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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.
Purpose The purpose of this study was to understand the experience of parenting an adolescent with type 1 diabetes (T1DM), to develop a prototype of an eHealth program for parents of adolescents with T1DM, and to evaluate the prototype content and acceptability from the perspective of parents and health care providers. Methods A multiphase method was used generating both qualitative and quantitative data at multiple time points. There were 27 parents of adolescents aged 12 to 18 years with T1DM and 16 health care providers who participated in semistructured interviews to identify parental challenges; 53 parents and 27 providers evaluated the prototype. Thematic content analysis was used to analyze interview transcripts, and descriptive statistics were used to summarize survey data. Results Challenges experienced by parents of adolescents with T1DM included understanding the developmental and hormonal changes of adolescence that affect diabetes care, feeling tension between adolescent independence and parent control, communicating without nagging or conflict, transferring diabetes care responsibility safely, dealing with feelings of stress and distress, and perceiving a lack of resources for T1DM care and insufficient personal time for self-care. In the prototype evaluation, both parents and providers found content to be relevant and provided feedback to guide the development of the full program. Conclusions Parents of adolescents with T1DM and providers expressed a need for parents to have more support in transitioning diabetes care from parent to adolescent. eHealth programs offer an ideal way to address these needs and ultimately can be linked to electronic medical records improving quality and efficiency of health care in this population.
BACKGROUND - Patient portals are online applications that allow patients to interact with healthcare organizations and view information. Portal messages exchanged between patients and providers contain diverse types of communications, including delivery of medical care. The types of communications and complexity of medical decision-making in portal messages sent to surgeons have not been studied.
MATERIALS AND METHODS - We obtained all message threads initiated by patients and exchanged with surgical providers through the Vanderbilt University Medical Center patient portal from June 1 to December 31, 2014. Five hundred randomly selected messages were manually analyzed by two research team members to determine the types of communication (i.e., informational, medical, logistical, or social), whether medical care was delivered, and complexity of medical decision-making as defined for outpatient billing in each message thread.
RESULTS - A total of 9408 message threads were sent to 401 surgical providers during the study period. In the 500 threads selected for detailed analysis, 1293 distinct issues were communicated, with an average of 2.6 issues per thread. Medical needs were communicated in 453 message threads (90.6%). Further, 339 message threads (67.8%) contained medical decision-making. Overall complexity of medical decision-making was straightforward in 210 messages (62%), low in 102 messages (30%), and moderate in 27 messages (8%). No highly complex decisions were made over portal messaging.
CONCLUSIONS - Through patient portal messages, surgeons deliver substantial medical care with varied levels of medical complexity. Models for compensation of online care must be developed as consumer and surgeon adoption of these technologies increases.
Copyright © 2017 Elsevier Inc. All rights reserved.
Automated methods for delivering peritoneal dialysis (PD) to persons with end-stage renal disease continue to gain popularity worldwide, particularly in developed countries. However, the endeavor to automate the PD process has not been advanced on the strength of high-level evidence for superiority of automated over manual methods. This article summarizes available studies that have shed light on the evidence that compares the association of treatment with continuous ambulatory PD or automated PD (APD) with clinically meaningful outcomes. Published evidence, primarily from observational studies, has been unable to demonstrate a consistent difference in residual kidney function loss rate, peritonitis rate, maintenance of euvolemia, technique survival, mortality, or health-related quality of life in individuals undergoing continuous ambulatory PD versus APD. At the same time, the future of APD technology appears ripe for further improvement, such as the incorporation of voice commands and expanded use of telemedicine. Given these considerations, it appears that patient choice should drive the decision about PD modality.
Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Automated retina image analysis has reached a high level of maturity in recent years, and thus the question of how validation is performed in these systems is beginning to grow in importance. One application of retina image analysis is in telemedicine, where an automated system could enable the automated detection of diabetic retinopathy and other eye diseases as a low-cost method for broad-based screening. In this work, we discuss our experiences in developing a telemedical network for retina image analysis, including our progression from a manual diagnosis network to a more fully automated one. We pay special attention to how validations of our algorithm steps are performed, both using data from the telemedicine network and other public databases.
Low-income, racial/ethnic minorities are often nonadherent to diabetes medications, have uncontrolled glycemia, and have high rates of diabetes-related morbidity. Cell phones provide a viable modality to support medication adherence, but few cell phone-based interventions have been designed for low-income persons, a population with more feature phone penetration than smartphone penetration. In an effort to reach the broadest range of patients, we leveraged the voice and text messaging capabilities shared by all cell phones to design the MEssaging for Diabetes intervention. We specifically advanced and adapted an existing tailored text messaging system to include interactive voice response functionality and support the medication adherence barriers of low-income, diverse adults with type 2 diabetes mellitus. We report on the design process and feasibility testing results (i.e., technical use patterns and subjective user experiences) from patients from the target population who used the intervention in one of three user-centered design iterations. The types of challenges encountered in design were related to providing text message content with valued information and support that engages patients. The design process also highlighted the value of obtaining mixed methods data to provide insight into legitimate versus illegitimate missing data, patterns of use, and subjective user experiences. The iterative testing process and results outlined here provide a potential template for other teams seeking to design technology-based self-care support solutions for comparable patient populations.
© 2013 Diabetes Technology Society.
BACKGROUND - The Internet and other eHealth technologies offer a platform for improving the dissemination and accessibility of psychoeducational programs for youth with chronic illness. However, little is known about the recruitment process and yield of diverse samples in Internet research with youth who have a chronic illness.
OBJECTIVE - The purpose of this study was to compare the demographic and clinical characteristics of youth with Type 1 diabetes on recruitment, participation, and satisfaction with 2 eHealth psychoeducational programs.
METHODS - Youth with Type 1 diabetes from 4 sites in the United States were invited to participate (N=510) with 320 eligible youth consenting (mean age=12.3, SD 1.1; 55.3% female; 65.2% white; and mean A1C=8.3, SD 1.5). Data for this secondary analysis included demographic information (age, race/ethnicity, and income), depressive symptoms, and recruitment rates, including those who refused at point of contact (22.0%), passive refusers who consented but did not participate (15.3%), and those who enrolled (62.7%). Participation (80% lessons completed) and a satisfaction survey (ie, how helpful, enjoyable) were also analyzed. Chi-square or analysis of variance (ANOVA) analyses were used.
RESULTS - There were significant differences in recruitment rates by income and race/ethnicity such that black, Hispanic, or mixed race/ethnicity and low-income youth were more likely to refuse passively compared to white and higher-income youth who were more likely to enroll (P<.001). Participation in program sessions was high, with 78.1% of youth completing at least 4 of 5 sessions. There were no significant differences in participation by program, age, gender, or race/ethnicity. Low-income youth were less likely to participate (P=.002). Satisfaction in both programs was also high (3.9 of 5). There were significant gender, race/ethnicity, and income differences, in that girls (P=.001), black, Hispanic, or mixed race/ethnicity youth (P=.02), and low-income youth (P=.02) reported higher satisfaction. There were no differences in satisfaction by program or age.
CONCLUSIONS - Results indicate that black, Hispanic, or mixed race/ethnicity youth and low-income youth with Type 1 diabetes are less likely to enroll in Internet-based research than white and higher-income youth; thus, creative recruitment approaches are needed. Low-income youth were less likely to participate, possibly due to access. However, once enrolled, youth of diverse race/ethnicity and low-income youth with Type 1 diabetes were as highly satisfied with the eHealth programs as white youth and those with higher income. Results suggest that eHealth programs have the potential to reach diverse youth and be appealing to them.
OBJECTIVE - We sought to determine the impact of rotavirus vaccine implementation on gastroenteritis (GE)-related calls to a large telephone triage service in Tennessee.
METHODS - Total and GE-related calls received by the Vanderbilt Telephone Triage Program for children <5 years of age were examined from May 1, 2004 to April 30, 2010. Time series adapted Poisson regression models were used to compare weekly GE-related call proportions between the prevaccine (May 2004 to April 2007) and postlicensure (May 2007 to April 2010) periods. Separate models compared GE-related call proportions in the historical rotavirus (February to April) and nonrotavirus (May to January) seasons. Associations between call data and laboratory-confirmed rotavirus detections and regionally reported norovirus activity were also assessed.
RESULTS - There were 156362 total calls and 19731 GE-related calls. Annual GE-related call proportions declined by 8% (95% confidence interval, 3%-12%) in the postlicensure period; declines ranging from 23% to 31% occurred during the historical rotavirus season in all 3 postlicensure years. No declines occurred in the nonrotavirus season. After vaccine licensure, reductions in laboratory-confirmed rotavirus activity were associated with declines in GE-related call proportions. Peak GE-related call proportions in the postlicensure period occurred earlier than in prevaccine years and were not strongly associated with laboratory-confirmed rotavirus but instead showed good correlation with norovirus outbreaks.
CONCLUSIONS - A decline in GE-related call proportions among young children after rotavirus vaccine licensure was documented by using a novel surveillance platform that captures mild GE not detected in other surveillance systems. Since rotavirus vaccine licensure, peak call proportions correlate with regional norovirus activity, highlighting the role of that pathogen in community GE.