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Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE). Limited data are available on the utilization of the Pulmonary Embolism Response Team (PERT) in the setting of the COVID-19 global pandemic. We performed a single-center study to evaluate treatment, mortality, and bleeding outcomes in patients who received PERT consultations in March and April 2020, compared to historical controls from the same period in 2019. Clinical data were abstracted from the electronic medical record. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding. The frequency of PERT utilization was nearly threefold higher during March and April 2020 ( n = 74) compared to the same period in 2019 ( n = 26). During the COVID-19 pandemic, there was significantly less PERT-guided invasive treatment (5.5% vs 23.1%, p = 0.02) with a numerical but not statistically significant trend toward an increase in the use of systemic fibrinolytic therapy (13.5% vs 3.9%, p = 0.3). There were nonsignificant trends toward higher in-hospital mortality or moderate-to-severe bleeding in patients receiving PERT consultations during the COVID-19 period compared to historical controls (mortality 14.9% vs 3.9%, p = 0.18 and moderate-to-severe bleeding 35.1% vs 19.2%, p = 0.13). In conclusion, PERT utilization was nearly threefold higher during the COVID-19 pandemic than during the historical control period. Among patients evaluated by PERT, in-hospital mortality or moderate-to-severe bleeding were not significantly different, despite being numerically higher, while invasive therapy was utilized less frequently during the COVID-19 pandemic.

Study Design:Review article.Objectives:There have been substantial increases in the utilization of complex spinal surgery in the last 20 years. Spinal instrumented surgery is associated with high costs as well as significant variation in approach and care. The objective of this manuscript is to identify and review drivers of instrumented spine surgery cost and explain how surgeons can reduce costs without compromising outcome.Methods:A literature search was conducted using PubMed. The literature review returned 217 citations. 27 publications were found to meet the inclusion criteria. The relevant literature on drivers of spine instrumented surgery cost is reviewed.Results:The drivers of cost in instrumented spine surgery are varied and include implant costs, complications, readmissions, facility-based costs, surgeon-driven preferences, and patient comorbidities. Each major cost driver represents an opportunity for potential reductions in cost. With high resource utilization and often uncertain outcomes, spinal surgery has been heavily scrutinized by payers and hospital systems, with efforts to reduce costs and standardize surgical approach and care pathways.Conclusions:Education about cost and commitment to standardization would be useful strategies to reduce cost without compromising patient-reported outcomes after instrumented spinal fusion.

Introduction. The COVID-19 pandemic resulted in significant medication, supply and equipment, and provider shortages, limiting the resources available for provision of surgical care. In response to mandates restricting surgery to high-acuity procedures during this period, our institution developed a multidisciplinary Low-Resource Operating Room (LROR) Taskforce in April 2020. This study describes our institutional experience developing an LROR to maintain access to urgent surgical procedures during the peak of the COVID-19 pandemic. Methods. A delineation of available resources and resource replacement strategies was conducted, and a final institution-wide plan for operationalizing the LROR was formed. Specialty-specific subgroups then convened to determine best practices and opportunities for LROR utilization. Orthopedic surgery performed in the LROR using wide-awake local anesthesia no tourniquet (WALANT) is presented as a use case. Results. Overall, 19 limited resources were identified, spanning across the domains of physical space, drugs, devices and equipment, and personnel. Based on the assessment, the decision to proceed with creation of an LROR was made. Sixteen urgent orthopedic surgeries were successfully performed using WALANT without conversion to general anesthesia. Conclusion. In response to the COVID-19 pandemic, a LROR was successfully designed and operationalized. The process for development of a LROR and recommended strategies for operating in a resource-constrained environment may serve as a model for other institutions and facilitate rapid implementation of this care model should the need arise in future pandemic or disaster situations.

Background Emergency departments (EDs) are complex socio-technical work systems that require staff to manage patients in an environment of fluctuating resources and demands. To better understand the purpose, and pressures and constraints for designing new ED facilities, we developed an abstraction hierarchy model as part of a work domain analysis (WDA) from the cognitive work analysis (CWA) framework. The abstraction hierarchy provides a model of the structure of the ED, encompassing the core objects, processes, and functions relating to key values and the ED’s overall purpose. Methods Reviews of relevant national and state policy, guidelines, and protocol documents applicable to care delivery in the ED were used to construct a WDA. The model was validated through focus groups with ED clinicians and subsequently validated using a series of WDA prompts. Results The model shows that the ED system exhibits extremely interconnected and complex features. Heavily connected functions introduce vulnerability into the system with function performance determined by resource availability and prioritization, leading to a trade-off between time and safety priorities. Conclusions While system processes (e.g., triage, fast-track) support care delivery in ED, this delivery manifests in complex ways due to the personal and disease characteristics of patients and the dynamic state of the ED system. The model identifies system constraints that create tension in care delivery processes (e.g., electronic data entry, computer availability) potentially compromising patient safety. Application The model identified aspects of the ED system that could be leveraged to improve ED performance through innovative ED system design.

Given the dearth of established safe and effective interventions to respond to COVID-19, there is an urgent ethical imperative to conduct meaningful clinical research. The good news is that interventions to be tested are not in short supply. Unfortunately, the human and material resources needed to conduct these trials are finite. It is essential that trials be robust and meet enrollment targets and that lower-quality studies not be permitted to displace higher-quality studies, delaying answers to critical questions. Yet, with few exceptions, existing research review bodies and processes are not designed to ensure these conditions are satisfied. To meet this challenge, we offer guidance for research institutions about how to ethically consolidate and prioritize COVID-19 clinical trials, while recognizing that consolidation and prioritization should also take place upstream (among manufacturers and funders) and at a higher level (e.g. nationally). In our proposed three-stage process, trials must first meet threshold criteria. Those that do are evaluated in a second stage to determine whether the institution has sufficient capacity to support all proposed trials. If it does not, the third stage entails evaluating studies against two additional sets of comparative prioritization criteria: those specific to the study and those that aim to advance diversification of an institution’s research portfolio. To implement these criteria fairly, we propose that research institutions form COVID-19 research prioritization committees. We briefly discuss some important attributes of these committees, drawing on the authors’ experiences at our respective institutions. Although we focus on clinical trials of COVID-19 therapeutics, our guidance should prove useful for other kinds of COVID-19 research, as well as non-pandemic research, which can raise similar challenges due to the scarcity of research resources.

Background: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted the health and psychological well-being of hospital nursing staff. While additional support is needed to better cope with increased job stressors, little is known about what types of hospital resources have been provided and how nursing staff perceive them. This study addressed this gap by describing nursing staff perceptions of resources provided by hospitals during the COVID-19 pandemic in the United States. Methods: Registered nurses and nursing assistants who were working in hospitals during the pandemic were recruited to an online survey via social media posts and emails between May and June 2020. A total of 360 free-text responses to an open-ended survey question were analyzed using content analysis. Results: Over half of participants reported being provided with hospital resources. “Basic needs” resources that included food on-site, groceries, and childcare support were the most frequently reported compared with four other types of resources (personal health and safe practice, financial support, managerial support, communication). Four themes emerged related to staff perceptions of support: community support, unequal benefits, decreasing resources, and insufficient personal protective equipment. Conclusion: Our findings can assist organizational leaders in the planning and allocation of different types of resources that are meaningful to nursing staff and thus ensure sustainability, optimal performance, and worker well-being during crises.

Background: For health care services to address the health care needs of populations and respond to changes in needs over time, workforces must be planned. This requires quantitative models to estimate future workforce requirements that take account of population size, oral health needs, evidence-based approaches to addressing needs, and methods of service provision that maximize productivity. The aim of this scoping review was to assess whether and how these 4 elements contribute to existing models of oral health workforce planning. Methods: A scoping review was conducted. MEDLINE, Embase, HMIC, and EconLit were searched, all via OVID. Additionally, gray literature databases were searched and key bodies and policy makers contacted. Workforce planning models were included if they projected workforce numbers and were specific to oral health. No limits were placed on country. A single reviewer completed initial screening of abstracts; 2 independent reviewers completed secondary screening and data extraction. A narrative synthesis was conducted. Results: A total of 4,009 records were screened, resulting in 42 included articles detailing 47 models. The workforce planning models varied significantly in their use of data on oral health needs, evidence-based services, and provider productivity, with most models relying on observed levels of service utilization and demand. Conclusions: This review has identified quantitative workforce planning models that aim to estimate future workforce requirements. Approaches to planning the oral health workforce are not always based on deriving workforce requirements from population oral health needs. In many cases, requirements are not linked to population needs, while in models where needs are included, they are constrained by the existence and availability of the required data. It is critical that information systems be developed to effectively capture data necessary to plan future oral health care workforces in ways that relate directly to the needs of the populations being served. Knowledge Transfer Statement: Policy makers can use the results of this study when making decisions about the planning of oral health care workforces and about the data to routinely collect within health services. Collection of suitable data will allow for the continual improvement of workforce planning, leading to a responsive health service and likely future cost savings.

Severe pelvic fractures (PF) in the elderly are common and analysis of outcomes and resource utilization are lacking. Using the National Trauma Databank (2007-2016), 13 267 patients aged ≥65 years with severe PF (Abbreviated Injury Scale [AIS] pelvis ≥3; AIS 3 = 10 388; AIS 4 = 2124; AIS 5 = 805) were studied. Demographic data, management, resource utilization, complications, and mortality were analyzed for each group. Data are represented as % or median interquartile range (IQR). Multivariate logistic regression analyzed risk factors for mortality, Intensive Care Unit (ICU) admission, and ventilator use. Median age was 77, and most of them were females (59%). Falls occurred in 52%, motor vechicle crash in 21.5%, and pedestrian struck in 11.6%. Median injury severity score was 16 (IQR: 9,27). Shock on admission (9.4%) increased with injury severity. Glasgow Coma Scale < 8 occurred in 8%. Blood transfusion increased with injury severity (17%, 29%, and 51%). Angiography occurred in 9%, external fixation in 4%, internal fixation in 16%, and pelvic packing in 1%, the majority in the AIS 5 group. Overall, 46% required ICU admission and 30% underwent mechanical ventilation; median Hospital Length of Stay was 6 (IQR 4,11), ICU length of stay was 5 (IQR 2,10), and median ventilator days were 4 (IQR 1-11). Mortality rate was 13.3% (AIS 3 = 10%, AIS 4 = 19%, and AIS 5 = 44%).Severe PF in the elderly is associated with high resource utilization, complications, and mortality.

Background To study the relationship between race and outcomes of patients with firearm injuries hospitalized in the United States. Methods The 2016 National Inpatient Sample was used. Patients were included if they had a principal diagnosis of firearm injury. Exclusion criteria were age Results The sample included 31 335 patients; 52% were Black and 29% were Caucasian. The mean age was 32 years and 88% were male. Black patients had lower odds of mortality (adjusted odds ratio (aOR): 0.41 (95% CI: 0.32-0.53), P < .01). However, compared with Caucasians, Blacks had higher mean total hospitalization charges (adjusted mean difference (aMD) : $14 052 (CI: $1469-$26 635), P = .03) and costs (aMD: $3248 (CI: $654-$5842), P = .01) despite similar mean length of stay (aMD: 0.70 (CI: −0.05-1.45), P = .07). Both racial groups had similar rates of traumatic shock (aOR: 0.91 (0.72-1.15), P = .44), prolonged mechanical ventilation (aOR: 0.82 (0.63-1.09), P = .17), ARDS (aOR: 1.18 (0.45-3.07), P = .74) and VAP (aOR: 1.27 (0.47-3.41), P = .63). Discussion Black patients with firearm injuries had a lower adjusted odds of in-hospital mortality compared with other races. However, despite having a similar hospital length of stay and in-hospital morbidity, -Black patients had higher total hospitalization costs and charges.

Background Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population. Methods The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (pResults A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, pConclusions Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.

The present study reports an evaluation of web analytics, over a 5-year period, for HeadsUpGuys.org , an eHealth resource for men with depression. Google Analytics, Search Console, and Tag Manager were used to monitor user activity over the course of the website’s first 5 years (June 15, 2015–June 15, 2020). Through this period, HeadsUpGuys had a total of 1,665,356 unique users, amounting to 1,948,481 sessions and 3,328,258 page views. Organic traffic accounted for the highest proportion (53.44%; n = 1,041,277) of website sessions. Four of the top 10 Google search queries that brought users to the website related to suicidality. Three countries (United States, United Kingdom, Canada) accounted for almost three-quarters (71.10%; n = 1,385,485) of the site’s traffic. Nearly three-quarters (73.35%; n = 1,429,285) of sessions occurred on a mobile device. The goal conversion rate for the Self Check was 60.27%. The average time on page was 2 min 53 s, with a bounce rate of 65.92%, and an exit rate of 57.20%. The goal conversion rate for the Stress Test was 52.89%. The average time on page was 4 min 8 s, with a bounce rate of 72.40% and an exit rate of 48.88%. The conversion rate for the final goal was 11.53%, indicating that approximately one in 10 visitors to the site had a session of at least 3 min. The findings illustrate the potential of eHealth resources to support men’s mental health and provide a real-world benchmark to help advance the men’s eHealth field.

Foundry empowers youth and young adults aged 12 to 24 years to lead healthy lives through a province-wide network of centers and online resources in British Columbia, Canada. However, initial evaluation data gathered from Foundry centers have shown that boys and young men are half as likely to access Foundry compared to girls and young women. To address this need, we set out to understand why boys and young men aged 12 to 17 years aren’t accessing mental health supports and to develop a promotional campaign to connect them with the resources available through Foundry. A campaign concept called “Everything Is Fine” was chosen; the campaign depicts boys and young men trying to appear as if they are OK, even though their facial expressions clearly show they are holding back stress. The campaign concept was chosen through an iterative process of research and testing. Promotion materials were created for social media (Instagram, Snapchat) and school posters, which were distributed across British Columbia, Canada . Evaluation was conducted through social media analytics and google analytics. Pre- and postsurveys were also distributed to two school districts to assess recognition of Foundry. Approximately 160,000+ persons viewed the media on Instagram, while 170,000+ viewed on Snapchat. There was a 70% increase in website traffic compared with the 3 months prior (18,881 vs. 11,126). In the surveyed school districts, Foundry awareness increased by 10% and 15%. The lessons learned from our campaign were to prioritize research and to leverage media agency experience for large campaigns.

Background/aims: After a new treatment is recommended to be first-line treatment for a specific indication, outcome and population, it may be unethical to use placebo as a comparator in trials for that setting. Nevertheless, in specific circumstances, use of a placebo group might be warranted, for example, when it is believed that an active treatment may not be efficacious or cost-effective for a specific subpopulation. An example is antibiotic treatment for pneumonia, which may not be effective for many patients taking it due to the emergence of antibiotic-resistant strains or the high prevalence of viral and low prevalence of bacterial pneumonia. Methods: We explore the applicability of different design options in cases where the benefit of an established treatment is questioned, with particular emphasis on issues that arise in a low-resource setting. Using the example of a clinical trial comparing the effectiveness of placebo versus amoxicillin in treating children 2–59 months of age with fast breathing pneumonia in Lilongwe, Malawi, we discuss the pros and cons of superiority versus non-inferiority designs, an intent-to-treat versus as-treated analysis and the use and interpretation of one- versus two-sided confidence intervals. Results: We find that a non-inferiority design using an intent-to-treat analysis is the most appropriate design and analysis option. In addition, the presentation of one- versus two-sided confidence intervals can depend on the results but can maintain type I error. Conclusion: In the setting where the benefit of a previously established beneficial treatment is questioned, a non-inferiority design that includes placebo as the tested treatment option can be the most appropriate design option.

AimTo compare healthcare resource use and costs between newly diagnosed multiple myeloma (NDMM) patients with and without skeletal-related events (SREs).MethodsAdults newly diagnosed with MM (1 January 2006 and 30 June 2017) with at least 12 months continuous health coverage prior to diagnosis were identified using the IBM MarketScan administrative claims. To control for baseline differences, NDMM patients with SREs were propensity score matched to NDMM patients without SREs. Outcomes included annual HRU and costs during follow-up along with number and type of SREs (SRE cohort only). Patients with SREs were stratified by number of SREs, and annual SRE-related costs were reported. Student's t test and Chi-squared test were used to compare outcomes.ResultsBefore matching, the 6648 patients in the SRE cohort had more comorbidities, were more likely to have MM treatment, and had higher pre-index healthcare costs than the 7458 patients in the non-SRE cohort. After matching, cohorts of 3432 patients were well balanced on baseline characteristics. Patients with SREs (vs. without SREs) had significantly higher inpatient, outpatient, and pharmacy HRU. Patients with SREs had significantly higher mean annual all-cause healthcare costs ($213,361 vs. $94,896, p ConclusionsNDMM patients with SREs have more than twice the all-cause healthcare costs than matched patients without SREs. Costs increase with the number of SRE events.

BackgroundIn this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored.Research designA qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used.Ethical considerationsApproval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary.FindingsBased on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness.ConclusionMoral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

Nurses provide the majority of health care in sub-Saharan Africa, which has high rates of Hepatitis B Virus (HBV) and human immunodeficiency virus (HIV). This systematic review used PRISMA methodology to synthesize the literature published between January 2008 and December 2018 examining the occupational health of nurses practicing in the Economic Community of West African States (ECOWAS). The United States’ National Institute for Occupational Safety and Health’s Hierarchy of Controls is used to frame the findings. This research was mostly conducted in Nigeria and Ghana and focused on administrative controls. Nurses practicing in ECOWAS are at high risk of acquiring a bloodborne illness due to inadequate engineering and administrative controls, as well as limited access to personal protective equipment (PPE). These findings indicate interventions to improve these controls would likely lower the occupational risks faced by nurses practicing in ECOWAS. Research in more countries in ECOWAS would likely find differences in occupational health practices in Nigeria and Ghana, which are relatively wealthy, and other countries in the region. This literature showed nurses practicing in ECOWAS did not have adequate protection from biological hazards. Regional health groups, such as the West African Health Organization, should commit to improving occupational health practice. Needle recapping and double gloving must be discontinued, and PPE must be made more widely available in ECOWAS. Occupational health professionals in the region should advocate for better distribution of PPE and consider offering trainings on these behaviors.

Introduction Growing populations of elderly patients with chronic obstructive pulmonary disease (COPD) or heart failure (HF) require more healthcare. A four-year telehealth intervention – the Health Diary system based on digital pen technology – was implemented. We hypothesized that study patients with advanced COPD or HF would have lower rates of hospitalization when using the Health Diary. The aim was to investigate the effects of the intervention on healthcare costs and the number of hospitalizations, as well as other care required in COPD and HF patients. Methods Patients were introduced to the telemonitoring system which was supervised by a specialized hospital-based home care (HBHC) unit. Staff associated with this unit were responsible for the healthcare provided. The study included patients with COPD or HF, aged ≥ 65 years who were frequently hospitalized due to exacerbations – at least two inpatient episodes within the last 12 months. Observed number of hospitalizations and total healthcare costs were compared with the expected values, which were calculated using the generalized estimating equations (GEE) method. Results A total of 36 COPD and 58 HF patients with advanced stages of disease were included. The number of hospitalizations was significantly reduced for both HF and COPD patients participating in telemonitoring. Accordingly, hospitalization costs were significantly reduced for both groups, but the total healthcare cost was not significantly different from the expected costs. Conclusion A telemonitoring system, the Health Diary, combined with a specialized HBHC unit significantly decreases the need for hospital care in elderly patients with advanced HF or COPD without increasing total healthcare costs.

IntroductionThe effect of electronic inhaler monitoring (EIM) on healthcare utilization in chronic obstructive pulmonary disease (COPD) has not been studied. We hypothesized that the use of EIM in conjunction with a disease management program reduces healthcare utilization in patients with COPD.MethodsThis is a retrospective pre- and post-analysis of a quality improvement project. Patients with COPD and high healthcare utilization (≥one hospitalization or emergency room visit during the year prior to enrolment) were provided with electronic monitoring devices for monitoring controller and rescue inhaler utilization for one year. Patients were contacted when alerts were triggered, indicating suboptimal adherence to controller inhaler or increased use of rescue inhalers, potentially signalling an impending exacerbation. Healthcare utilization was assessed pre- and post-monitoring, with each subject serving as his/her own control.ResultsPatients with COPD and high healthcare utilization ( n = 39) were recruited. Mean EIM duration was 280.5 (±120.6) days. The mean age was 68.6 (±9.9) years, FEV1 (mean forced expiratory volume in one second) was 1.1 (±0.4) L, and mean Charlson Comorbidity index was 5.6 (±2.7). Average adherence was 44.4% (28.4%). Compared with the year prior to enrolment, EIM was associated with a reduction in COPD-related healthcare utilization per year (2.2 (±2.3) versus 3.4 (±3.2), p = 0.01). Although there was a reduction in all-cause healthcare utilization, this was not statistically significant (3.4 (±2.6) versus 4.7 (±4.1), p = 0.06).DiscussionEIM in conjunction with a disease management program may play a role in reducing healthcare utilization in COPD patients with a history of high healthcare utilization.

Background:One widely accepted approach to identify children with life-limiting health problems is the complex chronic conditions (CCCs) classification system. Although considered the “gold standard” for classifying children with serious illness, little is known about its performance, especially among infants.Objective/Hypothesis:This research examined the prevalence of CCCs and the infant characteristics related to a CCC classification.Methods:Multivariate regression analysis was conducted with 2012 Kids’ Inpatient Database, Healthcare Cost and Utilization Project data files, using a national sample of infant decedents less than 1 year.Results:Our findings showed that 40% of the infants were classified with a CCC. African Americans were negatively associated with a CCC classification (adjusted odds ratio [aOR] = 0.63; 95% confidence interval [CI] = 0.543-0.731). When infants had other insurance coverage, they were less likely (aOR = 0.63; 95% CI = 0.537-0.748) to have a CCC classification. Infants who resided in nonurban areas (aOR = 1.21; 95% CI =1.034-1.415) and had comorbidities (aOR = 38.19; 95% CI = 33.12-44.04) had greater odds of having a CCC classification.Conclusions:The findings suggested that the infants are not commonly classified with a CCC and highlighted the significant variation in race with African American infants exhibiting different CCC classifications than Caucasian infants. Given the importance of reducing disparities in palliative care, critical attention to using CCC classifications in research is warranted.

Background Lanreotide and octreotide acetate suspension for injectable (LAR) are both recommended for clinical use in patients with locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors. However, each agent possesses unique attributes in terms of their drug-delivery characteristics. The study objective was to compare overall drug-delivery efficiency between lanreotide and octreotide LAR in gastroenteropancreatic neuroendocrine tumor patients. Methods This study employed an observational time and motion design among patients treated with lanreotide or octreotide LAR across five US cancer centers. Baseline patient data collection included age, disease grade and duration, prior therapies and performance status. Drug-delivery time (drug preparation and administration), total patient time and resource use data were collected for gastroenteropancreatic neuroendocrine tumors receiving lanreotide (n = 22) or octreotide LAR (n = 22). Following each administration, qualitative data on the drug-delivery experience was collected from patients and nurses. Results Lanreotide was associated with a significant reduction in mean delivery time (2.5 min; 95% CI:2.0 to 3.1) compared to octreotide LAR (6.2 min; 95%CI: 4.4 to 7.9; p = 0.004). The mean total patient time for lanreotide and octreotide LAR was comparable between groups (32.1 vs. 36.6 minutes; p = 0.97). Nurses reported increased concerns with octreotide LAR related to needle clogging ( p = 0.034) and device failures ( p = 0.057). Overall, lanreotide had a median satisfaction score of 5.0 compared to a score of 4.0 with octreotide LAR ( p = 0.03). Conclusions Lanreotide was associated with significant reductions in drug-delivery time compared to octreotide LAR, which contributed to an improvement in overall healthcare efficiency. Trial registration clinicaltrials.gov Identifier: NCT03017690.

Objectives: To assess the burden of disease and disability in older persons in Mexico from the Global Burden of Disease (GBD) 2016 study data. Methods: Analysis of the Mexican data from the GBD 2016 study is presented by state, sex, and stratified into four age groups: 60 to 69, 70 to 79, 80 to 89, and 90+ years. Results: The majority of disability-adjusted life-years (DALYs) attributable to disorders in persons 60+ in Mexico were due to premature mortality (68%). Diabetes mellitus, ischemic heart disease, and chronic kidney disease were the main causes of DALYs. With progressing age, sense organ diseases, dementias, and falls climbed to the top causes of years lived with disability (YLDs) in both sexes. Discussion: Most of the burden of disease in older Mexicans is due to premature mortality, underlining the need to strengthen the health system to respond better to health care needs of older persons with non-communicable diseases. This analysis provides information for the development of national health policies.

Background: Research demonstrates that the attitudes of religious physicians toward end-of-life care treatment can differ substantially from their nonreligious colleagues. While there are various religious perspectives regarding treatment near the end of life, the attitudes of Muslim physicians in this area are largely unknown. Objective: This article attempts to fill in this gap by presenting American Muslim physician attitudes toward end-of-life care decision-making and by examining associations between physician religiosity and these attitudes. Methods: A randomized national sample of 626 Muslim physicians completed a mailed questionnaire assessing religiosity and end-of-life care attitudes. Religiosity, religious practice, and bioethics resource utilization were analyzed as predictors of quality-of-life considerations, attitudes regarding withholding and withdrawing life-sustaining treatment, and end-of-life treatment recommendations at the bivariate and multivariable level. Results: Two-hundred fifty-five (41% response rate) respondents completed surveys. Most physicians reported that religion was either very or the most important part of their life (89%). Physicians who reported consulting Islamic bioethics literature more often had higher odds of recommending active treatment over hospice care in an end-of-life case vignette. Physicians who were more religious had higher odds of viewing withdrawal of life-sustaining treatment more ethically and psychologically challenging than withholding it and had lower odds of agreeing that one should always comply with a competent patient’s request to withdraw life-sustaining treatment. Discussion: Religiosity appears to impact Muslim physician attitudes toward various aspects of end-of-life health-care decision-making. Greater research is needed to evaluate how this relationship manifests itself in patient care conversations and shared clinical decision-making in the hospital.

Patients with chronic illness are associated with high health-care utilization and this is exacerbated in the end of life, when health-care utilization and costs are highest. Complex Care Management (CCM) is a model of care developed to reduce health-care utilization, while improving patient outcomes. We aimed to examine the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in CCM over the last 2 years of life. Generalized estimating equation models were used. The sample (n = 126) was 52% female with an average age of 85 years. Health-care utilization rose sharply in the last 3 months of life with at least one hospitalization for 67% of participants and an emergency department visit for 23% of participants. In the last 6 months of life, there was an average of 2.17 care transitions per participant. The odds of hospitalization increased by 27% with each time interval ( P < .001). Participants demonstrated 11% greater odds of having a hospitalization for each additional comorbidity ( P = .05). A primary diagnosis of heart failure or coronary artery disease was associated with 21% greater odds of hospitalization over time compared to other primary diagnoses ( P = .017). Females had 70% greater odds of an emergency department visit compared to males ( P = .046). For each additional year of life, the odds of an emergency department visit increased by about 7% ( P < .001). Findings suggest the need for further interventions targeting chronically ill older adults nearing end of life within CCM models.

Disparities in chronic disease and life expectancy remain a significant public health problem and are largely attributable to social determinants of health. Community health workers (CHWs) promote health equity through individual- and community-level activities, and leadership and advocacy skills training make CHWs more likely to catalyze structural change. CHWs are increasingly being integrated into clinical practices to support care management, creating a need for new grassroots community-level advocates. We adapted for community residents an existing CHW training curriculum focused on social determinants of health and effecting community change. We offered 36 hours of training at community-based locations in New Orleans, Louisiana. We assessed baseline civic and community participation and pre- and postknowledge for each lesson. Among 43 enrollees, 42 completed the program. The majority were Black (92.7%), female (92.7%), and retired or unemployed (77.5%), with a median age of 61.5 years. In the past year, 85% of participants had volunteered, 57.1% had been involved with a community organization, and 32.4% had contacted the city council. Participants demonstrated statistically significant increases in knowledge in 5 of 6 lessons. Our success in increasing knowledge of advocacy among a civically engaged group suggests that trainees may become community leaders in addressing social determinants of health.

Introduction: This article outlines the processes used to meaningfully and authentically engage Australian Aboriginal communities in Northern New South Wales, Australia, to develop culturally appropriate stroke health resources. Methodology: Participatory action research using the research topic yarning framework is a collaborative, culturally safe way to uncover vital information and concepts. There were two stages in the participatory action research project: community engagement and evaluation of the processes involved in developing the localised, culturally appropriate health resources. Results: Establishing relationships built on trust, mutual sharing of knowledge, and bringing together the wider community, enabled the health message to be embedded within the community, ensuring the message was culturally appropriate and sustainable. Discussion: The stroke education resource is a tangible outcome and a major achievement; however, the process of authentic engagement to achieve the final product was the ultimate accomplishment.

Objective: To measure the association of intensive care unit (ICU) capacity strain with processes of care and outcomes of critical illness in a resource-limited setting. Methods: We performed a retrospective cohort study of 5332 patients referred to the ICUs at 2 public hospitals in South Africa using the country’s first published multicenter electronic critical care database. We assessed the association between multiple ICU capacity strain metrics (ICU occupancy, turnover, census acuity, and referral burden) at different exposure time points (ICU referral, admission, and/or discharge) with clinical and process of care outcomes. The association of ICU capacity strain at the time of ICU admission with ICU length of stay (LOS), the primary outcome, was analyzed with a multivariable Cox proportional hazard model. Secondary outcomes of ICU triage decision (with strain at ICU referral), ICU mortality (with strain at ICU admission), and ICU LOS (with strain at ICU discharge), were analyzed with linear and logistic multivariable regression. Results: No measure of ICU capacity strain at the time of ICU admission was associated with ICU LOS, the primary outcome. The ICU occupancy at the time of ICU admission was associated with increased odds of ICU mortality (odds ratio = 1.07, 95% confidence interval: 1.02-1.11; P = .004), a secondary outcome, such that a 10% increase in ICU occupancy would be associated with a 7% increase in the odds of ICU mortality. Conclusions: In a resource-limited setting in South Africa, ICU capacity strain at the time of ICU admission was not associated with ICU LOS. In secondary analyses, higher ICU occupancy at the time of ICU admission, but not other measures of capacity strain, was associated with increased odds of ICU mortality.

We reviewed the resource utilization of patients with human rhinovirus/enterovirus (HRV/ENT), influenza A/B (FLU), or respiratory syncytial virus (RSV). A total of 2013 patients with nasopharyngeal swabs positive for HRV/ENT, RSV, or FLU were included. Records were reviewed for respiratory support, vascular access procedures, emergency department care only versus admission versus pediatric intensive care unit (PICU) care, antibiotics, length of stay, and billing data. Of the 2013 subjects, 1251 tested positive for HRV/ENT, 558 for RSV, and 204 for FLU. Fewer HRV/ENT patients were discharged from the emergency department ( P < .001); and they were more likely to be admitted to the pediatric intensive care unit ( P < .001). HRV/ENT and RSV patients were more likely to require invasive procedures ( P = .01). Median hospital costs for HRV/ENT patients were more than twice that of FLU patients ( P < .001). HRV/ENT infection in pediatric patients poses a significant resource and cost burden, even when compared with other organisms.

Conducting clinical trials in resource-poor settings may contribute to local capacity building. We describe the perspectives of local research personnel regarding the impact of collaborating in a clinical trial in rural Ghana. Forty-six Ghanaian research personnel were eligible to complete an anonymous survey, and 35 (76%) participated. Of the 35 respondents, 32 (91%) agreed that future patients will benefit because the hospital was part of the study. All 35 respondents reported a personal benefit derived from study involvement, most commonly citing skills or knowledge gained. Of the 35 individuals, 21 reported one or more burdens, most commonly citing nonspecific research responsibilities. Our data support the hypothesis that participation in clinical trials can contribute to capacity building in district hospitals in a lower middle-income country.

Improving hospital safety is challenging in resource-poor countries. Before a new hospital opened in Malawi, we simulated a patient’s pathway from admission to discharge, through which we identified associated administrative and clinical activities. Newly recruited hospital personnel enacted the simulation: admission procedures; preoperative clinical assessment; patient preparation for theatre and surgery; safety checks of surgical and anaesthetic equipment; adherence to aseptic technique; postoperative care; and hospital discharge. Hospital personnel were familiar with their clinical and administrative roles. Some essential equipment required repair/recalibration. Additional supplies of oxygen, nitrous oxide and anaesthetic drugs were needed. Policies requiring clarification, forms requiring amendment and general maintenance tasks for completion were identified. The simulation exercise identified areas for safety improvement and thus could be replicated to promote hospital safety elsewhere.

Objective To evaluate the association between exposure to oral corticosteroids and future healthcare resource utilization and costs for patients with systemic lupus erythematosus. Methods Adults diagnosed with systemic lupus erythematosus (index date) between 1 January 2008 and 30 June 2013 and naive to oral corticosteroids with continuous health plan enrollment for ≥6 months pre- and ≥5 years post-index were identified from a large health plan claims database. Per-patient monthly average daily dose of oral corticosteroids (prednisone or its equivalent) was calculated for the first 2 years post-index to categorize patients into four steroid exposure cohorts: low (≤5 mg/day), medium (6–20 mg/day), high (>20 mg/day) and no steroids. Differences in healthcare resource utilization and total healthcare costs during the third year post-index across corticosteroid exposure cohorts were modeled with adjustment for baseline characteristics. Results The study included 18,618 systemic lupus erythematosus patients (163 high dose, 1127 medium dose, 6717 low dose and 10,611 no steroids). Compared to low-dose corticosteroid users, high-dose corticosteroid users were more likely to have emergency room visits (39.3% vs. 29.7%; p = 0.0085) and to be hospitalized (21.5% vs. 12.3%; p = 0.0005). After adjustment for baseline characteristics, they also had significantly greater average annual total healthcare costs (US$60,366 vs. US$18,777; p Conclusion Long-term high-dose oral corticosteroid use was associated with significantly greater future healthcare resource utilization and costs. Judicious reduction in daily steroid dose may decrease the imminent economic burden associated with high-dose steroid use in systemic lupus erythematosus.

This study examined relationships among personal and social resourcefulness and spiritual practices and their associations with perceived stress, depressive symptoms, and self-assessed health in 138 women caregivers of elders with dementia. Caregivers who rated high on personal and social resourcefulness and spiritual practices (by median splits) had the lowest perceived stress, fewest depressive symptoms, and best self-assessed health, followed in sequence by women rating high on two of the three, high on one of the three, and low on all three. Hierarchical regression analyses that introduced spiritual practices after resourcefulness showed significant increases in the R-square change by 3% and 5% for perceived stress and depressive symptoms, respectively, but no significant change for self-assessed health. Strong associations among personal and social resourcefulness and spiritual practices, and similar relationships with two health outcomes, suggest that spiritual practices may be a third dimension of resourcefulness.

Introduction: Several efforts are being implemented at the European level to measure provision of up-to-date radiation treatments across the continent. Methods: A snapshot survey involving all radiation oncology centers within Lombardy, Italy, was performed in 2012 and repeated in 2014 and 2016, in cooperation with regional governmental officers. Centers were asked to provide detailed information concerning all individual patients being treated on the index day, and to report data on available local resources. Results: We observed an increase in the number of centers and of megavoltage units (MVU) (from 76 to 87, i.e., 8.7 MVU per million inhabitants in 2016). Mean number of MVU per center was 2.5. Average age of MVU increased from 5.3 to 7.5 years and patients on the waiting list also increased. Conformal 3D radiotherapy (RT) treatments decreased from 56% to 42% and were progressively replaced by intensity-modulated RT treatments (from 39% to 49%). Waiting times were overall satisfactory. Radiation oncologists treated on average 152 and radiation therapists 100 RT courses per year. Average reimbursement per course was €4,879 (range €2,476–€8,014). Conclusions: The methodology of snapshot survey proved feasible and provided valuable information about radiation oncology provision and accessibility in Lombardy.

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Before completing a nursing PhD program, doctoral students are encouraged to seek out and apply for a position in one of many, often highly competitive postdoctoral programs. These programs include the more traditional National Institutes of Health (NIH) funded experiences, such as the T32, as well as the nontraditional institution funded positions, including the associate faculty role. Graduates often need guidance on which postdoctoral programs are available, the resources each program offers to promote development of the applicant’s program of research, the disadvantages of each program, and what each program uses as benchmarks for success. This article summarizes both traditional and nontraditional postdoctoral positions including the T32, F32, F99/K00, T90/R90, research supplements, associate faculty, research associate, and hospital-affiliated postdoctoral positions. This article updates previous papers describing postdoctoral opportunities and offers a starting place to aide PhD students planning their postgraduate activities in seeking and evaluating these positions.

This survey evaluated resources available to men and boys at the state level including state public health departments (SPHDs), other state agencies, and governor’s offices. Most of the resources and programs are found in the SPHDs and these administer state-initiated and federally funded health programs to provide services and protection to a broad range of populations; however, many men’s health advocates believe that SPHDs have failed to create equivalent services for men and boys, inadvertently creating a health disparity. Men’s Health Network conducts a survey of state resources, including those found in SPHDs, every 2 years to identify resources available for men and women, determine the extent of any disparity, and establish a relationship with SPHD officials. Data were obtained from all 50 states and Washington, D.C. An analysis of the 2016 survey data indicates that there are few resources allocated and a lack of readily available information on health and preventive care created specifically for men and boys. The data observed that most health information intended for men and boys was scarce among states or oftentimes included on websites that primarily focused on women’s health. A potential result of this is a loss of engagement with appropriate health-care providers due to a lack of information. This study continues to validate the disparity between health outcomes for women and men. It continues to highlight the need for better resource allocation, outreach, and health programs specifically tailored to men and boys in order to improve overall community well-being.

Objective In a scenario of new expensive cancer therapies entering the market, strategies of optimisation and cost containment are crucial in oncology care. Better management of drug waste and centralization of drug preparation can be effective strategies to achieve these goals. The aim of this work is to describe the economic management of a high cost anticancer drug (ipilimumab) in some Italian reference centres. Methods This was an observational, multicentred study in which economical and clinical data of 21 cancer centres (418 patients) were collected during the enrollment period from February 2013 to August 2014. The follow-up period ended in July 2015. Results Participants purchased 10.7% more vials of ipilimumab than necessary for compounding. The results were variable among centres, and only five centres had a deviation lower than 5% between the drug purchased and the drug prescribed. Hospitals applying the drug day reached a statistically significant residual of drug effectively used compared to the amount prescribed (P = 0.018). Consequently, the price for treating a model patient was significantly lower in those hospitals (median spare of 7456 euro per patient). Conclusions This study demonstrated that the careful management of drug waste and the application of drug-day, through a proper selection of vial and the ability to use the leftover drug, can generate economic savings. However, tailoring the drug stock to clinical need is still an open issue which deserves further analysis.

This study explores ethical issues raised in providing medical care to participants and communities of low-resource settings involved in a Phase II/III pediatric malaria vaccine trial (PMVT). We conducted 52 key informant interviews with major stakeholders of an international multi-center PMVT (GSK/PATH-MVI RTS,S) (NCT00866619) in Ghana and Tanzania. Based on their stakeholder experiences, the responses fell into three main themes: (a) undue inducement, (b) community disparities, and (c) broad therapeutic misconceptions. The study identified the critical ethical aspects, from the perspectives of stakeholders, of delivering health care during a PMVT. The study showed that integrating research into health care services needs to be addressed in a manner that upholds the favorable risk–benefit ratio of research and attends to the health needs of local populations. The implementation of research should aim to improve local standards of care through building a collaborative agenda with local institutions and systems of health.

Background Most stroke research is conducted in high income countries, yet most stroke occurs in low- and middle-income countries. There is an urgent need to build stroke research capacity in low- and middle-income countries. Aims To review the global health literature on how to improve research capacity in low- and middle-income countries, provide additional data from the recently completed ATTEND Trial and provide examples from our own experience. Summary of review The main themes from our literature review were: manpower and workload, research training, research question and methodology and research funding. The literature and our own experience emphasized the importance of local stakeholders to ensure that the research was appropriate, that there were robust local ethics and regulatory processes, and research was conducted by trained personnel. Research training opportunities can be developed locally, or internationally, with many international schemes available to help support new researchers from low- and middle-income country settings. International collaboration can successfully leverage funding from high income countries that not only generate data for the local country, but also provide new data appropriate to high income countries. Conclusions Building stroke research capacity in low- and middle-income countries will be vital in improving global health given the huge burden of stroke in these countries.

The stigma related to HIV status, gender identity, and sexual orientation has negative implications for the quality of life of individuals. A qualitative study was conducted to explore the resources that these stigmatized groups recognize as tools to cope with stigma and maintain their psychological well-being. Four focus groups were conducted with gay men and transgender women divided by HIV status. A thematic analysis revealed that individual, interpersonal, and institutional resources are commonly recognized as coping resources. This article discusses the importance of enhancing self-acceptance, social support, and a legal framework that legitimizes these groups as right holders.