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BACKGROUND - Older adults with advanced CKD have significant pain, other symptoms, and disability. To help ensure that care is consistent with patients' values, nephrology providers should understand their patients' priorities when they make clinical recommendations.
METHODS - Patients aged ≥60 years with advanced (stage 4 or 5) non-dialysis-dependent CKD receiving care at a CKD clinic completed a validated health outcome prioritization tool to ascertain their health outcome priorities. For each patient, the nephrology provider completed the same health outcome prioritization tool. Patients also answered questions to self-rate their health and completed an end-of-life scenarios instrument. We examined the associations between priorities and self-reported health status and between priorities and acceptance of common end-of-life scenarios, and also measured concordance between patients' priorities and providers' perceptions of priorities.
RESULTS - Among 271 patients (median age 71 years), the top health outcome priority was maintaining independence (49%), followed by staying alive (35%), reducing pain (9%), and reducing other symptoms (6%). Nearly half of patients ranked staying alive as their third or fourth priority. There was no relationship between patients' self-rated health status and top priority, but acceptance of some end-of-life scenarios differed significantly between groups with different top priorities. Providers' perceptions about patients' top health outcome priorities were correct only 35% of the time. Patient-provider concordance for any individual health outcome ranking was similarly poor.
CONCLUSIONS - Nearly half of older adults with advanced CKD ranked maintaining independence as their top heath outcome priority. Almost as many ranked being alive as their last or second-to-last priority. Nephrology providers demonstrated limited knowledge of their patients' priorities.
Copyright © 2018 by the American Society of Nephrology.
INTRODUCTION - Hospital readmissions within 30 days are a healthcare quality problem associated with increased costs and poor health outcomes. Identifying interventions to improve patients' successful transition from inpatient to outpatient care is a continued challenge.
METHODS AND ANALYSIS - This is a single-centre pragmatic randomised and controlled clinical trial examining the effectiveness of a discharge follow-up phone call to reduce 30-day inpatient readmissions. Our primary endpoint is inpatient readmission within 30 days of hospital discharge censored for death analysed with an intention-to-treat approach. Secondary endpoints included observation status readmission within 30 days, time to readmission, all-cause emergency department revisits within 30 days, patient satisfaction (measured as mean Hospital Consumer Assessment of Healthcare Providers and Systems scores) and 30-day mortality. Exploratory endpoints include the need for assistance with discharge plan implementation among those randomised to the intervention arm and reached by the study nurse, and the number of call attempts to achieve successful intervention delivery. Consistent with the Learning Healthcare System model for clinical research, timeliness is a critical quality for studies to most effectively inform hospital clinical practice. We are challenged to apply pragmatic design elements in order to maintain a high-quality practicable study providing timely results. This type of prospective pragmatic trial empowers the advancement of hospital-wide evidence-based practice directly affecting patients.
ETHICS AND DISSEMINATION - Study results will inform the structure, objective and function of future iterations of the hospital's discharge follow-up phone call programme and be submitted for publication in the literature.
TRIAL REGISTRATION NUMBER - NCT03050918; Pre-results.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
The aging population with its concomitant medical conditions, physical and cognitive impairments, at a time of strained resources, establishes the urgent need to explore advanced technologies that may enhance function and quality of life. Recently, robotic technology, especially socially assistive robotics has been investigated to address the physical, cognitive, and social needs of older adults. Most system to date have predominantly focused on one-on-one human robot interaction (HRI). In this paper, we present a multi-user engagement-based robotic coach system architecture (ROCARE). ROCARE is capable of administering both one-on-one and multi-user HRI, providing implicit and explicit channels of communication, and individualized activity management for long-term engagement. Two preliminary feasibility studies, a one-on-one interaction and a triadic interaction with two humans and a robot, were conducted and the results indicated potential usefulness and acceptance by older adults, with and without cognitive impairment.
BACKGROUND - Use of secure messaging through patient portals has risen substantially in recent years due to provider incentives and consumer demand. Secure messaging may increase patient satisfaction and improve outcomes, but also adds to physician workload. Most prior studies of secure messaging focused on primary care and medical specialties. We examined surgeons' use of secure messaging and the contribution of messaging to outpatient interactions in a broadly deployed patient portal.
METHODS - We determined the number of clinic visits and secure messages for surgical providers in the first 3 years (2008-2010) after patient portal deployment at an academic medical center. We calculated the proportion of outpatient interaction conducted through messaging for each specialty. Logistic regression models compared the likelihood of message-based versus clinic outpatient interaction across surgical specialties.
RESULTS - Over the study period, surgical providers delivered care in 648,200 clinic visits and received 83,912 messages, with more than 200% growth in monthly message volume. Surgical specialties receiving the most messages were orthopedics/podiatry (25.1%), otolaryngology (20.1%), urology (10.8%), and general surgery (9.6%); vascular surgery (0.8%) and pediatric general surgery (0.2%) received the fewest. The proportion of outpatient interactions conducted through secure messaging increased significantly from 5.4% in 2008 to 15.3% in 2010 (p < 0.001) with all specialties experiencing growth. Heart/lung transplantation (74.9%), liver/kidney/pancreas transplantation (69.5%), and general surgery (48.7%) had the highest proportion of message-based outpatient interaction by the end of the study.
CONCLUSIONS - This study demonstrates rapid adoption of online secure messaging across surgical specialties with significant growth in its use for outpatient interaction. Some specialties, particularly those with long-term follow-up, interacted with patients more through secure messaging than in person. As surgeons devote more time to secure messaging, additional research will be needed to understand the care delivered through online interactions and to develop models for reimbursement.
AIMS - African American women carry a disproportionate diabetes burden, yet there is limited information on strategies to identify outcomes women perceive as important intervention outcomes (patient-centered outcomes). This study presents a brief strategy to solicit these outcomes and to describe outcomes identified using the highlighted strategy.
METHODS - Thirty-four African-American women with type 2 diabetes were enrolled in group-based, diabetes/weight management interventions. A diabetes educator asked participants to write down their intervention expectations followed by verbal sharing of responses. Expectation-related themes were identified using an iterative, qualitative, team analytic approach based on audio-recorded responses.
RESULTS - The majority of the expectation-related themes (6 of 10) were reflective of self-care education/management and weight loss-related patient-centered outcomes. The remaining themes were associated with desires to help others prevent or manage diabetes, reduce negative diabetes-related emotions, get rid of diabetes, and stop taking diabetes medications.
CONCLUSION - This study adds to a limited body of knowledge regarding patient-centered outcomes among a group that experiences a disproportionate diabetes burden. Future work could include integrating outcomes that are less commonly addressed in diabetes-related lifestyle interventions (e.g., diabetes-related negative emotions), along with more commonly addressed outcomes (e.g., weight loss), to increase the patient-centeredness of the interventions.
Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
INTRODUCTION - Novel interventions are needed to improve adherence to treatment in adolescents with type 1 diabetes. In this article, we describe the development, feasibility, and acceptability of a positive psychology intervention for this population.
METHOD - Adolescents and their parents (n = 39) were randomly assigned to either a positive psychology intervention or an attention control group. Quantitative and qualitative data were collected on feasibility and acceptability. Descriptive and content analysis methods were used.
RESULTS - Recruitment was successful, participation and satisfaction were high in both groups, and retention was excellent over 6 months. In the positive psychology group, adolescents and their parents noted benefits related to increased positive communication and thinking more about diabetes care. We also identified challenges to implementation.
DISCUSSION - Although more research is indicated, a positive psychology framework emphasizing positive emotions and strengths, rather than problems, may be beneficial to adolescents living with a complex chronic illness.
Copyright © 2014 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
OBJECTIVE - Few studies of hypospadias repair in childhood have used validated questionnaires to investigate outcomes of cosmesis, urinary function, and sexual function in adulthood. We sought to investigate long-term outcomes in adult patients who had undergone severe hypospadias repair as children using an existing web-based application available to multiple institutions in order to develop an online patient survey of previously validated questionnaires.
MATERIALS AND METHODS - Patients aged 18 years or older who underwent severe hypospadias repair between 1992 and 1997 at our institution were contacted to complete an online survey. Through medical chart reviews, we analyzed the location of meatus, type of repair, and complications. The online survey included questions about penile appearance, and validated questionnaires to assess urinary and sexual function.
RESULTS - Of 58 patients who met the inclusion criteria, we contacted 19, and 13 completed the survey. Fifty-nine percent had complications, with an average of 2.2 procedures per patient. Most (85.0%) were satisfied with penile appearance, although 38.0% had residual penile curvature. Hypospadias patients had mean lower orgasmic function than normal controls. Mean scores for urinary function and other domains of sexual function were similar to normal controls.
CONCLUSIONS - Although the majority of adult patients were satisfied with the outcomes of penile appearance, urinary function, and sexual function, our online survey suggests decreased lower orgasmic function as measured by validated questionnaire. An online survey accessible to multiple institutions with validated questionnaires may facilitate assessment of long-term hypospadias results.
Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
OBJECTIVES - Patient satisfaction is a key determinant of the quality of care and an important component of pay for performance metrics. The purpose of this study was to evaluate the impact of a simple intervention aimed to increase patients' understanding of their orthopaedic trauma surgeon and improve patient satisfaction with the overall quality of inpatient care delivered by the attending surgeon.
DESIGN - Prospective quality improvement initiative using a randomized intervention.
SETTING - Level 1 academic trauma center.
PATIENTS/PARTICIPANTS - Two hundred twelve patients were eligible; 100 patients were randomized to the intervention group, and 112 patients were randomized to the control group. Overall, 76 patients could be reached for follow-up satisfaction survey, including 34 patients in the intervention group and 42 patients in the control group.
INTERVENTION - Patients randomized to the intervention group received an attending biosketch card, which included a picture of the attending orthopaedic surgeon with a brief synopsis of his educational background, specialty, surgical interests, and research interests.
MAIN OUTCOME MEASURES - Our primary outcome measure was a patient satisfaction survey assessing patients' rating of the overall quality of inpatient care delivered by the attending surgeon.
RESULTS - Overall, 25 (74%) of 34 patients who received an attending biosketch card reported "excellent overall quality of doctor care," whereas only 22 (52%) of 42 patients in the control group reported "excellent overall quality of doctor care" (P = 0.05). Age, gender, race, education, insurance status, primary injury type, and the length of hospital stay were not significant with reference to "excellent" outcome.
CONCLUSIONS - Clinically significant improvements in satisfaction with the overall quality of inpatient care by the attending surgeon were identified in patients who received a biosketch card of his or her attending orthopaedic surgeon.
The National Kidney Foundation and the U.S. Food and Drug Administration (FDA) convened a symposium in September 2010, bringing together more than 70 experts, including representatives from the FDA, the National Institutes of Health, the Critical Path Institute, nephrologists, patients, and the pharmaceutical industry to discuss the feasibility and process of developing patient-reported outcome (PRO) measures to access how patients feel or function to be used in clinical trials for regulatory review of treatment benefit. Three disease areas were evaluated for development of end point models in which PRO measures may be useful: anemia secondary to chronic kidney disease, autosomal dominant polycystic kidney disease (ADPKD), and nephrotic syndrome. The participants thought it valuable to use observational data to generate hypotheses regarding patient baseline characteristics that are likely to predict clinically important changes in PROs in response to anemia treatment and to design adequately powered blinded randomized controlled trials of anemia treatment using PROs as primary rather than secondary end points. Validated PRO instruments that reflect the patient experience in ADPKD and nephrotic syndrome are essential to incorporate into clinical trials of new therapeutic interventions because glomerular filtration rate decline may occur late in the disease course, at which point therapeutic benefit is less likely. Conference attendees addressed how PRO measures could be used to evaluate, monitor, provide care, and facilitate the introduction of treatments for patients with these challenging conditions.
Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
BACKGROUND - Dexamethasone, when added to local anesthetics, has been shown to prolong the duration of peripheral nerve blocks; however, there are limited studies utilizing large numbers of patients. The purpose of this study was to examine the effect of adding dexamethasone to ropivacaine on duration of nerve blocks of the upper and lower extremity.
METHODS - We reviewed 1,040 patient records collected in an orthopedic outpatient surgery center that had received an upper or lower extremity peripheral nerve block with ropivacaine 0.5% with or without dexamethasone and/or epinephrine. The primary outcome was duration of analgesia in upper or lower extremity blocks containing dexamethasone as an adjunct. Secondary outcomes included postoperative patient pain scores, satisfaction, and the incidence of block related complications. Linear and ordinal logistic regression models were used to examine the independent effect of dexamethasone on outcomes.
RESULTS - Dexamethasone was observed to increase median block duration by 37% (95% confidence interval: 31-43%). The increased block duration persisted within body regions (upper and lower) and across a range of block types. Dexamethasone was also observed to reduce pain scores on the day of surgery (P = 0.001) and postoperative day 1 (P < 0.001). There was no significant difference in duration of nerve blocks when epinephrine (1:400,000) was added to 0.5% ropivacaine with or without dexamethasone.
CONCLUSION - The addition of dexamethasone to 0.5% ropivacaine prolongs the duration of peripheral nerve blocks of both the upper and lower extremity.
Wiley Periodicals, Inc.