To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.
Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an ...Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.
The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.
Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.
Children with care for acute illness available through the Health-e-Access telemedicine model at childcare and schools were previously found to have 22% less emergency department (ED) use than ...counterparts without this service, but they also had 24% greater acute care use overall.
We assessed the hypothesis that increased utilization reflected improved access among impoverished inner-city children to a level experienced by more affluent suburban children. This observational study compared utilization among children without and with telemedicine access, beginning in 1993, ending in 2007, and based on 84,287 child-months of billing claims-based observation.
Health-e-Access Telemedicine was initiated in stepwise manner over 187 study-months among 74 access sites (childcare, schools, community centers), beginning in month 105. Children dwelled in inner city, rest-of-city Rochester, NY, or in surrounding suburbs. Rate of total acute care visits (office, ED, telemedicine) was measured as visits per 100 child-years. Observed utilization rates were adjusted in multivariate analysis for age, sex, insurance type, and season of year.
When both suburban and inner-city children lacked telemedicine access, overall acute illness visits were 75% greater among suburban than inner-city children (suburban:inner-city rate ratio 1.75, p < 0.0001). After telemedicine became available to inner-city children, their overall acute visits approximated those of suburban children (suburban:inner-city rate ratio 0.80, p = 0.07), whereas acute visits among suburban children remained at least (worst-case comparison) 56% greater than inner-city children without telemedicine (rate ratio 1.56, p < 0.0001).
At baseline, overall acute illness utilization of suburban children exceeded that of inner-city children. Overall utilization for inner-city children increased with telemedicine to that of suburban children at baseline. Without telemedicine, however, inner-city use remained substantially less than for suburban counterparts.
Health-e-Access Telemedicine redressed socioeconomic disparities in acute care access in the Rochester area, thus contributing to a more equitable community.
•Race-ethnic disparities in cardiovascular conditions emerge early in the life course.•Race-ethnic disparities in cardiovascular conditions do not mirror socioeconomic disparities.•Black-White ...disparities in cardiovascular conditions vary considerably by gender.
To document gender-specific racial-ethnic disparities in cardiovascular (CV) conditions and risk factors net of socioeconomic status (SES) across the lifespan.
Using pooled data from the 1999 to 2016 U.S. National Health and Nutrition Examination Survey, we document gender-specific proportions of non-Hispanic Whites, non-Hispanic Blacks, and Hispanics ages 12–69 years with various socioeconomic characteristics and CV conditions. We then further disaggregate into 10-year age groups and present unadjusted and SES-adjusted prevalence of each CV condition for each gender/racial-ethnic/age group.
Racial-ethnic differences in the prevalence of CV conditions are large for some conditions, emerge early in adulthood, and remain relatively constant though age 69. Only small proportions of the differences can be attributed to differences in SES across groups; attenuation after adjusting for income, education, and available measures of wealth ranged from 0 to 2.3 percentage points. Black-White differences in prevalence of CV conditions differ substantially and systematically by gender; White females have larger advantages or smaller disadvantages (depending on indicator) relative to Black females than White males do relative to Black males.
Racial-ethnic disparities in CV conditions are rooted early in the life course, do not mirror socioeconomic disparities, and vary considerably by gender. Explanations likely involve early life experiences such as racial discrimination and entrenched inequality.
Despite the high rate of anxiety in individuals with autism spectrum disorder (ASD), measuring anxiety in ASD is fraught with uncertainty. This is due, in part, to incomplete consensus on the ...manifestations of anxiety in this population. Autism Speaks assembled a panel of experts to conduct a systematic review of available measures for anxiety in youth with ASD. To complete the review, the panel held monthly conference calls and two face-to-face meetings over a fourteen-month period. Thirty eight published studies were reviewed and ten assessment measures were examined: four were deemed appropriate for use in clinical trials, although with conditions; three were judged to be potentially appropriate, while three were considered not useful for clinical trials assessing anxiety. Despite recent advances, additional relevant, reliable and valid outcome measures are needed to evaluate treatments for anxiety in ASD.
Neuropathy is a common and potentially disabling complication of adjuvant taxane therapy. Recent studies have identified candidate single nucleotide polymorphisms associated with taxane-induced ...neuropathy. Therefore, we sought to determine whether neuropathy was associated with breast cancer recurrence in a clinical trial population who received adjuvant taxane therapy.
Trial E1199 included 4,554 eligible women with operable breast cancer who received up to four cycles of doxorubicin and cyclophosphamide every 3 weeks followed by paclitaxel 175 mg/m(2) every 3 weeks for four cycles (P3), paclitaxel 80 mg/m(2) weekly for 12 cycles (P1), docetaxel 100 mg/m(2) every 3 weeks for four cycles (D3), or docetaxel 35 mg/m(2) weekly for 12 cycles (D1). A Cox proportional hazards model was used to determine the relationship between neuropathy and disease-free survival (DFS), overall survival (OS), and recurrence-free survival (RFS) by treating neuropathy status as a time dependent covariate and using a landmark analysis.
Of 4,554 patients who received at least one taxane dose, grade 2 to 4 neuropathy developed in 18%, 22%, 15%, and 13% of patients in the P3, P1, D3, and D1 arms, respectively. In a model that included age, race, obesity, menopausal status, tumor size, nodal status, treatment arm, neuropathy, and hyperglycemia, no significant relationship was found between neuropathy and DFS, OS, or RFS.
There was no association between taxane-induced neuropathy and outcome.
To estimate the extent of activity and participation of individuals 6 months poststroke and their influence on health-related quality of life (QOL) and overall QOL, information that would be useful ...in identifying services that stroke patients would need in the community.
Inception cohort study.
Ten acute care hospitals in metropolitan areas of the province of Quebec.
Persons with first-ever stroke, either ischemic or hemorrhagic. In parallel, a population-based sample of community-dwelling individuals without stroke, frequency matched in age and city district, were also recruited.
Not applicable.
Stroke subjects were interviewed by telephone at 6-month intervals for 2 years of follow-up. The community-dwelling individuals without stroke were also followed.
A total of 434 persons were interviewed approximately 6 months poststroke. Their average age +/- standard deviation was 68.4+/-12.5 years; the average age of the 486 controls was 61.7+/-12.4 years. The stroke group scored on average 90.6/100 on the Barthel Index; 39% reported a limitation in functional activities, 54% reported limitations with higher-level activities of daily living such as housework and shopping, and 65% reported restrictions in reintegration into community activities. By using the Medical Outcomes 36-Item Short-Form Health Survey (SF-36), persons with stroke rated their physical health 7 points lower than healthy peers; also, 7 of the 8 subscales of the SF-36 were affected by stroke.
Almost 50% of the community-dwelling stroke population lived with sequelae of stroke such that, unless there was a full-time and able-bodied caregiver at home, they needed some form of home help. A large proportion also reported lack of meaningful activity, indicating a need for organized support groups for people with stroke; otherwise, boredom will lead to depression and worsening of function, affect, health status, and QOL.
The Stroke Canada Optimization of Rehabilitation by Evidence-Implementation Trial (SCORE-IT) showed that a facilitated knowledge translation (KT) approach to implementing a stroke rehabilitation ...guideline was more likely than passive strategies to improve functional walking capacity, but not gross manual dexterity, among patients in rehabilitation hospitals. This paper presents the results of a planned process evaluation designed to assess whether the type and number of recommended treatments implemented by stroke teams in each group would help to explain the results related to patient outcomes.
As part of a cluster randomized trial, 20 rehabilitation units were stratified by language and allocated to a facilitated or passive KT intervention group. Sites in the facilitated group received the guideline with treatment protocols and funding for a part-time nurse and therapist facilitator who attended a 2-day training workshop and promoted guideline implementation for 16 months. Sites in the passive group received the guideline excluding treatment protocols. As part of a process evaluation, nurses, and occupational and physical therapists, blinded to study hypotheses, were asked to record their implementation of 18 recommended treatments targeting motor function, postural control and mobility using individualized patient checklists after treatment sessions for 2 weeks pre- and post-intervention. The percentage of patients receiving each treatment pre- and post-intervention and between groups was compared after adjusting for clustering and covariates in a random-effects logistic regression analysis.
Data on treatment implementation from nine and eight sites in the facilitated and passive KT group, respectively, were available for analysis. The facilitated KT intervention was associated with improved implementation of sit-to-stand (p = 0.028) and walking (p = 0.043) training while the passive KT intervention was associated with improved implementation of standing balance training (p = 0.037), after adjusting for clustering at patient and provider levels and covariates.
Despite multiple strategies and resources, the facilitated KT intervention was unsuccessful in improving integration of 18 treatments concurrently. The facilitated approach may not have adequately addressed barriers to integrating numerous treatments simultaneously and complex treatments that were unfamiliar to providers.
Unique identifier- NCT00359593.
Objectives: To evaluate the efficacy of a task‐oriented walking intervention in improving balance self‐efficacy in persons with stroke and to determine whether effects were task‐specific, influenced ...by baseline level of self‐efficacy and associated with changes in walking and balance capacity.
Design: Secondary analysis of a two‐center, observer‐blinded, randomized, controlled trial.
Setting: General community.
Participants: Ninety‐one individuals with a residual walking deficit within 1 year of a first or recurrent stroke.
Intervention: Task‐oriented interventions targeting walking or upper extremity (UE) function were provided three times a week for 6 weeks.
Measurements: Activities‐specific Balance Confidence Scale, Six‐Minute Walk Test, 5‐m walk, Berg Balance Scale, and Timed “Up and Go” administered at baseline and postintervention.
Results: The walking intervention was associated with a significantly greater average proportional change in balance self‐efficacy than the UE intervention. Treatment effects were largest in persons with low self‐efficacy at baseline and for activities relating to tasks practiced. In the walking group, change in balance self‐efficacy correlated with change in functional walking capacity (correlation coefficient=0.45, 95% confidence interval=0.16–0.68). Results of multivariable modeling suggested effect modification by the baseline level of depressive symptoms and a prognostic influence of age, sex, comorbidity, time poststroke, and functional mobility on change in self‐efficacy.
Conclusion: Task‐oriented walking retraining enhances balance self‐efficacy in community‐dwelling individuals with chronic stroke. Benefits may be partially the result of improvement in walking capacity. The influence of baseline level of self‐efficacy, depressive symptoms, and prognostic variables on treatment effects are of clinical importance and must be verified in future studies.
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