) funded by the Australian Government via the Medical Research Future Fund. This online version of the Clinical Guidelines for Stroke Management updates and supersedes the Clinical Guidelines for Stroke Management 2017. The Clinical Guidelines have been updated in accordance with the 2011 NHMRC Standard for clinical practice guidelines and therefore recommendations are based on the best evidence available. The Clinical Guidelines cover the whole continuum of stroke care, across 8 chapters. Review of the Clinical Guidelines used an internationally recognised guideline development approach, known as GRADE (Grading of Recommendations Assessment, Development and Evaluation), and an innovative guideline development and publishing platform, known as MAGICapp (Making Grade the Irresistible Choice). GRADE ensures a systematic process is used to develop recommendations that are based on the balance of benefits and harms, patient values, and resource considerations. MAGICapp enables transparent display of this process and access to additional practical information useful for guideline recommendation implementation.

Colorectal cancer survivorship care plans: Variations in documentation and posttreatment surveillance recommendations.

BACKGROUND: Survivorship care plans (SCP) should outline pertinent information about cancer treatment and follow-up. METHODS: We descriptively analyzed the content of 74 colorectal cancer SCPs completed as part of a randomized, controlled trial of SCPs at an academic and community cancer center. Surveillance recommendations were compared with American Cancer Society, American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines. RESULTS: SCP information provided in >80% of the plans included participant age, cancer diagnosis, details, and side-effects of treatment (surgery, chemotherapy, radiation) and health promotion recommendations. SCP content documented less frequently included predisposing conditions, genetic counseling/testing information and staging. Posttreatment surveillance recommendations were documented in >90% SCPs. For stage 2-3 cancer, rates of guideline concordant recommendations were 100% for colonoscopy surveillance (Year 1 only), 87% for imaging surveillance, 65% for carcinoembryonic antigen surveillance, and 33% for follow-up visits. Excluding colonoscopy, >15 unique recommendations were listed for each modality across stages and sites, with more variation at the academic site. CONCLUSIONS: SCPs consistently recorded information about cancer diagnosis and treatment but omitted critical information about cancer-specific details denoting risk. Surveillance recommendations varied considerably between cancer centers. Future work to improve the consistency of surveillance recommendations documented in SCPs may be needed.

Financial impacts of the COVID-19 pandemic on cystic fibrosis care: lessons for the future.

BACKGROUND: Chronic care delivery models faced unprecedented financial pressures, with a reduction of in-person visits and adoption of telehealth during the COVID-19 pandemic. We sought to understand the reported financial impact of pandemic-related changes to the cystic fibrosis (CF) care model. METHODS: The U.S. CF Foundation State of Care surveys fielded in Summer 2020 (SoC1) and Spring 2021 (SoC2) included questions for CF programs on the impact of pandemic-related restrictions on overall finances, staffing, licensure, and reimbursement of telehealth services. Descriptive analyses were conducted based on program type. RESULTS: Among the 286 respondents (128 pediatric, 118 adult, 40 affiliate), the majority (62%) reported a detrimental financial impact to their CF care program in SoC1, though fewer (42%) reported detrimental impacts in SoC2. The most common reported impacts in SoC1 were redeployment of clinical staff (68%), furloughs (52%), hiring freezes (51%), decreases in salaries (34%), or layoffs (10%). Reports of lower reimbursement for telehealth increased from 30% to 40% from SoC1 to SoC2. Projecting towards the future, only a minority (17%) of program directors in SoC2 felt that financial support would remain below pre-pandemic levels. CONCLUSIONS: The COVID-19 pandemic resulted in financial strain on the CF care model, including challenges with reimbursement for telehealth services and reductions in staffing due to institutional changes. Planning for the future of CF care model needs to address these short-term impacts, particularly to ensure a lack of interruption in high-quality multi-disciplinary care.

Preliminary findings on the experiences of care for parents who suffered perinatal bereavement during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic poses an unprecedented risk to the global population. Maternity care in the UK was subject to many iterations of guidance on how best to reconfigure services to keep women, their families and babies, and healthcare professionals safe. Parents who experience a pregnancy loss or perinatal death require particular care and support. PUDDLES is an international collaboration investigating the experiences of recently bereaved parents who suffered a late miscarriage, stillbirth, or neonatal death during the global COVID-19 pandemic, in seven countries. In this study, we aim to present early findings from qualitative work undertaken with recently bereaved parents in the United Kingdom about how access to healthcare and support services was negotiated during the pandemic. METHODS: In-depth semi-structured interviews were undertaken with parents (N = 24) who had suffered a late miscarriage (n = 5; all mothers), stillbirth (n = 16; 13 mothers, 1 father, 1 joint interview involving both parents), or neonatal death (n = 3; all mothers). Data were analysed using a template analysis with the aim of investigating bereaved parents' access to services, care, and networks of support, during the pandemic after their bereavement. RESULTS: All parents had experience of utilising reconfigured maternity and/or neonatal, and bereavement care services during the pandemic. The themes utilised in the template analysis were: 1) The Shock & Confusion Associated with Necessary Restrictions to Daily Life; 2) Fragmented Care and Far Away Families; 3) Keeping Safe by Staying Away; and 4) Impersonal Care and Support Through a Screen. Results suggest access to maternity, neonatal, and bereavement care services were all significantly reduced, and parents' experiences were notably affected by service reconfigurations. CONCLUSIONS: Our findings, whilst preliminary, are important to document now, to help inform care and service provision as the pandemic continues and to provide learning for ongoing and future health system shocks. We draw conclusions on how to enable development of safe and appropriate services during this pandemic and any future health crises, to best support parents who experience a pregnancy loss or whose babies die.

Continuity and coordination of care in highly selected chronic cancer patients treated with multiple repeat radiation therapy.

INTRODUCTION AND BACKGROUND: As cancer is developing into a chronic disease due to longer survival, continuity and coordination of oncological care are becoming more important for patients. As radiation oncology departments are an integral part of cancer care and as repeat irradiation becomes more commonplace, the relevance of continuity and coordination of care in operating procedures is increasing. This study aims to perform a single-institution analysis of cancer patients in which continuity and coordination of care matters most, namely the highly selected group with multiple repeat course radiotherapy throughout their chronic disease. MATERIALS AND METHODS: All patients who received at least five courses of radiotherapy at the Department of Radiation Oncology at the University Hospital Zurich from 2011 to 2019 and who were alive at the time of the initiation of this project were included into this study. Patient and treatment characteristics were extracted from the hospital information and treatment planning systems. All patients completed two questionnaires on continuity of care, one of which was designed in-house and one of which was taken from the literature. RESULTS: Of the 33 patients identified at baseline, 20 (60.6%) participated in this study. A median of 6 years (range 3-13) elapsed between the first and the last visit at the cancer center. The median number of involved primary oncologists at the radiation oncology department was two (range 1-5). Fifty-seven percent of radiation therapy courses were preceded by a tumor board discussion. Both questionnaires showed high levels of experienced continuity of care. No statistically significant differences in experienced continuity of care between groups with more or less than two primary oncologists was found. DISCUSSION AND CONCLUSION: Patients treated with multiple repeat radiation therapy at our department over the past decade experienced high levels of continuity of care, yet further efforts should be undertaken to coordinate care among oncological disciplines in large cancer centers through better and increased use of interdisciplinary tumor boards.

Hepatitis C continuum of care: Experience of integrative hepatitis C treatment within a human immunodeficiency virus clinic in Indonesia.

INTRODUCTION: Direct-acting antiviral drugs (DAAs) have changed the paradigm of hepatitis C therapy for both HCV/HIV co-infected and HCV mono-infected patients. We aimed to describe the HCV continuum of care of HIV-infected patients treated in an HIV clinic after a free DAA program in Indonesia and identify factors correlated with sofosbuvir-daclatasvir (SOF-DCV) treatment failure. METHODS: We did a retrospective cohort study of adult HIV/HCV co-infected patients under routine HIV-care from November 2019 to April 2020 in the HIV integrated clinic of Cipto Mangunkusumo Hospital, Jakarta, Indonesia. We evaluated some factors correlated with sofosbuvir-daclatasvir treatment failure: gender, diabetes mellitus, previous IFN failure, cirrhosis, concomitant ribavirin use, high baseline HCV-RNA, and low CD4 cell count. RESULTS AND DISCUSSION: Overall, 640 anti-HCV positive patients were included in the study. Most of them were male (88.3%) and former intravenous drug users (76.6%) with a mean age of 40.95 (SD 4.60) years old. Numbers and percentages for the stages of the HCV continuum of care were as follows: HCV-RNA tested (411; 64.2%), pre-therapeutic evaluation done (271; 42.3%), HCV treatment initiated (210; 32.8%), HCV treatment completed (207; 32.2%), but only 178 of these patients had follow-up HCV-RNA tests to allow SVR assessment; and finally SVR12 achieved (178; 27.8%). For the 184 who completed SOF-DCV treatment, SVR12 was achieved by 95.7%. In multivariate analysis, diabetes mellitus remained a significant factor correlated with SOF-DCV treatment failure (adjusted RR 17.0, 95%CI: 3.28-88.23, p = 0.001). CONCLUSIONS: This study found that in the HCV continuum of care for HIV/HCV co-infected patients, gaps still exist at all stages. As the most commonly used DAA combination, sofosbuvir daclatasvir treatment proved to be effective and well-tolerated in HIV/HCV co-infected patients. Diabetes mellitus was significant factor correlated with not achieving SVR12 in this population.

Ensuring medication continuity in older people after hospital discharge.

Overview of: Tomlinson J, Cheong VL, Fylan B, et al Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity. Age and Ageing 2020;49:558-69.

Impact of pharmacist involvement on medication safety in interprofessional transfer of care activity.

AIM: Any transition of patient care is a high-risk time for communication error. This paper explores whether the presence of a pharmacist as part of an interprofessional group provides additional benefit and safety in transitions of care. METHOD: Six pharmacy interns and newly qualified pharmacists joined participants from seven other health professional training programmes to take part in an interprofessional education activity. Participants were assigned to 24 mixed-professional groups. Each group was required to craft a discharge summary for the same simulated patient. Groups without a pharmacist were given additional written documentation, including medication reconciliation, discharge prescription and discharge recommendations. The 24 discharge summaries were assessed for any medication-related information, both positive and negative. Groups with a pharmacist (6) were compared with groups who did not have a pharmacist (18) for completeness and accuracy of medication management. RESULTS: An in-person pharmacist provided more thorough, comprehensive, accessible and accurate information for the community team (p=0.003). Although there was no difference in the absolute number of medication errors between the groups (p=0.057), the groups with a pharmacist showed a significant reduction in the severity of the errors (p=0.009). This result happened despite the groups without a pharmacist being provided with all the required medication information for safe transition of care. CONCLUSION: These findings support the case for greater involvement from a pharmacist in a patient's healthcare team, particularly for any transition of care. Healthcare teams that include a pharmacist are more likely to exceed minimum safety expectations and make less severe errors.

Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure?

Background Readmissions in patients with congestive heart failure are common and often preventable. Limited data suggest that patients discharged to a less intensive postacute care setting than recommended are likely to readmit. We examined whether postacute setting discordance (discharge to a less intensive postacute setting than recommended by a physical and occupational therapist) was associated with hospital readmission in patients with congestive heart failure. We also assessed sociodemographic and clinical predictors of setting discordance. Methods and Results Retrospective analysis of administrative claims and electronic health record data was conducted on 25 500 adults with a discharge diagnosis of congestive heart failure from 12 acute care hospitals in Western Pennsylvania. Generalized linear mixed models were estimated to examine the association between postacute setting discordance and 30-day hospital readmission and to identify predictors of setting discordance. The 30-day readmission and postacute setting discordance rates were high (23.7%, 20.6%). While controlling for demographic and clinical covariates, patients in discordant postacute settings were more likely to be readmitted within 30 days (adjusted odds ratio [OR], 1.12; 95% CI, 1.04-1.20). The effect was also seen in the subgroup of patients with low mobility scores (adjusted OR, 1.20; 95% CI, 1.08-1.33). Factors associated with setting discordance were lower-income, higher comorbidity burden, therapist recommendation disagreement, and midrange mobility limitations. Conclusions Postacute setting discordance was associated with an increased readmission risk in patients hospitalized with congestive heart failure. Maximizing concordance between therapist recommended and actual postacute discharge setting may decrease readmissions. Understanding factors associated with post-acute setting discordance can inform strategies to improve the quality of the discharge process.

Methodological quality of guidelines for the management of opioid use disorder: A systematic review.

WHAT IS KNOWN AND OBJECTIVE: Opioid Use Disorder (OUD) has a high mortality rate and affects millions of people worldwide. Many organizations and societies develop Clinical Practice Guidelines (CPGs) to serve as a framework for healthcare providers to decide and support best practice to manage and treat OUD. However, not all CPGs sufficiently address all the important aspects of optimal care for managing OUD. This study aims to review current CPGs for management of OUD, evaluate their methodological quality and summarize their recommendations. METHODS: We conducted this systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Various databases were searched for CPGs and Appraisal of Guidelines for Research and Evaluation (AGREE-II) instrument was used to assess the methodological quality. We also summarized the treatments plans of CPGs across continuum of care (diagnosis and assessment, treatment initiation, pharmacotherapy and psychosocial). RESULTS: This review included 28 CPGs of varying qualities. CPGs from high-income countries and international organizations rated high for their methodological quality. Most CPGs scored high for the scope and purpose domain and scored low for applicability domain. Recommendations for the continuum of care for OUD varied across CPGs. Buprenorphine was recommended in most of the CPGs, followed by methadone. Recommendations for psychosocial interventions also varied, with cognitive behaviour therapies and counselling or education being the common recommendations in many CPGs WHAT IS NEW AND CONCLUSION: We found most CPGs have scope and purpose and clarity of presentation. However, the methodological rigour and applicability scored low. CPGs need to frame health questions in a comprehensible manner and provide an update as evidence grows. It is important for CPG developers to consider methodological quality as a factor when developing CPG recommendations.

What Happens to Our Neuromuscular Patients in Adulthood: Pathway to Independence and Maximal Function.

BACKGROUND: Children with neuromuscular disorders regularly seek care from pediatric orthopaedic surgeons. These conditions can have a significant impact on the growth and development of children and their function and well-being as adults. Questions exist about the long-term outcomes of musculoskeletal interventions performed during childhood. METHODS: A search of recent literature pertaining to the musculoskeletal and functional consequences of cerebral palsy, spina bifida, Duchenne muscular dystrophy, and spinal muscle atrophy was performed. Information from those articles was combined with the experience of the authors and their institutions. RESULTS: Neuromuscular conditions can result in limb and spine deformities that lead to impaired physical function. Orthopaedic interventions during childhood can improve function and well-being and can be durable into adulthood. Unfortunately, many individuals with these conditions transition to adult health care that lacks the informed, collaborative multidisciplinary care they received as children. This can lead to unmet health care needs and a shortage of long-term natural history and outcome studies that would inform the care of children today. CONCLUSIONS: Adults with childhood-onset neuromuscular conditions need, and deserve, dedicated health care systems that include the best aspects of the care they received as children. Pediatric orthopaedic surgeons have a role in promoting the development of such systems and a responsibility to learn from their adult patients. LEVEL OF EVIDENCE: Expert Opinion.

Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms.

BACKGROUND: The literature examining healthcare-associated infections (HAI) points to two main problems in conforming to infection prevention and control (IPC) guidelines among healthcare professionals (HP). One is the discrepancy between HPs' behavioral intentions and their implementation in practice. The other refers to how HPs maintain these practices after the intervention stage ends. The method proposed in this study seeks to address both these issues by using the Positive Peviance (PD) approach to focus on the dissemination stage of interventions. The study seeks to offer a method for disseminating 27 PD practices to 135 HPs, among them nurses, nurse assistants and physicians, so as to help them maintain IPC guidelines, offer feedback on the dissemination process and examine the impact of the dissemination stage on changes in their behavior. METHODS: The theoretical model underlying this qualitative research was the Recognition-Primed dDecision (RPD) model, which we implemented in the field of healthcare-associated infections (HAIs). Moreover, we used the Discovery & Action Dialogue (DAD) and Think Aloud (TA) techniques to describe the methodological development of simulations for HPs. Feedback from the HP demonstrators underwent content analysis, while descriptive statistics were used to characterize behavioral changes. RESULTS: HPs' information processing regarding infection prevention shifts from peripheral/automatic processing to intuition and analytical/central processing, turning PD practices into positive norms. The HPs personally experienced finding a solution and made repeated corrections until they overcame the barriers. Most of the HPs (69.4%) reported that the practices were fully implemented, together with additional practices. CONCLUSIONS: Implementation of the dissemination stage indicates that in order for HPs to integrate and assimilate practices that are not in the official guidelines, merely observing simulations is not sufficient. Rather, each staff member must personally carry out the procedures.

Post-ICU Care in the Outpatient Setting.

More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually, and an increasing percentage of patients treated in the ICU survive to hospital discharge. Because these patients require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications. Risk factors for complications after ICU discharge include previous ICU admissions, preexisting mental illness, greater number of comorbidities, and prolonged mechanical ventilation or higher opioid exposure while in the ICU. Early nutritional support and mobilization in the ICU decrease the risk of complications. After ICU discharge, patients should be screened for depression, anxiety, insomnia, and cognitive impairment using standardized screening tools. Physicians should also inquire about weakness, fatigue, neuropathy, and functional impairment and perform a targeted physical examination and laboratory evaluation as indicated; treatment depends on the underlying cause. Exercise regimens are beneficial for reducing several post-ICU complications. Patients who were treated for COVID-19 in the ICU may require additional instruction on reducing the risk of virus transmission. Telemedicine and telerehabilitation allow patients with COVID-19 to receive effective care without increasing exposure risk in communities, hospitals, and medical offices.

[Experience of care and daily life during national sanitary confinement in patients followed and treated in Cancer Control Centers: The BaroCov Inquiry]. / Expérience des soins et de la vie quotidienne pendant le confinement sanitaire national chez des patients suivis et traités en centre de lutte contre le cancer : l'enquête BaroCov.

Confinement within the framework of Covid 19 required organizations in cancer centers, in particular with postponing certain treatments. We interviewed 6080 patients who had a scheduled appointment during this period. 2478 patients gave their opinion regarding access and organization of care, teleconsultation, their concerns and their reasons for satisfaction. While 83 % of them say they are satisfied with the organization of care, 25 % of respondents say they have given up care that they consider essential in 1/3 of cases. The concern related to the follow-up of the cancerous disease takes precedence over that of being infected with the Sars-cov-2 virus, unlike the general population, and relationships with their loved ones are spontaneously cited as a reason for satisfaction. This method captures the experience of patients, despite certain limitations. Such an approach could be used to set up a specific system during normal periods.

Quality of Preventive and Chronic Illness Care for Insured Adults With Opioid Use Disorder.

Importance: Nearly all initiatives to improve care for individuals with opioid use disorder (OUD) have focused on improving OUD identification and treatment. Whether individuals with OUD have lower quality of care than individuals without OUD remains unclear. Objective: To measure quality of non-OUD preventive and chronic illness care and care coordination for individuals with OUD compared with individuals without OUD. Design, Setting, and Participants: A cross-sectional study of deidentified data on outpatients throughout the US was conducted. Claims for 79 372 commercially insured and Medicare Advantage enrollees aged 18 years or older with diagnosis codes for OUD between January 1, 2018, and December 31, 2019, and 46 601 individuals without OUD were included in the analysis. Exposure: Diagnosis of OUD. Main Outcomes and Measures: Quality indicator performance was calculated, using claims for individuals with OUD and matched comparators without OUD. Within 3 domains of outpatient care quality (preventive care, chronic illness care, and care coordination), 6 indicators used in accountability programs were selected. Performance for individuals with and without OUD was compared, and logistic regression was used to analyze sociodemographic and comorbidity characteristics associated with higher quality of health care. Results: The study included 125 973 individuals, including 69 466 (55.1%) women and 78 225 (62.1%) White individuals, with a mean (SD) age of 59.0 (16.1) years. For the preventive care measure examining breast cancer screening, performance for the OUD cohort was 55.4% (95% CI, 54.7%-56.0%) compared with 65.6% (95% CI, 64.4%-66.7%) for individuals without OUD (P < .001). Quality of care for adherence to statin therapy was lower for individuals with OUD (70.4%; 95% CI, 68.7%-72.1%) compared with individuals without OUD (76.7%; 95% CI, 74.4%-78.7%) (P < .001) and for the hemoglobin A1c testing indicator (OUD: 80.9%; 95% CI, 80.4%-81.5%; comparator: 85.8%; 95% CI, 84.9%-86.8%; P < .001). Care coordination quality also was lower for individuals with OUD compared with those without OUD for mental health follow-up (OUD: 45.3%; 95% CI, 44.6%-46.0%; comparator: 52.5%; 95% CI, 50.0%-55.0%; P < .001) and for potentially avoidable hospitalizations for chronic conditions (OUD: 11.4%; 95% CI, 11.2%-11.7%; comparator: 8.8%; 95% CI, 8.3%-9.2%; P < .001) and diabetes, where a lower score indicates higher quality (OUD: 2.4%; 95% CI, 2.3%-2.5%; comparator: 1.9%; 95% CI, 1.7%-2.1%; P = .001). Conclusions and Relevance: These findings suggest that individuals with OUD have moderately lower quality of care across preventive and chronic illness care and care coordination for non-OUD care compared with individuals without OUD. More attention to measurement and improvement of non-OUD care for these individuals is needed.

Patients with inflammatory bowel disease on immunosuppressive drugs: perspectives' on COVID-19 and health care service during the pandemic.

BACKGROUND AND AIMS: Patients with inflammatory bowel diseases (IBD) have experienced changes to the routine management because of the SARS-CoV-2 pandemic. The aim of this study was to examine patients with IBD's adherence to the restrictions imposed by society and the hospital, worries and concerns regarding medical treatment and clinical follow-up under the pandemic. METHODS: IBD patients (≥18 years) at the outpatient clinic at Oslo University Hospital were included and answered a self-report questionnaire including concerns regarding their disease, medical therapy and follow-up during SARS-CoV-2 pandemic. RESULTS: In total, 522 IBD patients were included, 317 Crohn's disease, 205 ulcerative colitis, 386 patients <50 years. Eighteen percent were in obligatory quarantine, and more often patients <50 years compared to patients ≥50 years. Five patients tested positive to SARS- CoV-2. A higher proportion <50 years reported worries for their medical treatment and risk of COVID -19 disease compared to those ≥50 years. Forty percent avoided family, two-thirds avoided friends, and 4% cancelled their scheduled consultation at the hospital. The hospital changed physical consultation to telephone consultation for 15% of the patients. The preferred follow-up was physical consultation. A higher proportion of the patients <50 years preferred telephone consultation compared to those ≥50 years. Four out of five IBD patients were satisfied with the information about their IBD and COVID-19. CONCLUSIONS: SARS-CoV-2 pandemic affects the daily lives for patients with IBD. It is important to develop evidence-base guidelines in follow-up and treatment, as well as patient information about COVID-19and IBD.

Examining the hurdles in defining the practice of Nurse Navigators.

BACKGROUND: Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care. PURPOSE: A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident. DISCUSSION: Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance. CONCLUSION: Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

Real-world Compliance With Percutaneous Tibial Nerve Stimulation Maintenance Therapy in an American Population.

OBJECTIVE: To evaluate percutaneous tibial nerve stimulation (PTNS) maintenance therapy dropout rates and identify factors associated with compliance in an American population. METHODS: We retrospectively queried our PTNS database for patients from 2014-2019. Demographic, relevant clinical, and visit data were collected. Maintenance therapy was patient-driven and frequency of sessions was tapered based on symptomology. Upon completion of 12 initial sessions, we assessed dropout from maintenance at 3, 6, 9, and 12 months. Multiple variables were tested for correlation with dropout in patients continuing maintenance therapy for 1 year vs those who dropped out. RESULTS: One hundred and sixty-three PTNS patients were identified, of which 104 completed initial therapy and 81 proceeded with maintenance therapy. At 3, 6, 9, and 12 months, maintenance continuation rates were 77.8% (63/81), 58.0% (47/81), 45.6% (37/81), and 39.5% (32/41), respectively. Primary reasons for dropout were worsening of urinary symptoms/lack of efficacy (n = 21), time commitment (n = 9), loss of insurance (n = 5), medical comorbidities (n = 4), request for alternative OAB treatment (n = 2), and unknown (n = 8). On both univariate and multivariate analysis, perceived symptom improvement (P<.01; HR = 0.02, P< .01) was associated with continuing maintenance therapy. On only univariate analysis, neurological history (P = .02) and multiple sclerosis history (0.02) were associated with continuing therapy. CONCLUSION: Only 39.5% of patients continue to undergo maintenance PTNS therapy after 1 year. Future studies are required to understand and ameliorate factors for low compliance in PTNS maintenance therapy.