RESUMO
BACKGROUND: Expanding access to shorter regimens for tuberculosis (TB) prevention, such as once-weekly isoniazid and rifapentine taken for 3 months (3HP), is critical for reducing global TB burden among people living with HIV (PLHIV). Our coprimary hypotheses were that high levels of acceptance and completion of 3HP could be achieved with delivery strategies optimized to overcome well-contextualized barriers and that 3HP acceptance and completion would be highest when PLHIV were provided an informed choice between delivery strategies. METHODS AND FINDINGS: In a pragmatic, single-center, 3-arm, parallel-group randomized trial, PLHIV receiving care at a large urban HIV clinic in Kampala, Uganda, were randomly assigned (1:1:1) to receive 3HP by facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), or informed choice between facilitated DOT and facilitated SAT using a shared decision-making aid. We assessed the primary outcome of acceptance and completion (≥11 of 12 doses of 3HP) within 16 weeks of treatment initiation using proportions with exact binomial confidence intervals (CIs). We compared proportions between arms using Fisher's exact test (two-sided α = 0.025). Trial investigators were blinded to primary and secondary outcomes by study arm. Between July 13, 2020, and July 8, 2022, 1,656 PLHIV underwent randomization, with equal numbers allocated to each study arm. One participant was erroneously enrolled a second time and was excluded in the primary intention-to-treat analysis. Among the remaining 1,655 participants, the proportion who accepted and completed 3HP exceeded the prespecified 80% target in the DOT (0.94; 97.5% CI [0.91, 0.96] p < 0.001), SAT (0.92; 97.5% CI [0.89, 0.94] p < 0.001), and Choice (0.93; 97.5% CI [0.91, 0.96] p < 0.001) arms. There was no difference in acceptance and completion between any 2 arms overall or in prespecified subgroup analyses based on sex, age, time on antiretroviral therapy, and history of prior treatment for TB or TB infection. Only 14 (0.8%) participants experienced an adverse event prompting discontinuation of 3HP. The main limitation of the study is that it was conducted in a single center. Multicenter studies are now needed to confirm the feasibility and generalizability of the facilitated 3HP delivery strategies in other settings. CONCLUSIONS: Short-course TB preventive treatment was widely accepted by PLHIV in Uganda, and very high levels of treatment completion were achieved in a programmatic setting with delivery strategies tailored to address known barriers. TRIAL REGISTRATION: ClinicalTrials.gov NCT03934931.
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Infecções por HIV , Tuberculose Latente , Rifampina/análogos & derivados , Tuberculose , Humanos , Isoniazida/efeitos adversos , Tuberculose/tratamento farmacológico , Tuberculose/prevenção & controle , Antituberculosos/efeitos adversos , Uganda , Tuberculose Latente/tratamento farmacológico , Quimioterapia Combinada , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológicoRESUMO
PURPOSE: To use a mixed methods approach to investigate the patient waiting experience for a medically underserved population at an outpatient surgical clinic. METHODS: We used lean methodology to perform 96 time-tracked observations of the patient journey in clinic, documenting the duration of activities from arrival to departure. We also used human-centered design (HCD) to perform and analyze 43 semi-structured interviews to understand patients' unmet needs. RESULTS: Patients spent an average of 68.5% of their total clinic visit waiting to be seen. While the average visit was 95.8 minutes, over a quarter of visits (27%) were over 2 hours. Patients waited an average of 24.4 minutes in the waiting room and 41.2 minutes in the exam room; and only spent 19.7% of their visit with an attending provider and 11.8% with a medical assistant. Interviews revealed that patients arrive to their visit already frustrated due to difficulties related to scheduling and attending their appointment. This is exacerbated during the visit due to long wait times, perceived information opacity, and an uncomfortable waiting room, resulting in frustration and anxiety. CONCLUSIONS: While time tracking demonstrated that patients spend a majority of their visit waiting to be seen, HCD revealed that patient frustrations span the waiting experience from accessing the appointment to visit completion. These combined findings are crucial for intervention design and implementation for medically underserved populations to improve the quality and experience with healthcare and also address system inefficiencies such as long wait times.
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Instituições de Assistência Ambulatorial , Área Carente de Assistência Médica , Humanos , Assistência AmbulatorialRESUMO
BACKGROUND: Adherence to and completion of tuberculosis (TB) treatment remain problematic in many high-burden countries. 99DOTS is a low-cost digital adherence technology that could increase TB treatment completion. METHODS AND FINDINGS: We conducted a pragmatic stepped-wedge cluster-randomized trial including all adults treated for drug-susceptible pulmonary TB at 18 health facilities across Uganda over 8 months (1 December 2018-31 July 2019). Facilities were randomized to switch from routine (control period) to 99DOTS-based (intervention period) TB treatment supervision in consecutive months. Patients were allocated to the control or intervention period based on which facility they attended and their treatment start date. Health facility staff and patients were not blinded to the intervention. The primary outcome was TB treatment completion. Due to the pragmatic nature of the trial, the primary analysis was done according to intention-to-treat (ITT) and per protocol (PP) principles. This trial is registered with the Pan African Clinical Trials Registry (PACTR201808609844917). Of 1,913 eligible patients at the 18 health facilities (1,022 and 891 during the control and intervention periods, respectively), 38.0% were women, mean (SD) age was 39.4 (14.4) years, 46.8% were HIV-infected, and most (91.4%) had newly diagnosed TB. In total, 463 (52.0%) patients were enrolled on 99DOTS during the intervention period. In the ITT analysis, the odds of treatment success were similar in the intervention and control periods (adjusted odds ratio [aOR] 1.04, 95% CI 0.68-1.58, p = 0.87). The odds of treatment success did not increase in the intervention period for either men (aOR 1.24, 95% CI 0.73-2.10) or women (aOR 0.67, 95% CI 0.35-1.29), or for either patients with HIV infection (aOR 1.51, 95% CI 0.81-2.85) or without HIV infection (aOR 0.78, 95% CI 0.46-1.32). In the PP analysis, the 99DOTS-based intervention increased the odds of treatment success (aOR 2.89, 95% CI 1.57-5.33, p = 0.001). The odds of completing the intensive phase of treatment and the odds of not being lost to follow-up were similarly improved in PP but not ITT analyses. Study limitations include the likelihood of selection bias in the PP analysis, inability to verify medication dosing in either arm, and incomplete implementation of some components of the intervention. CONCLUSIONS: 99DOTS-based treatment supervision did not improve treatment outcomes in the overall study population. However, similar treatment outcomes were achieved during the control and intervention periods, and those patients enrolled on 99DOTS achieved high treatment completion. 99DOTS-based treatment supervision could be a viable alternative to directly observed therapy for a substantial proportion of patients with TB. TRIAL REGISTRATION: Pan-African Clinical Trials Registry (PACTR201808609844917).
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Antituberculosos/uso terapêutico , Adesão à Medicação/estatística & dados numéricos , Tecnologia/estatística & dados numéricos , Tuberculose Pulmonar/tratamento farmacológico , Adulto , Análise por Conglomerados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Uganda , Adulto JovemRESUMO
BACKGROUND: Scaling up shorter regimens for tuberculosis (TB) prevention such as once weekly isoniazid-rifapentine (3HP) taken for 3 months is a key priority for achieving targets set forth in the World Health Organization's (WHO) END TB Strategy. However, there are few data on 3HP patient acceptance and completion in the context of routine HIV care in sub-Saharan Africa. METHODS AND FINDINGS: The 3HP Options Trial is a pragmatic, parallel type 3 effectiveness-implementation randomized trial comparing 3 optimized strategies for delivering 3HP-facilitated directly observed therapy (DOT), facilitated self-administered therapy (SAT), or informed choice between DOT and SAT using a shared decision-making aid-to people receiving care at a large urban HIV clinic in Kampala, Uganda. Participants and healthcare providers were not blinded to arm assignment due to the nature of the 3HP delivery strategies. We conducted an interim analysis of participants who were enrolled and exited the 3HP treatment period between July 13, 2020 and April 30, 2021. The primary outcome, which was aggregated across trial arms for this interim analysis, was the proportion who accepted and completed 3HP (≥11 of 12 doses within 16 weeks of randomization). We used Bayesian inference analysis to estimate the posterior probability that this proportion would exceed 80% under at least 1 of the 3HP delivery strategies, a coprimary hypothesis of the trial. Through April 2021, 684 participants have been enrolled, and 479 (70%) have exited the treatment period. Of these 479 participants, 309 (65%) were women, mean age was 41.9 years (standard deviation (SD): 9.2), and mean time on antiretroviral therapy (ART) was 7.8 years (SD: 4.3). In total, 445 of them (92.9%, 95% confidence interval (CI): [90.2 to 94.9]) accepted and completed 3HP treatment. There were no differences in treatment acceptance and completion by sex, age, or time on ART. Treatment was discontinued due to a documented adverse event (AE) in 8 (1.7%) patients. The probability that treatment acceptance and completion exceeds 80% under at least 1 of the three 3HP delivery strategies was greater than 99%. The main limitations are that the trial was conducted at a single site, and the interim analysis focused on aggregate outcome data to maintain blinding of investigators to arm-specific outcomes. CONCLUSIONS: 3HP was widely accepted by people living with HIV (PLHIV) in Uganda, and very high levels of treatment completion were achieved in a programmatic setting. These findings show that 3HP can enable effective scale-up of tuberculosis preventive therapy (TPT) in high-burden countries, particularly when delivery strategies are tailored to target known barriers to treatment completion. TRIAL REGISTRATION: ClinicalTrials.gov NCT03934931.
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Antituberculosos/uso terapêutico , Terapia Diretamente Observada , Isoniazida/uso terapêutico , Rifampina/análogos & derivados , Tuberculose/prevenção & controle , Adulto , Terapia Diretamente Observada/classificação , Quimioterapia Combinada , Feminino , Infecções por HIV/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Rifampina/uso terapêutico , UgandaRESUMO
BACKGROUND: Extreme disparities in access, experience, and outcomes highlight the need to transform how pregnancy care is designed and delivered in the United States, especially for low-income individuals and people of color. METHODS: We used human-centered design (HCD) to understand the challenges facing Medicaid-insured pregnant people and design interventions to address these challenges. The HCD method has three phases: Inspiration, Ideation, and Implementation. This study focused on the first and second. In the Inspiration phase we conducted semi-structured interviews with a purposeful sample of stakeholders who had either received or participated in the care of Medicaid-insured pregnant people within our community, with a specific emphasis on representation from marginalized communities. Using a general inductive approach to thematic analysis, we identified themes, which were then framed into design opportunities. In the Ideation phase, we conducted structured brainstorming sessions to generate potential prototypes of solutions, which were tested and iterated upon through a series of community events and engagement with a diverse community advisory group. RESULTS: We engaged a total of 171 stakeholders across both phases of the HCD methodology. In the Inspiration phase, interviews with 23 community members and an eight-person focus group revealed seven insights centered around two main themes: (1) racism and discrimination create major barriers to access, experience, and the ability to deliver high-value pregnancy care; (2) pregnancy care is overmedicalized and does not treat the pregnant person as an equal and informed partner. In the Ideation phase, 162 ideas were produced and translated into eight solution prototypes. Community scoring and feedback events with 140 stakeholders led to the progressive refinement and selection of three final prototypes: (1) implementing telemedicine (video visits) within the safety-net system, (2) integrating community-based peer support workers into healthcare teams, and (3) delivering co-located pregnancy-related care and services into high-need neighborhoods as a one-stop shop. CONCLUSIONS: Using HCD methodology and a collaborative community-health system approach, we identified gaps, opportunities, and solutions to address perinatal care inequities within our urban community. Given the urgent need for implementable and effective solutions, the design process was particularly well-suited because it focuses on understanding and centering the needs and values of stakeholders, is multi-disciplinary through all phases, and results in prototyping and iteration of real-world solutions.
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Assistência Perinatal , Desenho Universal , Criança , Feminino , Grupos Focais , Humanos , Recém-Nascido , Medicaid , Gravidez , Cuidado Pré-Natal , Estados UnidosRESUMO
BACKGROUND: Care teams on complex surgical services face a growing list of competing expectations. Approaches to quality improvement must use minimal resources and address both system and human requirements to meet expectations without compromising care. The purpose of this study was to demonstrate that iterative prototyping, combined with a rigorous quantitative evaluation approach, can effectively improve system and stakeholder efficiency on daily trauma surgical rounds at an academic safety-net hospital and level 1 trauma center. MATERIALS AND METHODS: This study occurred between May 2017 and October 2017 at the Zuckerberg San Francisco General Hospital and Trauma Center. Care team members rounding on the trauma service included attending trauma surgeons, fellows, residents, interns, nurse practitioners, pharmacists, and medical students. We used human-centered design to develop and test solutions to improve the surgical rounding process. Each prototype was evaluated using qualitative design research methods, which informed the next iteration. Time observations of rounding activities were adopted from the Lean methodology and tracked before and after implementation. Intern work hours, on-time operative starts, and discharge order times were also tracked before and after implementation. RESULTS: Four prototypes were designed and iteratively implemented, producing care team satisfaction by the end of the implementation period. Discharge order times decreased by a median of 58 min, intern work hours were decreased by 97 min/d, and first operative case on-time starts increased from 40% to 63% (P < 0.05). The time spent on clarifications decreased by 4.7% (P < 0.05), allowing for more time to discuss care plans with the patients themselves. CONCLUSIONS: Iterative prototyping as part of a human-centered design methodology is a powerful tool to address complex systems with diverse interests and competing priorities. Rapid, in-context prototyping is feasible on a complex trauma surgical service and can result in improved workflows and efficiency for the system and its stakeholders.
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Eficiência Organizacional , Equipe de Assistência ao Paciente/organização & administração , Melhoria de Qualidade , Visitas de Preceptoria/organização & administração , Centros de Traumatologia/organização & administração , Centros Médicos Acadêmicos/organização & administração , Humanos , Motivação , Estudos Prospectivos , Pesquisa Qualitativa , Provedores de Redes de Segurança/organização & administração , Participação dos Interessados , Desenho Universal , Fluxo de TrabalhoRESUMO
Historically, medical trainees were educated in the hospital on real patients. Over the last decade, there has been a shift to practicing skills through simulations with mannequins or patient actors. Virtual reality (VR), and in particular, the use of 360-degree video and audio (cineVR), is the next-generation advancement in medical simulation that has novel applications to augment clinical skill practice, empathy building, and team training. In this paper, we describe methods to design and develop a cineVR medical education curriculum for trauma care training using real patient care scenarios at an urban, safety-net hospital and Level 1 trauma center. The purpose of this publication is to detail the process of finding a cineVR production partner; choosing the camera perspectives; maintaining patient, provider, and staff privacy; ensuring data security; executing the cineVR production process; and building the curriculum.
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Simulação por Computador/normas , Educação Médica/métodos , Treinamento por Simulação/métodos , Realidade Virtual , Humanos , Ferimentos e LesõesRESUMO
BACKGROUND: Trauma patient rounds are complex, with a high volume of complicated patients in a dynamic environment with competing priorities and workflows. This presents challenges to quality improvement as single-method research approaches fail to comprehensively understand these complex systems. We used a mixed-methods approach to understand factors contributing to system inefficiency and user dissatisfaction on daily patient rounds at a safety-net teaching hospital and level 1 trauma center. MATERIALS AND METHODS: A human-centered design uses ethnographic observations and in-depth interviews to understand the challenges and needs facing users of a system. We performed in-context observations and 22 in-depth interviews with a cross-section of care team members, patients, and families. Using the lean methodology, we performed time observations of 15 rounds, tracking activities related to flow, and classified them as 'value added' and 'non-value added.' RESULTS: Lean time observations revealed that 34.2% of time was spent on 'non-value-added' activities. Qualitative interviews revealed that all users reported perceived inefficiency as their greatest challenge on rounds. Among these users, there were three distinct user groups: connectors, learners, and doers, and each group had a different set of needs and priorities for rounds which were not being met. CONCLUSIONS: To adequately address complex environments, we need to understand the strains on both the system and its users so that we can create sustainable quality-improvement programs. By mixing methods using lean and human-centered design processes, we were able to gain a more comprehensive understanding of the system- and human-centered factors affecting rounds on a trauma surgical service.
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Eficiência , Visitas de Preceptoria/estatística & dados numéricos , Centros de Traumatologia , HumanosAssuntos
Anestesia/efeitos adversos , Anestesiologia , Pesquisa Biomédica , Falha da Terapia de Resgate , Equipe de Respostas Rápidas de Hospitais , Monitorização Intraoperatória , Diagnóstico Precoce , Humanos , Segurança do Paciente , Período Perioperatório , Valor Preditivo dos Testes , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Medição de Risco , Fatores de RiscoRESUMO
Families of newborns are frequently referred to child protection systems because of parental substance use, yet many families face barriers to accessing prenatal care and substance use treatment services. Although federal legislation requires states to develop Plans of Safe Care to address families' health and substance use treatment needs, few have developed comprehensive and systematic approaches to provide perinatal support to parents and infants. In this commentary, we describe the development and initial testing of a Plan of Safe Care that engages patients and their providers in perinatal care coordination. Developed out of an in-depth analysis of current care workflows at an urban safety net health system, the Plan of Safe Care facilitates conversations with clients around delivery planning and aligns resources to support families with substance use disorders.
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Assistência Perinatal , Transtornos Relacionados ao Uso de Substâncias , Criança , Lactente , Gravidez , Feminino , Humanos , Recém-Nascido , Cuidado Pré-Natal , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p<0.001). People with TB received SMS dosing reminders on 90.5% of treatment days. Health worker support actions were documented for 261/409 (63.8%) people with TB who missed >3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.
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CONTEXT: Medical students receive little exposure to organ donation and procurement programs. OBJECTIVE: To describe a student-run elective and its effect on participants' knowledge about and attitudes toward organ donation. INTERVENTION: Preclinical students interacted directly with donor families, organ recipients, and donation representatives; many participated in an organ procurement with the surgical team. DESIGN: Between 2005 and 2007, 13 students who participated in the elective and a procurement were compared with 72 students who took the elective but did not participate in a procurement and with 22 control students. Students who participated in a procurement wrote reflections about their experience. In 2010, 15 first-year students who participated in the elective and a procurement and 59 randomly selected control students completed a previously validated measure. OUTCOME: Themes included awe, surgical procedures, learning opportunities, and brain death. Regardless of procurement participation, the elective participants from 2005 to 2007 reported higher 4-item knowledge scores (P<.001) than control students reported, but their 4-item attitude scores did not differ (P = .21). The 2010 students did not differ from control students in their number of correct responses to the 20 knowledge questions (P = .48) or their individual responses to each of the 14 attitude questions (all P>.05). RESULTS: Although elective participants reflected positively on their experiences and professed greater knowledge than control students via a researcher-made tool, these results were not sustained with a previously validated measure. These results point to the need for careful elective design and the need for more accurate measures to study the effectiveness of such interventions.
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Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Estudantes de Medicina/psicologia , Obtenção de Tecidos e Órgãos , Adulto , Feminino , Humanos , Masculino , Adulto JovemRESUMO
BACKGROUND: It is estimated that over half of medical students experience severe distress, a condition that correlates with low mental quality-of-life, suicidal ideation and serious thoughts of dropping out. While several risk factors for the development of severe distress have been identified, most focus on individual student characteristics. Currently, little is known about the impact medical schools have on student wellbeing. METHODS: Prospective, observational survey study from 2019-2020 from a national cohort of US medical students. Student wellbeing, school characteristics, and wellbeing resource availability was measured with a 30-question electronic survey. Medical student distress was defined as a Medical Student Wellbeing Index (MS-WBI) of ≥4. Risk factors for the development of severe distress were evaluated in a multivariate logistic regression model. The impact of the number of wellbeing resources available on student wellbeing was measured along multiple wellbeing domains. Independent reviewers categorized free text analysis of survey responses about desired wellbeing resources into themes. RESULTS: A total of 2,984 responses were included in the study, representing 45 unique medical schools. Medical school characteristics independently associated with severe distress included low faculty support (OR 4.24); the absence of mentorship resources (OR 1.63) and the absence of community building programs (OR 1.45) in a multivariate model. Increased availability of wellbeing resources was associated with lower average MS-WBI (4.58 vs. 3.19, p<0;05) and a smaller percentage of students who had taken or considered taking a leave of absence (40% vs. 16%, p<0.05). The resources most desired by students were mental health services and scheduling adjustments. CONCLUSIONS: The majority of medical school characteristic that contribute to student distress are modifiable. Improving faculty support and offering more and varied wellbeing resources may help to mitigate medical student distress. Student feedback is insightful and should be routinely incorporated by schools to guide wellbeing strategies.
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Faculdades de Medicina , Estudantes de Medicina , Docentes , Humanos , Estudos Prospectivos , Fatores de Risco , Estudantes de Medicina/psicologiaRESUMO
OBJECTIVE: To use architectural mapping to understand how patients and families utilize the waiting space at an outpatient surgery clinic in a safety-net hospital. BACKGROUND: The waiting period is an important component of patient experience and satisfaction. Studies have found that patients value privacy, information transparency and comfort. However, approaches common in the architecture field have rarely been used to investigate interactions between patients and the built environment in a safety-net healthcare setting. METHODS: This was a prospective observational study in a general surgery outpatient clinic at a safety-net hospital and level 1 trauma center. We used a web-based application generated from the design and architecture industry, to quantitatively track waiting space utilization over 2 months. RESULTS: A total of 728 observations were recorded across 5 variables: time, location, chair selection, person/object, and activity. There were 536 (74%) observations involving people and 179 (25%) involving personal items. People most frequently occupied chairs facing the door (43%, n = 211), and least frequently occupied seats in the hallway (5%, n = 23), regardless of the time of their appointment (p-value = 0.92). Most common activities included interacting with personal phone, gazing into space, and talking face to face. Thirteen percent of people brought mobility devices, and 64% of objects were placed on an adjacent chair, indicating the desire for increased personal space. CONCLUSION: Architectural behavioral mapping is an effective information gathering tool to help design waiting space improvement in the safety-net healthcare setting.
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Provedores de Redes de Segurança , Salas de Espera , Humanos , Instituições de Assistência Ambulatorial , Satisfação do Paciente , Agendamento de ConsultasRESUMO
BACKGROUND: The large-scale social distancing efforts to reduce SARS-CoV-2 transmission have dramatically changed human behaviors associated with traumatic injuries. Trauma centers have reported decreases in trauma volume, paralleled by changes in injury mechanisms. We aimed to quantify changes in trauma epidemiology at an urban Level I trauma center in a county that instituted one of the earliest shelter-in-place orders to inform trauma care during future pandemic responses. METHODS: A single-center interrupted time-series analysis was performed to identify associations of shelter-in-place with trauma volume, injury mechanisms, and patient demographics in San Francisco, California. To control for short-term trends in trauma epidemiology, weekly level data were analyzed 6 months before shelter-in-place. To control for long-term trends, monthly level data were analyzed 5 years before shelter-in-place. RESULTS: Trauma volume decreased by 50% in the week following shelter-in-place (p < 0.01), followed by a linear increase each successive week (p < 0.01). Despite this, trauma volume for each month (March-June 2020) remained lower compared with corresponding months for all previous 5 years (2015-2019). Pediatric trauma volume showed similar trends with initial decreases (p = 0.02) followed by steady increases (p = 0.05). Reductions in trauma volumes were due entirely to changes in nonviolent injury mechanisms, while violence-related injury mechanisms remained unchanged (p < 0.01). CONCLUSION: Although the shelter-in-place order was associated with an overall decline in trauma volume, violence-related injuries persisted. Delineating and addressing underlying factors driving persistent violence-related injuries during shelter-in-place orders should be a focus of public health efforts in preparation for future pandemic responses. LEVEL OF EVIDENCE: Epidemiological study, level III.
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COVID-19 , Transmissão de Doença Infecciosa/prevenção & controle , Abuso Físico/estatística & dados numéricos , Distanciamento Físico , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões , Adulto , COVID-19/epidemiologia , COVID-19/prevenção & controle , Criança , Correlação de Dados , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Estudos Retrospectivos , SARS-CoV-2 , São Francisco/epidemiologia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Preclinical education plays a pivotal role in improving the quality of patient care and safety. Early exposure to surgical skills training and surgical mentors enhance students' retention and confidence in those skills, and may promote their interest in surgery. METHODS: Based upon a needs assessment survey of surgical education at UCSF, we introduced a curriculum to teach basic surgical techniques in the preclinical years with the intent of emphasizing several important skills and providing students with exposure to surgical mentors in a small group environment. We then surveyed the students to assess satisfaction with the new curriculum and the effect on perceptions regarding a career in surgery. RESULTS: Rising fourth y students at UCSF identified the need for increased exposure to basic surgical skills in preparation for third y clerkships. Collaboration between the Departments of Anatomy and Surgery subsequently produced an integrated suturing curriculum in the anatomy lab as part of the first y medical school coursework. The curriculum offered a focused exposure to skills identified by senior students as important for their clinical rotations. The vast majority of respondents agreed or strongly agreed that the exercise was enjoyable and worth continuing, and that their interactions with the surgeon volunteers were positive. Furthermore, 33% stated that their interest in surgery increased after the exercise. Qualitative comments praised both the experience and surgical faculty participation. CONCLUSION: A needs-based surgical skills curriculum can be integrated into the traditional first-y anatomy course without detracting from didactic instruction in anatomy. Furthermore, students received early exposure to surgical mentors and skills training, which may translate into greater confidence on the wards and increased interest in surgical careers.
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Anatomia/educação , Competência Clínica , Cirurgia Geral/educação , Currículo , Humanos , Laboratórios , Avaliação das Necessidades , Estudos Retrospectivos , Técnicas de Sutura/educaçãoRESUMO
BACKGROUND: In 2012, over half of US medical students experienced burnout and depression. Since that time, there have been many changes to student demographics, school resources and awareness of burnout in the medical field altogether. New tools are also available to screen for student distress, a condition that correlates with low mental quality-of-life, suicidal ideation and serious thoughts of dropping out. Despite increased attention on wellbeing and improved screening methods, no large-scale studies have evaluated student distress in the modern era of medical education. The objective of this study was to determine the current prevalence of medical student distress and contributing risk factors. METHODS: Student wellbeing from a national cohort of US medical students was measured with an electronic survey in a prospective, observational survey study from 2019-2020. Medical student distress was defined as a Medical Student Wellbeing Index (MS-WBI) of ≥4. Demographic details including age, race, gender, marital status, disability, desired specialty, and debt burden were evaluated in a multivariate logistic regression model to determine possible risk factors for the development of distress. RESULTS: A total of 3,162 students responded to the survey, representing 110 unique medical schools. Of these respondents, 52.9% met criteria for distress and 22% had either taken or considered taking a leave of absence for personal wellbeing. Independent risk factors for distress included involvement in the clinical phase of medical school (OR 1.37); non-male gender (OR 1.6); debt burden >$20,000 (OR 1.37), >$100,000 (OR 1.81), and >$300,000 (OR 1.96); and disability status (OR 1.84). CONCLUSIONS: Medical student wellbeing remains poor in the modern era of medical education despite increased attention to wellbeing and increased availability of wellbeing resources. Disability status is a novel risk factor for distress identified in this study. The persistence of previously identified risk factors such as non-male gender, debt burden and clinical phase of school suggest that efforts to curb medical student distress have been inadequate to date.
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Estresse Psicológico/psicologia , Estudantes de Medicina/psicologia , Estudantes de Medicina/estatística & dados numéricos , Adulto , Esgotamento Profissional/epidemiologia , Depressão/epidemiologia , Educação Médica/economia , Educação Médica/métodos , Feminino , Humanos , Masculino , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , Faculdades de Medicina , Estresse Psicológico/epidemiologia , Ideação Suicida , Inquéritos e Questionários , Apoio ao Desenvolvimento de Recursos Humanos , Adulto JovemRESUMO
BACKGROUND: As the coronavirus disease 2019 (COVID-19) pandemic continues to spread, swift actions and preparation are critical for ensuring the best outcomes for patients and providers. We aim to describe our hospital and Department of Surgery's experience in preparing for the COVID-19 pandemic and caring for surgical patients during this unprecedented time. STUDY DESIGN: This is a descriptive study outlining the strategy of a single academic health system for addressing the following 4 critical issues facing surgical departments during the COVID-19 pandemic: developing a cohesive leadership team and system for frequent communication throughout the department; ensuring adequate hospital capacity to care for an anticipated influx of COVID-19 patients; safeguarding supplies of blood products and personal protective equipment to protect patients and providers; and preparing for an unstable workforce due to illness and competing personal priorities, such as childcare. RESULTS: Through collaborative efforts within the Department of Surgery and hospital, we provided concise and regular communication, reduced operating room volume by 80%, secured a 4-week supply of personal protective equipment, and created reduced staffing protocols with back-up staffing plans. CONCLUSIONS: By developing an enabling infrastructure, a department can nimbly respond to crises like COVID-19 by promoting trust among colleagues and emphasizing an unwavering commitment to excellent patient care. Sharing principles and practical applications of these changes is important to optimize responses across the country and the world.
Assuntos
Infecções por Coronavirus/epidemiologia , Hospitais Universitários/organização & administração , Pneumonia Viral/epidemiologia , Centro Cirúrgico Hospitalar/organização & administração , Comitês Consultivos , Betacoronavirus , COVID-19 , Comunicação , Humanos , Controle de Infecções , Salas Cirúrgicas/estatística & dados numéricos , Pandemias , Equipamento de Proteção Individual/provisão & distribuição , Recursos Humanos em Hospital , SARS-CoV-2 , Cirurgiões , Procedimentos Cirúrgicos OperatóriosRESUMO
BACKGROUND: Digital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes. OBJECTIVE: This study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase. METHODS: 99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency with the predetermined design principles. Prototypes were revised with feedback from the entire team. The envelope and call-in experience prototypes were tested and iteratively revised through focus groups with health workers (n=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration. RESULTS: The 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. The flap was adorned with either a blank calendar or map of Uganda. The inside cover contained a personalized message from a local health worker including contact information, pictorial pill-taking instructions, and a choice of stickers to tailor education to the patient and phase of treatment. Pill-taking order was indicated with colors, chevron arrows, and small mobile phone icons. Last, the call-in experience when patients report dosing was changed to a rotating series of audio messages centered on the themes of prevention, encouragement, and reassurance that tuberculosis is curable. CONCLUSIONS: We demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes.