Registered Nurses' Well-Being, Michigan, 2022.

Objectives. To examine nurses' well-being and identify individual and workplace factors associated with adverse outcomes. Methods. We administered an e-mail survey to registered nurses in Michigan in March 2022. Outcomes included the Oldenburg Burnout Inventory-Exhaustion scale, self-harm thoughts (yes/no), and overall wellness on a 0 to 10 visual analog scale. Covariates included practice environment, psychological safety, workplace abuse, staffing adequacy, stress coping strategies, and demographics. We examined associations between covariates and exhaustion, thoughts of self-harm (both via logistic regression), and overall wellness (via linear regression). Results. Among surveyed nurses, 93.63% reported significant exhaustion, 9.88% reported self-harm thoughts, and the mean (SD) overall wellness score was 6.2 (2.3). Factors associated with exhaustion included inadequate staffing, lower psychological safety, and younger age. Factors associated with self-harm thoughts included recent workplace physical abuse and younger age. Factors associated with higher wellness scores included employer support, favorable practice environments, higher job satisfaction, and positive coping strategies. Conclusions. Negative well-being outcomes were prevalent among registered nurses and were associated with correctable workplace deficits. Nurses' well-being is a national public health problem that warrants comprehensive interventions at individual, workplace, and community levels. (Am J Public Health. 2024;114(S2):S180-S188. https://doi.org/10.2105/AJPH.2023.307376).

Association between accelerometry measured patterns of sedentary behaviors and functional status in older adults.

BACKGROUND: Older adults are highly sedentary, and too much sedentary behavior (SB) is associated with negative health effects, but little is known about SB patterns and their associations with functional status. AIMS: To examine the association between objectively measured sedentary behavior time (SBT) and sedentary behavior fragmentation (SBF) and functional status in older adults using the National Health Aging Trends Study (NHATS) dataset, a nationally representative sample from 2021. METHODS: Data from NHATS were analyzed using weighted linear regressions to examine the association between objective measures of SBT (mean hours spent in SB/day during waking hours) and SBF, and six functional variables (difficulties with activities of daily living [ADL], short physical performance battery, hand grip strength, immediate word recall, delayed word recall, and mental health), accounting for sociodemographic, body mass index, and the number of chronic conditions. RESULTS: A total of 738 individuals from the NHATS were included. Higher SBT was associated with greater difficulties with ADL, poorer short physical performance battery and hand grip strength, lower scores in both immediate and delayed word recall, and poorer mental health. Higher SBF was associated with fewer difficulties with ADL, better short physical performance battery and hand grip strength, a higher score in immediate word recall, and better mental health. DISCUSSIONAND CONCLUSIONS: Greater fragmentation of SB was associated with better function, and increasing SBF may be a useful strategy for mitigating the effects of SB in older adults, but prospective research is needed to support this approach.

Patterns and Correlates of Nurse Departures From the Health Care Workforce: Results From a Statewide Survey.

BACKGROUND: Health care executives and policymakers have raised concerns about the adequacy of the US nursing workforce to meet service demands. Workforce concerns have risen given the SARS-CoV-2 pandemic and chronically poor working conditions. There are few recent studies that directly survey nurses on their work plans to inform possible remedies. METHODS: In March 2022, 9150 nurses with a Michigan license completed a survey on their plans to leave their current nursing position, reduce their hours, or pursue travel nursing. Another 1224 nurses who left their nursing position within the past 2 years also reported their reasons for departure. Logistic regression models with backward selection procedures estimated the effects of age, workplace concerns, and workplace factors on the intent to leave, hour reduction, pursuit of travel nursing (all within the next year), or departure from practice within the past 2 years. RESULTS: Among practicing nurses surveyed, 39% intended to leave their position in the next year, 28% planned to reduce their clinical hours, and 18% planned to pursue travel nursing. Top-ranked workplace concerns among nurses were adequate staffing, patient safety, and staff safety. The majority of practicing nurses (84%) met the threshold for emotional exhaustion. Consistent factors associated with adverse job outcomes include inadequate staffing and resource adequacy, exhaustion, unfavorable practice environments, and workplace violence events. Frequent use of mandatory overtime was associated with a higher likelihood of departure from the practice in the past 2 years (Odds Ratio 1.72, 95% CI 1.40-2.11). CONCLUSIONS: The factors associated with adverse job outcomes among nurses-intent to leave, reduced clinical hours, travel nursing, or recent departure-consistently align with issues that predated the pandemic. Few nurses cite COVID as the primary cause for their planned or actual departure. To maintain an adequate nursing workforce in the United States, health systems should enact urgent efforts to reduce overtime use, strengthen work environments, implement anti-violence protocols, and ensure adequate staffing to meet patient care needs.

Challenging the 50-50 rule for the basal-bolus insulin ratio in patients with type 2 diabetes who maintain stable glycaemic control.

BACKGROUND: For patients using basal-bolus insulin therapy, it is widespread clinical practice to aim for a 50-50 ratio between basal and total daily bolus. However, this practice was based on a small study of individuals without diabetes. To assess the rule in real-world practice, we retrospectively analyzed patients on basal-bolus therapy that was adjusted at least weekly by an artificial intelligence-driven titration within the d-Nav® Insulin Management Technology. MATERIALS AND METHODS: We obtained de-identified data from the Diabetes Centre of Ulster Hospital for patients with four inclusion criteria: type 2 Diabetes (T2D), on d-Nav >6 months, on basal-bolus insulin therapy >80% of the time (based on insulin analogs), and no gap in data >3 months. RESULTS: We assembled a cohort of 306 patients, followed by the d-Nav service for 3.4 ± 1.8 years (mean ± SD), corresponding to about 180 autonomous insulin dose titrations and about 5000 autonomous individual dose recommendations per patient. After an initial run-in period, mean glycated hemoglobin (HbA1c) values in the cohort were maintained close to 7%. Surprisingly, in just over three-quarters of the cohort, the average basal insulin fraction was <50%; in half of the cohort average basal insulin fraction <41.2%; and in one-quarter the basal insulin fraction was <33.6%. Further, the basal insulin fraction did not remain static over time. In half of the patients, the basal insulin fraction varied by ≥1.9×; and, in 25% of the patients, ≥2.5×. CONCLUSION: Our data show that a 50-50 ratio of basal-to-bolus insulin does not generally apply to patients with T2D who successfully maintain stable glycemia. Therefore, the 50-50 ratio should not serve as an ongoing treatment guide. Moreover, our results emphasize the importance of at least weekly insulin titrations.

Cost-effectiveness of carotid artery stenting vs endarterectomy: A simulation.

OBJECTIVE: Clinical trials conducted before the introduction of modern medical management to prevent stroke demonstrated that carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke following transient ischemic attack (TIA). We compared the cost-effectiveness of CEA, CAS, and modern medical management in two secular settings of medical management in individuals with incident TIA and type 2 diabetes. METHODS: Using simulation modeling, our base-case analyses were performed from the healthcare sector perspective over a 20-year time horizon with an annual 3% discount rate applied to both costs and quality-adjusted life years (QALYs). Outcomes depended on age, sex, biomarkers associated with cardiovascular risk, and treatment effects based on a validated model of type 2 diabetes. Our simulation population was drawn from the National Health and Nutrition Examination Survey (NHANES) 2014 cohort. Costs for modern medical management were based on average wholesale prices, and revascularization costs were derived from published literature. One-way and probabilistic sensitivity analyses were conducted. RESULTS: Compared to all other strategies, historical medical management plus CEA was either cost-saving or cost-effective at a threshold of $100,000 per QALY gained. Modern medical management was cost-effective compared to historical medical management without revascularization at a $100,000 acceptability threshold. However, both revascularization approaches (plus medical management) were cost-saving compared to modern medical management alone. CONCLUSION: Among individuals requiring carotid revascularization, carotid endarterectomy is the cost-effective strategy to treat individuals with type 2 diabetes following a TIA. For individuals for whom revascularization is contraindicated, modern medical therapy is cost-effective.

Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach.

BACKGROUND: The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE. OBJECTIVE: Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens. METHODS: We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift. RESULTS: From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys). INTERPRETATION: Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review.

Older adults in assisted living facilities (ALF) are at risk for low physical activity (PA) and high sedentary behavior (SB), both of which place them at risk for negative health outcomes. The purpose of this scoping review was to synthesize evidence describing the volume of device-measured PA/SB, factors associated with PA/SB, and interventions designed to change PA/SB in older adults living in ALF. Twenty articles representing 15 unique studies were identified from eight electronic databases and grey literature. Residents in ALF spent 96-201 min/day in light PA (n = 2 studies), 1-9.74 min/day in moderate to vigorous PA (n = 2 studies), and 8.5-11.01 hr/day of SB during waking hours (n = 3 studies). Factors associated with PA included 16 personal factors (n = 6 articles), one social factor (n = 2 articles), and two environmental factors (n = 2 articles). Factors associated with SB included 14 personal factors (n = 4 articles) and one social factor (n = 1 article). No intervention successfully changed PA/SB.

Retention and weight outcomes after transitioning an intensive behavioral weight management program from an in-person to a virtual format.

Background: Virtual care offers many potential advantages over traditional in-person care for people with chronic diseases including obesity. Before the COVID-19 pandemic, virtual care was not broadly implemented because of regulatory, legal, and reimbursement barriers. Objective: To evaluate the impact of the transition from an entirely in-person format to a virtual format during the COVID-19 pandemic on retention and weight reduction in a 2-year, structured, intensive behavioral weight management program for people with moderate to severe obesity. Methods: Retrospective cohort study of 1313 program participants stratified according to the phase of the program during which the transition to virtual visits occurred. Results: Age, sex, and baseline weight were independent predictors of program retention. Transition to virtual visits was associated with greater 2-year program retention. Retention but not mode of program delivery was associated with reduction in weight at 2-year. Conclusions: Transition from in-person to virtual program delivery improved retention and by doing so, indirectly improved weight loss at 2 years. Telemedicine has the potential to overcome many of the limitations associated with traditional in-person weight loss interventions. Clinical Trial Registration: This research was reviewed and approved by the University of Michigan Institutional Review Board and registered on ClinicalTrials.gov (NCT02043457). All participants provided written informed consent.

Biopsychosocial Attributes of Single-region and Multi-region Body Pain During Early Adolescence: Analysis of the ABCD Cohort.

OBJECTIVES: Multi-region pain during adolescence is associated with a higher symptom burden and lower quality of life. The purpose of this study was to describe and compare the biopsychosocial attributes of single-region and multi-region pain among healthy young adolescents. MATERIALS AND METHODS: We analyzed data from 10,320 children aged 10.6 to 14 years who self-reported pain in the Adolescent Brain and Cognitive Development Study. Pain was coded as single-region or multi-region based on body map data. RESULTS: One in 5 young adolescents indicated recent multi-region pain. Sequential regression supported improved model fit when psychological and sociocultural factors were added to a biological model of pain; however, these models improved the classification of multi-region but not single-region pain. A significant interaction effect of sex and puberty remained constant across models with increased odds of pain at each advancing pubertal stage for both sexes compared with prepuberty, but no difference between girls and boys at late puberty (adjusted odds ratio [OR]=2.45 [1.72, 3.49] and adjusted OR=1.63 [1.20, 2.23], respectively). Psychological factors improved the classification of multi-region pain with significant effects of anxiety, somatic symptoms, and somnolence. Finally, compared with White and non-Hispanic children, Black and Hispanic children were less likely to report pain (adjusted OR=0.70 [0.61, 0.80]; adjusted OR=0.88 [0.78, 0.99], respectively) but had significantly higher pain interference when pain was present (adjusted OR=1.49 [1.29, 1.73] and adjusted OR=1.20 [1.06, 1.35], respectively). DISCUSSION: Pain is a biopsychosocial phenomenon, but psychological and sociocultural features may be more relevant for multi-region compared with single-region pain during early adolescence.

Tolerance of esophageal pressure monitoring during polysomnography in children.

OBJECTIVES: To assess tolerance of esophageal pressure monitoring (EPM) among 5- to 13-year-old children during research polysomnography at study entry and again 1 year later. DESIGN: Prospective, observational study. SETTING: University-based sleep laboratory. PARTICIPANTS: Children scheduled for adenotonsillectomy or hernia repair. INTERVENTIONS: None; all operations were performed for clinical indications only. RESULTS: Forty-two of 336 families approached about the study declined to participate mainly to avoid EPM. The EPM was usually the main concern for the 47 adenotonsillectomy and 7 hernia-repair patients and families who did participate. Among 54 enrolled subjects, 51 allowed attempts at insertion of the esophageal catheter, and insertion was successful in all cases; 38 tolerated EPM for at least 2 hours; 33 maintained EPM for the entire night; and 36 had repeat EPM 1 year later for at least 2 hours. Reasons for EPM failure included crying at insertion, vomiting, pain, and inadvertent catheter removal during sleep. The children who tolerated EPM for at least 2 hours did not differ from other subjects based on age, sex, presence of a disruptive behavior disorder, anxiety, tonsil size, history of tonsillitis, or body mass index (all P > .05). CONCLUSIONS: The EPM was well tolerated in most school-aged volunteers, but many families did not volunteer, and some children were not able to endure EPM for at least 2 hours. Although better success might be achieved in clinical settings if EPM is medically indicated and not part of voluntary research, EPM is still likely to create significant concern, for children and parents, that must be weighed against anticipated benefits.

Polysomnography in children scheduled for adenotonsillectomy.

OBJECTIVE: Several studies suggest that a reliable diagnosis of childhood sleep-disordered breathing (SDB) requires polysomnography (PSG). We compared clinical and PSG-based diagnoses in children scheduled for adenotonsillectomy (AT). Parent responses on a validated Pediatric Sleep Questionnaire were used to determine which symptoms could help identify children with clinical diagnoses of SDB but normal PSG. STUDY DESIGN AND SETTING: Thirty-four children aged 5.0 to 12.9 years and scheduled for AT to treat clinically diagnosed sleep-disordered breathing underwent laboratory-based PSG. Results were scored by 3 different criteria: 1) >1 obstructive apnea (2 breaths or longer) per hour of sleep; 2) >5 apneas or hypopneas per hour of sleep; or 3) >1 apnea, hypopnea, or respiratory event-related arousal per hour of sleep. RESULTS: Depending on the criterion used, the PSG documented SDB from a minimum of 18/34 subjects (53%, for criterion I) to as many as 30/34 subjects (88%, for criterion III). Among symptoms studied, absence of daytime mouth breathing and habitual snoring were most helpful in identification of children who had no evidence of SDB on PSG, by criterion I (Chi-square, P < 0.05). The absence of other common symptoms, such as "loud snoring" or "trouble breathing" at night, were not helpful. CONCLUSION: Children with clinical diagnoses of SDB may not consistently meet PSG criteria for this disorder. Questions about daytime mouth breathing and habitual snoring might help clinicians recognize children who would not have SDB on objective testing. SIGNIFICANCE: Clinical identification of SDB confirmable on PSG could be improved. However, available outcome data do not yet clarify whether clinical or PSG criteria best identify children likely to suffer morbidity from SDB. EBM RATING: C.