Abstract Purpose An isolated focus on 1 disease at a time is insufficient to generate the scientific evidence needed to improve the health of persons living with more than 1 chronic condition. This ...article explores how to bring context into research efforts to improve the health of persons living with multiple chronic conditions (MCC). Methods Forty-five experts, including persons with MCC, family and friend caregivers, researchers, policy makers, funders, and clinicians met to critically consider 4 aspects of incorporating context into research on MCC: key contextual factors, needed research, essential research methods for understanding important contextual factors, and necessary partnerships for catalyzing collaborative action in conducting and applying research. Results Key contextual factors involve complementary perspectives across multiple levels: public policy, community, health care systems, family, and person, as well as the cellular and molecular levels where most research currently is focused. Needed research involves moving from a disease focus toward a person-driven, goal-directed research agenda. Relevant research methods are participatory, flexible, multilevel, quantitative and qualitative, conducive to longitudinal dynamic measurement from diverse data sources, sufficiently detailed to consider what works for whom in which situation, and generative of ongoing communities of learning, living and practice. Important partnerships for collaborative action include cooperation among members of the research enterprise, health care providers, community-based support, persons with MCC and their family and friend caregivers, policy makers, and payers, including government, public health, philanthropic organizations, and the business community. Conclusion Consistent attention to contextual factors is needed to enhance health research for persons with MCC. Rigorous, integrated, participatory, multimethod approaches to generate new knowledge and diverse partnerships can be used to increase the relevance of research to make health care more sustainable, safe, equitable and effective, to reduce suffering, and to improve quality of life.
Fitness bands are widely available and assist with tracking the number of steps taken. However, for older people with slow gaits, shorter step widths and/or use of ambulatory devices, the accuracy of ...fitness bands for step counting has not been well studied. Using four commercially available fitness bands (Garmin Vivofit2™, Fitbit Flex™, Up3™ and Microsoft Band™), we studied 30 older people with varying ambulatory abilities. We videotaped participants walking and compared the videotaped step count with the fitness band counts. Only 5 of the 30 participants had accurate readings within a ±20 percent accuracy for all four bands. There was no relationship between the step speed and accuracy of the fitness bands. Participants using walkers and walking sticks had none of the bands that met the ±20 percent accuracy. Canes were more variable with accuracy. Fitness band manufacturers may need to tune their algorithms for use by older people.
Although data obtained from regional trauma systems demonstrate improved outcomes for children treated at pediatric trauma centers (PTCs) compared with those treated at adult trauma centers (ATCs), ...differences in mortality have not been consistently observed for adolescents. Because trauma is the leading cause of death and acquired disability among adolescents, it is important to better define differences in outcomes among injured adolescents by using national data.
To use a national data set to compare mortality of injured adolescents treated at ATCs, PTCs, or mixed trauma centers (MTCs) that treat both pediatric and adult trauma patients and to determine the final discharge disposition of survivors at different center types.
Data from level I and II trauma centers participating in the 2010 National Trauma Data Bank (January 1 to December 31, 2010) were used to create multilevel models accounting for center-specific effects to evaluate the association of center characteristics (PTC, ATC, or MTC) on mortality among patients aged 15 to 19 years who were treated for a blunt or penetrating injury. The models controlled for sex; mechanism of injury (blunt vs penetrating); injuries sustained, based on the Abbreviated Injury Scale scores (post-dot values <3 or ≥3 by body region); initial systolic blood pressure; and Glasgow Coma Scale scores. Missing data were managed using multiple imputation, accounting for multilevel data structure. Data analysis was conducted from January 15, 2013, to March 15, 2016.
Type of trauma center.
Mortality at each center type.
Among 29 613 injured adolescents (mean SD age, 17.3 1.4 years; 72.7% male), most were treated at ATCs (20 402 68.9%), with the remainder at MTCs (7572 25.6%) or PTCs (1639 5.5%). Adolescents treated at PTCs were more likely to be injured by a blunt than penetrating injury mechanism (91.4%) compared with those treated at ATCs (80.4%) or MTCs (84.6%). Mortality was higher among adolescents treated at ATCs and MTCs than those treated at PTCs (3.2% and 3.5% vs 0.4%; P < .001). The adjusted odds of mortality were higher at ATCs (odds ratio, 4.19; 95% CI, 1.30-13.51) and MTCs (odds ratio, 6.68; 95% CI, 2.03-21.99) compared with PTCs but was not different between level I and II centers (odds ratio, 0.76; 95% CI, 0.59-0.99).
Mortality among injured adolescents was lower among those treated at PTCs, compared with those treated at ATCs and MTCs. Defining resource and patient features that account for these observed differences is needed to optimize adolescent outcomes after injury.
BACKGROUND/OBJECTIVES
Over a million older patients in the United States are admitted yearly for emergency general surgery (EGS) conditions. Seven procedure types dominate: colon, small bowel, ...gallbladder, ulcer disease, adhesiolysis, appendix, and laparotomy operations. A higher comorbidity burden is known to increase mortality in this population, but the impact of specific comorbidity combinations is unknown. Our objectives were to (1) characterize the distribution of procedures, comorbidities, and outcomes for older patients undergoing EGS; and (2) apply a data‐driven approach (association rule mining) to identify comorbidity combinations associated with disproportionately high mortality.
DESIGN, SETTING, AND PARTICIPANTS
Cross‐sectional study of patients 65 years and older who underwent one of the seven procedures previously cited, taken from the 2011 Nationwide Inpatient Sample. A total of 280 885 patient encounters were identified.
MEASUREMENTS
In‐hospital mortality, procedures, and comorbidities based on the Elixhauser Comorbidity Index.
RESULTS
Overall mortality was 5.6%. The most common procedures were gallbladder (33.7%), ulcer surgery (21.5%), and adhesiolysis (21.0%). Mortality increased for all procedures as patients aged. Comorbidities associated with the highest mortality included coagulopathy (adjusted odds ratio aOR = 3.74; 95% confidence interval CI = 3.41–4.11; p < .001), fluid and electrolyte disorders (FED) (aOR = 2.89; 95% CI = 3.66–3.14; p < .001), and liver disease (aOR = 1.89; 95% CI = 1.61–2.22; p < .001). Three‐way comorbidity combinations most highly associated with mortality were coagulopathy, FED, and peripheral vascular disease (aOR = 5.10; 95% CI = 4.17–6.24; p < .001), and coagulopathy, FED, and chronic pulmonary disease (aOR = 4.83; 95% CI = 4.00–5.82; p < .001).
CONCLUSION
For older patients, combinations of comorbidities portend additional risk beyond single comorbidities, and the associated risk burden is driven by the specific constellation of comorbidities present. Future work must continue to examine the effect of co‐occurring diseases to provide personalized and realistic prognostication for older patients undergoing EGS. J Am Geriatr Soc 67:503–510, 2019.
Highlights • The proliferation of electronic medical records (EMR) provides a rich source of clinical data. • Currently, no standardized approach has been proposed to assess data completeness. • The ...six-step data quality framework can guide standardized metadata assessment. • Applying the same assessment framework can lead to standardized reporting in research.
Measuring Quality in Home Healthcare Dick, Andrew W.; Murray, Meghan T.; Chastain, Ashley M. ...
Journal of the American Geriatrics Society,
September 2019, Volume:
67, Issue:
9
Journal Article
Peer reviewed
Open access
BACKGROUND/OBJECTIVES
Improving quality performance in home health is an increasingly high priority. The objective of this study was to examine trends in industry performance over time using three ...quality measures: a composite quality metric (Q index), an infection prevention measure (vaccination verification), and an outcome measure (hospital avoidance).
DESIGN/SETTING/PARTICIPANTS/MEASURES
We linked Home Health Compare and Provider of Services data from 2012 to 2016, which included 39 211 observations during the 5‐year study period and 7670 agencies in 2016. The Q index was developed to allow comparability over time, equally weighting the contributions of each element. After examining summary statistics, we developed three regression models stratified by ownership (for‐profit/nonprofit agency) and included two constructs of nurse staffing, in addition to controlling for known confounders.
RESULTS
Most agencies (80.4%) were for‐profit agencies. The Q index and vaccination verification improved substantially over time, but there was no change in hospital avoidance. Ownership status was associated with all three measures (P < .001). Registered nurse staffing (relative to licensed practical nurses and home health aides) was associated with higher Q index and vaccination verification (P < .001).
CONCLUSION
The Q index allows for assessment of trends over time in home healthcare. Ownership and nurse staffing are important factors in the quality of care. The overall home care market is driven by for‐profit agencies, but their characteristics and outcomes differ from nonprofit agencies. J Am Geriatr Soc 67:1859–1865, 2019
Despite growing demand for home care nursing, there is a growing home care workforce shortage, due in part to hospital-centric nursing curricula that lead students to undervalue of home care and ...community practice setting (Van Iersel et al., 2018a, 2018b).
Articulate an international vision for the future of home care education, research, practice, and management shared by experienced home care nurses working in leadership roles.
Qualitative content analysis.
The sample included 50 home care professionals from 17 countries.
Home care nurse leaders (in education, research, practice, and management roles) were recruited through professional international nursing networks to participate in a structured online survey about priorities for the future of home care in 2014. Responses were open coded by two independent researchers. Preliminary categories and sub-themes were developed by the research team and revised after a modified member-checking process that included presentation and discussion of preliminary findings at three international nursing meetings in 2015 and 2016.
Four major themes emerged reflecting international priorities for the future of home care education, research, practice, and management: 1) Build the evidence base for home care; 2) Design better systems of care; 3) Develop leaders at all levels; and 4) Address payment and policy issues.
Collectively, the findings provide a major call to action for nurse educators to re-design existing pre- and post-licensure educational programs to meet the growing demand for home care nurses. Innovations in education that focus on filling gaps in the evidence-base for community nursing practice, and improving access to continuing education and evidence-based resources for practicing home care nurses and nurse managers should be prioritized.
•Global priorities for the future of home care education, research, practice, and management include:•A call to generate (and use) evidence-based guidelines for home care•A call to re-design health systems for home care•A call to develop home care leaders at all levels•A call to address payment and policy issues that create barriers to care
Retrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass in patients with acute mesenteric ischemia (AMI) with variable reported 30-day mortality rates. Large studies ...evaluating patient outcomes following ROMS are scarce. Our study aims to assess the results of this approach among patients presenting with AMI.
We reviewed all the patients with AMI who were treated with ROMS (2011-2022). Patient demographics, presentation, operative details, and outcomes were analyzed. Primary end points were in-hospital, 30-day, and 1-year mortality. Kaplan-Meier estimate for 1-year mortality and primary patency loss were generated. Secondary end points included postoperative 30-day complications.
Between 2011 and 2022, ROMS was attempted on a total of 42 patients. The median age was 70 ± 15 years and the majority of patients were female. Pain out of proportion to the physical examination was the most common presenting symptom (n = 18, 42.9%) followed by peritonitis (n = 14, 33.4%). All patients underwent preoperative intravenous contrast computed tomography imaging. In situ thrombosis was identified as the etiology of AMI in 36 patients (85.7%). Technical success was achieved in 40 patients (95.2%). Conventional, non-hybrid operating rooms were used for the majority of cases. Revascularization of all 40 patients involved angioplasty and stenting of superior mesenteric artery. A single stent was placed in 35 patients (87.5%) and the reminder had more than one stent. Eighty percent of patients required bowel resection. A second-look laparotomy was required in 34 patients (85.0%). The mean operative time, including both the general surgery and vascular surgery portions of the index procedure, was 192 ± 57 minutes. Sepsis was the most common complication observed within 30 days, occurring in 8 patients (20.0%). In terms of mortality, 13 patients (32.5%) died during their index hospitalization, and 9 died (22.5%) within 30 days. On Kaplan-Meier analysis, the 1-year overall patient survival rate was 58.6%, and the primary patency rate for stents was 51.4%.
ROMS has an excellent technical success rate in management of AMI with lower than traditionally reported mortality rates for AMI. The dual benefits of rapid revascularization and bowel evaluation should make this surgical modality an alternative approach for treatment of AMI.
Endovascular and hybrid methods have been increasingly used to treat mesenteric ischemia. However, the long-term outcomes and risk of symptom recurrence remain unknown. The objective of the present ...study was to define the predictors of postoperative morbidity, mortality, and patency loss for acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI).
The inpatient and follow-up records for all patients who had undergone revascularization for AMI and CMI from 2010 to 2020 at a multicenter hospital system were reviewed. Patency and mortality were evaluated with Cox regression, visualized with Kaplan-Meier curves, and compared using log-rank testing. Patency was further evaluated using Fine-Gray regression with death as a competing risk. The postoperative major adverse events (MAE) and 30-day mortality were evaluated with logistic regression.
A total of 407 patients were included, 148 with AMI and 259 with CMI. For the AMI group, the 30-day mortality was 31%. Open surgery was associated with lower rates of bowel resection (odds ratio OR, 0.23; 95% confidence interval CI, 0.13-0.61). The etiology of AMI also did not change the outcomes (OR, 1.30; 95% CI, 0.77-2.19). Adjusted analyses indicated that a history of diabetes (OR, 2.77; 95% CI, 1.37-5.61) and sepsis on presentation (OR, 2.32; 95% CI, 1.18-4.58) were independently associated with an increased risk of 30-day MAE. In the CMI group, open surgery and chronic kidney disease were associated with a higher incidence of MAE (OR, 3.03; 95% CI, 1.14-8.05; OR, 2.37; 95% CI, 1.31-4.31). In contrast, chronic kidney disease (OR, 3.02; 95% CI, 1.10-8.37) and inpatient status before revascularization (OR, 2.78; 95% CI, 1.01-7.61) were associated with increased 30-day mortality. For the CMI group, the endovascular cohort had experienced greater rates of symptom recurrence (29% vs 13%) with a faster onset (endovascular, 64 days; vs bypass, 338 days).
AMI remains a morbid disease despite the evolving revascularization techniques. An open approach should remain the reference standard because it reduces the likelihood of bowel resection. For CMI, endovascular interventions have improved the postoperative morbidity but have also resulted in early symptom recurrence and reintervention. An endovascular-first approach should be the standard of care for CMI with close surveillance.
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