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Although studies suggest that patients with limited health literacy and/or low numeracy skills may stand to gain the most from shared decision making (SDM), the impact of these conditions on the effective implementation of SDM in the emergency department (ED) is not well understood. In this article from the proceedings of the 2016 Academic Emergency Medicine Consensus Conference on Shared Decision Making in the Emergency Department we discuss knowledge gaps identified and propose consensus-driven research priorities to help guide future work to improve SDM for this patient population in the ED.
© 2016 by the Society for Academic Emergency Medicine.
PURPOSE OF REVIEW - This review is written from the perspective of the pediatric clinician involved in the care of premature infants at risk for pulmonary hypertension. The main objective is to better inform the clinician in the diagnosis and treatment of pulmonary hypertension in premature infants by reviewing the available relevant literature and focusing on the areas for which there is the greatest need for continued research.
RECENT FINDINGS - Continued knowledge regarding the epidemiology of pulmonary hypertension in the premature infant population has aided better diagnostic screening algorithms. Included in this knowledge, is the association of pulmonary hypertension in infants with bronchopulmonary dysplasia (BPD). However, it is also known that beyond BPD, low birth weight and other conditions that result in increased systemic inflammation are associated with pulmonary hypertension. This information has led to the recent recommendation that all infants with BPD should have an echocardiogram to evaluate for evidence of pulmonary hypertension prior to discharge from the neonatal ICU.
SUMMARY - Pulmonary hypertension can be a significant comorbidity for premature infants. This review aims to focus the clinician on the available literature to improve recognition of the condition to allow for more timely interventions.
Dynamic reflexivity is central to enabling flexible and emergent qualitatively driven inductive mixed-method and multiple methods research designs. Yet too often, such reflexivity, and how it is used at various points of a study, is absent when we write our research reports. Instead, reports of mixed-method and multiple methods research focus on what was done rather than how it came to be done. This article seeks to redress this absence of emphasis on the reflexive thinking underpinning the way that mixed- and multiple methods, qualitatively driven research approaches are thought about and subsequently used throughout a project. Using Morse's notion of an armchair walkthrough, we excavate and explore the layers of decisions we made about how, and why, to use qualitatively driven mixed-method and multiple methods research in a study of mindfulness training (MT) in schoolchildren.
© The Author(s) 2015.
OBJECTIVE - Healthcare analytics research increasingly involves the construction of predictive models for disease targets across varying patient cohorts using electronic health records (EHRs). To facilitate this process, it is critical to support a pipeline of tasks: (1) cohort construction, (2) feature construction, (3) cross-validation, (4) feature selection, and (5) classification. To develop an appropriate model, it is necessary to compare and refine models derived from a diversity of cohorts, patient-specific features, and statistical frameworks. The goal of this work is to develop and evaluate a predictive modeling platform that can be used to simplify and expedite this process for health data.
METHODS - To support this goal, we developed a PARAllel predictive MOdeling (PARAMO) platform which (1) constructs a dependency graph of tasks from specifications of predictive modeling pipelines, (2) schedules the tasks in a topological ordering of the graph, and (3) executes those tasks in parallel. We implemented this platform using Map-Reduce to enable independent tasks to run in parallel in a cluster computing environment. Different task scheduling preferences are also supported.
RESULTS - We assess the performance of PARAMO on various workloads using three datasets derived from the EHR systems in place at Geisinger Health System and Vanderbilt University Medical Center and an anonymous longitudinal claims database. We demonstrate significant gains in computational efficiency against a standard approach. In particular, PARAMO can build 800 different models on a 300,000 patient data set in 3h in parallel compared to 9days if running sequentially.
CONCLUSION - This work demonstrates that an efficient parallel predictive modeling platform can be developed for EHR data. This platform can facilitate large-scale modeling endeavors and speed-up the research workflow and reuse of health information. This platform is only a first step and provides the foundation for our ultimate goal of building analytic pipelines that are specialized for health data researchers.
Copyright © 2013 Elsevier Inc. All rights reserved.
ST-segment elevation myocardial infarction (STEMI) systems of care have been associated with significant improvement in use and timeliness of reperfusion. Consequently, national guidelines recommend that each community should develop a regional STEMI care system. However, significant barriers continue to impede widespread establishment of regional STEMI care systems in the United States. We designed the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator, a national educational outcome research study in collaboration with the American Heart Association, to comprehensively accelerate the implementation of STEMI care systems in 17 major metropolitan regions encompassing >1,500 emergency medical service agencies and 450 hospitals across the United States. The goals of the program are to identify regional gaps, barriers, and inefficiencies in STEMI care and to devise strategies to implement proven recommendations to enhance the quality and consistency of care. The study interventions, facilitated by national faculty with expertise in regional STEMI system organization in partnership with American Heart Association representatives, draw upon specific resources with proven past effectiveness in augmenting regional organization. These include bringing together leading regional health care providers and institutions to establish common commitment to STEMI care improvement, developing consensus-based standardized protocols in accordance with national professional guidelines to address local needs, and collecting and regularly reviewing regional data to identify areas for improvement. Interventions focus on each component of the reperfusion process: the emergency medical service, the emergency department, the catheterization laboratory, and inter-hospital transfer. The impact of regionalization of STEMI care on clinical outcomes will be evaluated.
BACKGROUND - Use of complementary and alternative medical (CAM) therapies is common among adults with mental health concerns, but little is known about CAM use among adolescents with mental health concerns.
METHODS - Data from the 2007 National Health Interview Survey were analyzed for youth from 7 to 17 years old. The study focused on 3 common mental health conditions: attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression. CAM therapy use was identified by criteria from the National Institutes of Health National Center for Complementary and Alternative Medicine.
RESULTS - In a sample of 5651 individuals, representing 7 million youth, with 1 or more mental health concerns in the past 12 months, 28.9% used 1 or more types of CAM therapy, excluding vitamins/minerals. In contrast, only 11.6% of those without mental health concerns reported CAM therapy use (P < .05). Among youth with 1 or more mental health conditions, the most commonly used CAM therapies were mind-body therapies (16.3%) and biologically based therapies (11%); use was higher for therapies that could be directly accessed (18.6%) than for therapies delivered in groups (11.8%) or through a health professional (10.2%). In the multivariable regression model, demographic factors significantly associated with CAM therapy use were higher household income, higher parental education, having other chronic health conditions, use of prescription medications, and difficulty affording mental health counseling.
CONCLUSIONS - Readily accessible CAM therapies are commonly used by youth with ADHD, depression, and anxiety, particularly those who have comorbid chronic health conditions, receive prescription medications, and have difficulty affording counseling. Clinicians can use these data to guide inquiries and counseling. Researchers should explore the longitudinal relationship between access to coordinated care within a medical home and use of CAM therapies among youth with mental health concerns.
Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
Congress established the National Health Care Workforce Commission under section 5101 of the Affordable Care Act to provide data on the health care workforce and policy advice to both Congress and the administration. Although members of the Workforce Commission were appointed September 30, 2010, Congress has been unable to appropriate the $3 million requested by the administration to fund the commission. Consequently, the commission has never met and is not operational. As a new era of insurance coverage, care delivery, and payment reforms unfolds, the commission is needed to recommend policies that would help the nation achieve the goals of increased access to high-quality care and better preparation, configuration, and distribution of the nation's health workforce. In a climate where fiscal policy is dominated by spending on health care, the commission can also stimulate innovations aimed at reducing the cost of health care and achieving greater value and transparency.
Biostatistics--the application of statistics to understanding health and biology-provides powerful tools for developing research questions, designing studies, refining measurements, analyzing data, and interpreting findings. Biostatistics plays an important role in health-related research, yet biostatistics resources are often fragmented, ad hoc, or oversubscribed within academic health centers (AHCs). Given the increasing complexity and quantity of health-related data, the emphasis on accelerating clinical and translational science, and the importance of conducting reproducible research, the need for the thoughtful development of biostatistics resources within AHCs is growing.In this article, the authors identify strategies for developing biostatistics resources in three areas: (1) recruiting and retaining biostatisticians, (2) efficiently using biostatistics resources, and (3) improving biostatistical contributions to science. AHCs should consider these three domains in building strong biostatistics resources, which they can leverage to support a broad spectrum of research. For each of the three domains, the authors describe the advantages and disadvantages of AHCs creating centralized biostatistics units rather than dispersing such resources across clinical departments or other research units. They also address the challenges that biostatisticians face in contributing to research without sacrificing their individual professional growth or the trajectory of their research teams. The authors ultimately recommend that AHCs create centralized biostatistics units because this approach offers distinct advantages both to investigators who collaborate with biostatisticians as well as to the biostatisticians themselves, and it is better suited to accomplish the research and education missions of AHCs.
BACKGROUND - Increasingly, national programs and leaders are looking at interdisciplinary collaborations as essential to future research. Twelve years ago, the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) developed and implemented the Building Interdisciplinary Research Careers in Women's Health (BIRCWH) K12 program to focus on interdisciplinary mentored career development for junior faculty in women's health research.
METHODS - We applied a mixed-methods approach using an electronic survey and in-person presentations and discussions to understand best practices and lessons learned for interdisciplinary mentoring across BIRCWH K12 program leaders.
RESULTS AND CONCLUSIONS - We received responses from all 29 active BIRCWH programs. Factors associated with success included ensuring sufficient protected time for regular (weekly or biweekly) mentoring; mentors promoting the research independence of the Scholar; a team mentoring approach, including career as well as content mentors; and explicit and clear expectations outlined between the Scholar and mentor. The majority of programs conduct formal evaluations of mentorship, and 79% of programs offer training in mentorship for either Scholars, mentors, or both. This article presents program leaders' best practices, challenges, and lessons learned from mentoring junior faculty who are conducting women's health research, whether basic, clinical, behavioral, translational, or health services research, using an interdisciplinary mentoring approach.
BACKGROUND - In order to maximize the benefits of HIV care and treatment investments in sub-Saharan Africa, programs can broaden to target other diseases amenable to screening and efficient management. We nested cervical cancer screening into family planning clinics at select sites also receiving PEPFAR support for antiretroviral therapy (ART) rollout. This was done using visual inspection with acetic acid (VIA) by maternal child health nurses. We report on achievements and obstacles in the first year of the program in rural Mozambique.
METHODS - VIA was taught to clinic nurses and hospital physicians, with a regular clinical feedback loop for quality evaluation and retraining. Cryotherapy using carbon dioxide as the refrigerant was provided at clinics; loop electrosurgical excision procedure (LEEP) and surgery were provided at the provincial hospital for serious cases. No pathology services were available.
RESULTS - Nurses screened 4651 women using VIA in Zambézia Province in year one of the program, more than double the Ministry of Health service target. VIA was judged positive for squamous intraepithelial lesions in 8% (n=380) of the women (9% if age ≥ 30 years (n=3154) and 7% if age <30 years (n=1497); p=0.02). Of the 380 VIA-positive women, 4% (n=16) had lesions (0.3% of 4651 total screened) requiring referral to Quelimane Provincial Hospital. Fourteen (88%) of these 16 women were seen at the hospital, but records were inadequate to judge outcomes. Of women screened, 2714 (58%) either had knowledge of their HIV status prior to VIA or were subsequently sent for HIV testing, of which 583 (21%) were HIV positive.
CONCLUSIONS - Screening and clinical services were successfully provided on a large scale for the first time ever in these rural clinics. However, health manpower shortages, equipment problems, poor paper record systems and a limited ability to follow-up patients inhibited the quality of the cervical cancer screening services. Using prior HIV investments, chronic disease screening and management for cervical cancer is feasible even in severely resource-constrained rural Africa.