Adult Health Care Research Articles

Adult provider role in transition of care for young adult pediatric recipients of liver transplant: An expert position statement.

Health care transition (HCT) is the process of changing from a pediatric to an adult model of care. Young adult pediatric recipients of liver transplant transferring from pediatric to adult health care services are highly vulnerable and subject to poor long-term outcomes. Barriers to successful transition are multifaceted. A comprehensive HCT program should be initiated early in pediatrics and continued throughout young adulthood, even after transfer of care has been completed. It is critical that pediatric and adult liver transplant providers establish a partnership to optimize care for these patients. Adult providers must recognize the importance of HCT and the need to continue the transition process following transfer. While this continued focus on HCT is essential, current literature has primarily offered guidance for pediatric providers. This position paper outlines a framework with a sample set of tools for the implementation of a standardized, multidisciplinary approach to HCT for adult transplant providers utilizing "The Six Core Elements of HCT." To implement more effective strategies and work to improve long-term outcomes for young adult patients undergoing liver transplant, HCT must be mandated as a routine part of posttransplant care. Increased advocacy efforts with the additional backing and support of governing organizations are required to help facilitate these practices.

Assessing Competencies, Needs, and Satisfaction With the Transition From Pediatric to Adult Health Care in Rheumatology: Development and Validation of the Transition-KompAZ.

The aim of this study was to develop and psychometrically validate a self-report instrument to assess (1) competencies, (2) needs, and (3) satisfaction among youth transitioning from pediatric to adult rheumatology. The Transition-KompAZ was developed in several steps with conceptual and psychometric analyses. To test its psychometric properties, the instrument was administered to adolescents and young adults (AYAs; 16-25 years) with inflammatory rheumatic diseases before (group 1) or after (group 2) transfer to adult rheumatology. A 2-factor, higher-order confirmatory factor analysis (CFA) model was applied to test the hypothesized factor structure. Internal consistency was estimated using the approach of Raykov with the factor loadings and error variances estimated in the CFA. Spearman rank correlation coefficients were used to assess construct validity. The Transition-KompAZ includes the following modules: (1) competencies in transition (knowledge, self-management), (2) needs (healthcare services, information), and (3) satisfaction (general, transitional care). A total of 173 AYAs (group 1: n = 86; group 2: n = 87) from 12 rheumatology sites completed the Transition-KompAZ. It showed good model fit (comparative fit index > 0.9; Tucker-Lewis index > 0.9; weighted root mean square residual < 0.9) with good internal consistency. The instrument demonstrated moderate-to-good construct validity and good test-retest reliability. The Transition-KompAZ appears to be a reliable tool for assessing important dimensions of transition. It may support a structured and individualized transition, as well as the evaluation of transition services. However, further studies are required to assess its predictive value in terms of transfer readiness and successful transition.

Fetal alcohol syndrome and population level health care usage in British Columbia, Canada.

BackgroundThe literature indicates that youth with Fetal Alcohol Syndrome (FAS) may experience high rates of both physical and mental health issues compared to youth without FAS. However, there is little population level health data available for youth with FAS, particularly for youth transitioning from pediatric to adult healthcare services. ObjectiveThe objective of this study was to compare health care usage of youth with Fetal Alcohol Syndrome to youth without any intellectual/developmental disabilities (IDD). MethodsThis study used a retrospective cohort design and population-level administrative health data to examine five aspects of health care usage by youth with FAS and compare them to youth with no intellectual/developmental disability. The variables were medically required dental care, visits to emergency departments and visits for mental health issues. In addition, the study stratified data by age groups and examined the difference between youth aged 15-19 and youth aged 20-24. ResultsYouth with FAS had higher adjusted odds of medically required dental care, visits to the emergency department and visits for anxiety/depression, psychotic illnesses and substance use disorders compared to youth with no IDD. The odds of a medically required dental visit, emergency department visit and visit for psychotic illness or substance use disorder were also higher for youth aged 20-24 years compared to youth aged 15-19 years. ConclusionsThese findings indicate that youth with FAS require urgent attention for each of the medically-related variables included in this study. The need for attention to their health care needs may increase as these youth transition from pediatric to adult health care services.

Transition mentorship for spina bifida patients with the JUMP program: a pilot study.

The transition from pediatric to adult care is challenging for patients and families with spina bifida (SB). Lifelong care relationships yield to new care environments that are typically larger, less personal, and less engaged with the nuances of SB care. Adolescence and young adulthood are often characterized by personal and psychological stresses due to factors independent of illness or chronic medical complexity. Surveys have demonstrated that transition is associated with uncertainty, anxiety, and elevated risk of adverse events for many SB patients. To help mitigate this, the authors developed a trial mentorship program between teen patients with SB and undergraduate/medical students. This study analyzes and presents the initial outcomes from this program. The authors created the Join, Unite, Motivate, and Prepare (JUMP) program to improve readiness for the transition process. The mentee target population was patients aged 13-19 years receiving care at the authors' SB clinic. Mentors were screened/approved undergraduate/medical students who volunteered to participate and successfully completed online training in mentorship. Upon enrollment, each patient set a combination of clinical, self, and parent/guardian goals using the individualized transition plan. These goals were shared with the mentor, mentee, parent/guardian, and physician. To monitor success, the SB program director routinely met with each mentor to discuss progress made and areas of growth. These included continuous quantitative and qualitative goal setting and failures that needed to be addressed for each agenda. Thirteen mentor-mentee matches were created over 9 months. Of the 13 matches, 6 had more than 5 communications after the initial meeting, and 1 mentor-mentee match is still in contact today. Noted success in the program has been through mentees gaining employment, applying for scholarships, starting college, and connecting with others who are going through similar circumstances. Challenges have arisen through failure to follow-up after the initial office visit, risk with using the virtual platform, and wide geographic dispersion of both mentors and mentees across the authors' state. Transition from pediatric to adult care for adolescents with SB has proven to be a large hurdle. Easing this process through well-thought-out, interactive processes has the potential to improve readiness, increase patient autonomy, and provide exposure to the adult healthcare community. However, the mentorship model, in the SB setting, has not proven to be the remedy.

Navigating the transition: the crucial shift from pediatric to adult care for individuals living with spina bifida.

Spina bifida (SB) is a complex congenital condition characterized by incomplete closure of the neural tube, resulting in varying degrees of physical and neurological impairment. Although commonly managed by multidisciplinary pediatric clinics, a substantial proportion of SB patients are now living into adulthood, necessitating the transition from pediatric to adult healthcare. This transition introduces a myriad of challenges for individuals living with SB and their families. Prior research on SB transition programs has demonstrated anecdotal success; however, minimal research has been published on early posttransition health outcomes and compliance with medical recommendations. This quality improvement study assessed early posttransition compliance with medical recommendations, adverse health events, access to medical supplies/equipment, and patient-reported health outcome and confidence in medical providers. Adult participants in the Spina Bifida Transition Clinic at the authors' pediatric institution were invited to complete a telephone survey after transition to adult care. The mean (SEM) elapsed time since transition was 1.21 (0.11) years. The survey evaluated adult provider utilization, accessibility of medical supplies and equipment, adverse medical events, compliance with sleep study acquisition, patient-reported health status, and satisfaction with providers. Of 52 eligible participants, 49 (94%) completed a telephone survey. Within the cohort, 82% had open SB (myelomeningocele), with the remaining having occult SB (lipomyelomeningocele). The mean age at transition was 26.0 years. Since transition, 78% have attended at least one primary care visit, with 76% seeking care from at least one adult care specialist (69% sought care with urologists). Forty-five percent reported an adverse medical event: 31% required an emergency department visit, 22% were hospitalized, 18% underwent surgery, and 24% had skin breakdown. Access to medical supplies varied, with patients experiencing the most difficulty obtaining wheelchairs and assistive walking devices. Patients rated pediatric provider engagement and knowledge of SB significantly higher than adult providers (mean 3.92 vs 3.32, p < 0.001). This quality improvement study evaluated the effectiveness of our Spina Bifida Transition Clinic in the early post transition period. While patients have used primary and specialty care (urology), they have experienced many adverse events and low compliance with sleep study acquisition. Continued evaluation of transition programs is required to optimize the outcome of those living with SB.

Integrated primary and community mental health care for young adults with serious mental illness: A program evaluation.

Young adults with serious mental illness (SMI) have poor physical health and high Emergency Department (ED) and hospital utilization. Integrating primary care into community mental health care may be an important form of early intervention. Adjusted multivariable regressions assessed changes in self-reported annual primary care, ED and hospital utilization for 83 young adults with SMI enrolled in integrated care. Participants' mean annual per person utilization changed significantly as follows: primary care visits, from 1.8 to 3.6, p < .001; medical ED visits, from 1.0 to 0.6, p < .01; psychiatric ED visits from 0.6 to 0.2, p < .001; medical inpatient days, from 1.2 to 0.1, p < .001 and psychiatric inpatient days, from 6.3 to 2.6, p < .001. Young adults with SMI receiving integrated care increased primary care and reduced ED and inpatient utilization. Future controlled research is warranted to further assess integrated care for young adults with SMI.

Use of an electronic wellness instrument in the integrated health and social care of older adults: a group concept mapping study

BackgroundHealth system fragmentation directly contributes to poor health and social outcomes for older adults with multiple chronic conditions and their care partners. Older adults often require support from primary care, multiple specialists, home care, community support services, and other health-care sectors and communication between these providers is unstructured and not standardized. Integrated and interprofessional team-based models of care are a recommended strategy to improve health service delivery to older adults with complex needs. Standardized assessment instruments deployed on digital platforms are considered a necessary component of integrated care. The aim of this study was to develop strategies to leverage an electronic wellness instrument, interRAI Check Up Self Report, to support integrated health and social care for older adults and their care partners in a community in Southern Ontario, Canada.MethodsGroup concept mapping, a participatory mixed-methods approach, was conducted. Participants included older adults, care partners, and representatives from: home care, community support services, specialized geriatric services, primary care, and health informatics. In a series of virtual meetings, participants generated ideas to implement the interRAI Check Up and rated the relative importance of these ideas. Hierarchical cluster analysis was used to map the ideas into clusters of similar statements. Participants reviewed the map to co-create an action plan.ResultsForty-one participants contributed to a cluster map of ten action areas (e.g., engagement of older adults and care partners, instrument’s ease of use, accessibility of the assessment process, person-centred process, training and education for providers, provider coordination, health information integration, health system decision support and quality improvement, and privacy and confidentiality). The health system decision support cluster was rated as the lowest relative importance and the health information integration was cluster rated as the highest relative importance.ConclusionsMany person-, provider-, and system-level factors need to be considered when implementing and using an electronic wellness instrument across health- and social-care providers. These factors are highly relevant to the integration of other standardized instruments into interprofessional team care to ensure a compassionate care approach as technology is introduced.

Assessing how frailty and healthcare delays mediate the association between sexual and gender minority status and healthcare utilization in the All of Us Research Program.

To understand how frailty and healthcare delays differentially mediate the association between sexual and gender minority older adults (OSGM) status and healthcare utilization. Data from the All of Us Research Program participants ≥50 years old were analyzed using marginal structural modelling to assess if frailty or healthcare delays mediated OSGM status and healthcare utilization. OSGM status, healthcare delays, and frailty were assessed using survey data. Electronic health record (EHR) data was used to measure the number of medical visits or mental health (MH) visit days, following 12 months from the calculated All of Us Frailty Index. Analyses adjusted for age, race and ethnicity, income, HIV, marital status ± general MH (only MH analyses). Compared to non-OSGM, OSGM adults have higher rates of medical visits (adjusted rate ratio [aRR]: 1.14; 95% CI: 1.03, 1.24) and MH visits (aRR: 1.85; 95% CI: 1.07, 2.91). Frailty mediated the association between OSGM status medical visits (Controlled direct effect [Rcde] aRR: 1.03, 95% CI [0.87, 1.22]), but not MH visits (Rcde aRR: 0.37 [95% CI: 0.06, 1.47]). Delays mediated the association between OSGM status and MH visit days (Rcde aRR: 2.27, 95% CI [1.15, 3.76]), but not medical visits (Rcde aRR: 1.06 [95% CI: 0.97, 1.17]). Frailty represents a need for medical care among OSGM adults, highlighting the importance of addressing it to improve health and healthcare utilization disparities. In contrast, healthcare delays are a barrier to MH care, underscoring the necessity of targeted strategies to ensure timely MH care for OSGM adults.

Adverse Childhood Experiences: Health Care Utilization And Expenditures In Adulthood.

Adverse childhood experiences (ACEs) have been shown to be strong predictors of socioeconomic status, risky health behaviors, chronic health conditions, and adverse outcomes. However, less is known about their association with adult health care utilization and expenditures. We used new data from the 2021 Medical Expenditure Panel Survey-Household Component (MEPS-HC) to provide the first nationally representative estimates of ACEs-related health care utilization and expenditure differences based on direct observation, rather than model-based extrapolation. Compared to demographically similar adults without ACEs, those with ACEs had substantially higher utilization and 26.3percent higher expenditures. The aggregate spending difference across the 157.6million US adults with ACEs was $292billion in 2021. Moreover, we observed large, graded relationships between ACEs and health status, health behaviors, and some dimensions of socioeconomic status. We also found associations between ACEs and a range of adverse adult circumstances, also newly measured in the 2021 MEPS, including financial and housing problems, social network problems, little or no life satisfaction, stress, food insecurity, verbal abuse, physical harm, and discrimination.

Evaluation of the transition program at the University Hospital of Reims from 2015 to 2020.

The transition of young type 1 diabetic (T1D) patients from pediatric to adult healthcare is a high-risk period of loss to follow-up. Since 2015, we have implemented a transition program, involving both pediatric and adult clinicians. The main objective was to evaluate the number of patients who had succeeded this transition program at 1 year. We found that 86% of patients underwent the complete transition program. However, adverse outcomes occurred in 19.1% of patients at 1 year but decreased to 2.9% after 3 years. In 63% of patients their HbA1c level had deteriorated 1 year after the transition day and this level stabilized at around 8% in the following 2 and 3 years. In patients who had improved HbA1c levels the body mass index was lower (P = 0.03) and they lived alone (P = 0.04). Although our program seemed to allow a better follow-up than previously described, this study highlights the importance of further supporting this transition period.

Translation and psychometric properties of the Arabic version of the ageism scale for dental students (ASDS-Ar): A multi-institutional validation.

Ageism represents an important barrier to high-quality healthcare for older adults. The present study sought to translate and validate the Arabic version of the Ageism Scale for Dental Students (ASDS-Arabic). The 27-item ASDS tool was translated from English into Arabic following recommended cross-sectional forward and backward translation guidelines. The translated version was subjected to the content validity ratio (CVR) and sent to dental students in 21 institutes from 10 different Arab countries. Principal components analysis (PCA) was used to assess the dimensionality of the scale, and Cronbach's alpha was used to determine internal consistency reliability. The discriminant validity of the scale was assessed using the independent t-test. Confirmatory factor analysis (CFA) was also undertaken. Based on CVR, three items were removed. The 24-item Arabic version was completed by 3284 dental students. PCA and CFA retained 17 items in six components, explaining 50.3% of the total variance, with acceptable reliability, validity and discrimination. The first component "Adherence of older patients with dental treatment and instructions," included four items with a Cronbach α of 0.64 and scored 4.3 ± 0.8. The second component "Feasibility of the treatment plan," included three items with a Cronbach α of 0.66 and scored from 2.6 ± 1.2 to 2.9 ± 1.1. The third component "Cost of and responsibility for the dental treatment" included four items with a Cronbach α of 0.47 and scored 4.4 ± 0.8 to 4.5 ± 0.8. The fourth component "Medical history of older patients" included two items with a Cronbach α of 0.70 and scored 4.0 ± 1.0 to 4.1 ± 1.0. The fifth Component "Feeling towards older patients" included two items with a Cronbach α of 0.672 and scored 2.6 ± 1.2 to 2.0 ± 1.4. The sixth Component "Confidence and experience in treating older patients" included two items with a Cronbach α of 0.33 and scored 4.4 ± 1 to 4.6 ± 1. This preliminary validation of the ASDS-Ar resulted in a new 17-item scale with six components with acceptable validity, reliability and discrimination.

Unmet care needs in psychiatric healthcare context: A systematized literature review.

Missed, rationed or unfinished nursing care represents a global problem that jeopardizes the provision of quality and safe care. This phenomenon is frequently observed in adult, paediatric and child healthcare facilities and various care units. The findings of this review contribute valuable information to inform evidence-based practices, foster organizational improvements and ultimately optimize the overall quality of care in psychiatric healthcare settings. In addition, the review illuminates the far-reaching consequences of care on both patient and nurse outcomes, emphasizing the urgent need for tailored strategies to mitigate these effects. Based on the synthesis of the literature, a thorough and continuous assessment of patient care needs in the physical, psychological and social domains is needed, primarily utilizing standardized instruments designed for psychiatric settings to ensure a comprehensive understanding of unmet needs. Based on identified unmet needs, nurses should develop individualized care plans and tailor interventions to address them. In addition, nurse managers must adopt and implement regular monitoring mechanisms to track the prevalence of unmet care needs and at the same time establish reporting systems that capture the proportion of unmet needs, allowing timely interventions and adjustments to care delivery. Lastly, nurse managers must not only emphasize the importance of ethical care practices and dignity-focused interventions but also educate healthcare providers, especially nurses, on the potential threats to patient dignity arising from unmet care needs. INTRODUCTION: Despite frequent observations of unmet care needs in acute care adult settings, there are a limited number of studies that focus on investigating this phenomenon in the psychiatric setting. To synthesize the existing empirical research on unmet care needs in psychiatric healthcare settings. The search was carried out in August 2023 in four scientific databases, PubMed, ProQuest, Web of Science and OVID Nursing, based on their institutional availability. The search produced 1129 studies. The search and retrieval process reflected the recommendations of the Preferred Reporting Items for systematic reviews and meta-analyses. This review included 14 studies investigating unmet care needs in the psychiatric healthcare setting. Unmet care needs included three domains: physical, psychological and social. The analysis of the factors revealed factors related to the characteristics of the organization, nurse and patient. The classification of unmet needs provides a comprehensive understanding of the various challenges facing people in psychiatric healthcare settings. Identified factors that influence the occurrence of unmet care needs will help prevent the occurrence of unmet care needs and timely assessment. The resolution of needs helps to achieve patient and nurse outcomes, increase the quality of care provided and patient satisfaction in a psychiatric healthcare setting.

Changes in Empathy and Mental Resilience in Health Professionals After Completing the Certified "Generic Instructor Course" Seminar.

Factors that may affect the performance of healthcare professionals performing resuscitation include stress, social profile, fatigue, empathy, and resilience. Interpersonal skills are required for better performance. This study aimed at evaluating the change in empathy and mental resilience in health professionals who have the status of instructor potential achieved after successfully completing a certified training/intervention course and want to develop/certify as course instructors. Healthcare professionals attended the Generic Instructor Course (GIC), a two-day course training instructor candidates from different training courses. Empathy and the cultivation of mental resilience of adult healthcare professional trainers were measured in order to investigate whether participation in a simulated training processcan influence these characteristics of the trainer and how these characteristics interact with the training process. Four measurements were recorded: (i) baseline (before the GIC course), (ii) after the course, (iii) follow-up after one month, and (iv) follow-up after three months. Ninety participants in the GIC course were the study sample. Participants showed statistically higher empathy after participation in the GIC vs. baseline, one-month, and three-month follow-up (p = 0.023). Resilience did not reveal any statistical difference, after the participation in the GIC and follow-up measurements (p = 0.084). For both variables (empathy and resilience), demographics did not have any association with the variables. Besides its primary aim of training and certifying future instructors in resuscitation courses, the GICalso had a positive impact on the participants' empathy.

A Clinician's Guide To Effectively Transitioning and Transferring Care For Pediatric Patients With Inflammatory Bowel Diseases From The Pediatric To Adult Gastroenterologist.

Transition of care for pediatric patients with inflammatory bowel diseases (IBD) is a continuous, dynamic process that takes place over several years with a coordinated approach executed by a multidisciplinary team. We review the concepts, tools, and research in effective transitioning and transfer of care for adolescent/young adult patients with IBD. Given the constraints within the healthcare system, effective transitioning can be challenging to implement in everyday clinical practice. Different barriers include resources and expertise in effective transitioning by pediatric and adult gastroenterology healthcare providers and the impact of non-gastrointestinal issues facing young adult patients who are learning to manage and coordinate all aspects of their medical care and health maintenance. Factors that facilitate successful care transitioning and transfer include structured transitioning programs, utilization of validated transition checklists, and IBD medical summaries. Proactive transitioning by pediatric gastroenterologists in partnership with their emerging young adult patients with IBD leads to better clinical and psychosocial outcomes and ultimately, effective transfer of care to adult gastroenterology. By utilizing utilize comprehensive transition assessment tools and medical summaries in partnership with their patients, pediatric and adult gastroenterology teams can better prepare patients as they transfer to independent care and health maintenance.

Transition to Adulthood in Pediatric Palliative Care: A Narrative Review.

Pediatric palliative care (PPC) is defined as "the active care of the child's body, quality of life, mind and spirit, also giving support to the family". PPC should be established once a diagnosis of life-limiting or life-threatening disease is reached and should continue as long as necessary. Therefore, pediatric palliative care (PPC) can continue for years, also given the improved care approaches for children with life-limiting or life-threatening diseases. Over time, the child may grow to become a young adult, and when this happens, the transition to adult healthcare services must be undertaken. This article discusses possible interventions, fostering an efficient transition from pediatric to adult palliative care. A narrative review presents issues, experiences, and existing programs. A "Perspectives" section presents opinions and proposals by the authors. The transition process is not limited to a change from pediatric to adult services. Rather, it includes the entire process of the development of the child and requires interdisciplinary management with proper planning and collaboration among professionals of pediatric and adult teams.

“My support groups… have saved my life.”: facilitators of positive or satisfactory experiences in behavioral healthcare for transgender and gender nonconforming older adults

Objectives Transgender and gender nonconforming (TGNC) older adults experience significant behavioral health and healthcare disparities. Facilitators that contribute to positive behavioral healthcare experiences among this population, however, remain uncertain. In this study, we investigate facilitators contributing to positive or satisfactory behavioral healthcare experiences among a sample of TGNC older adults in the United States (US). Method Between September 2021 and January 2022, the first author conducted 47 semi-structured, individual interviews with TGNC adults aged 65 years or over in the US. Using an inductive grounded theory approach, we examined respondents’ positive or satisfactory experiences with accessing and utilizing behavioral health services, support, and resources. Analyses were conducted using NVivo (Release 1.6) software. Results Findings underscore the importance of addressing the specific or unique needs of TGNC older patients to promote positive or satisfactory experiences in behavioral healthcare. Three themes emerged: (1) engaging with behavioral healthcare practitioners who offer compassionate, patient-centered care; (2) accessing and utilizing culturally tailored peer-support groups; and (3) receiving equitable access to gender-affirming care and social services. Conclusion These findings highlight opportunities for expanding and incorporating these identified facilitators into behavioral healthcare research and practice, especially when promoting gender affirmation in care for TGNC older patients.

Transition between paediatric and adult diabetes healthcare services: An online global survey of healthcare professionals’ experiences and perceptions

IntroductionYouth with diabetes should transition from paediatric to adult diabetes services in a deliberate, organized and cooperative way. We sought to identify healthcare professionals’ (HCPs) experiences and perceptions around transition readiness planning, policies and procedures, and the actual transfer to adult services. MethodsData were collected via an online global survey (seven language options), broadly advertised by the International Society for Pediatric and Adolescent Diabetes (ISPAD), European Association for the Study of Diabetes (EASD), team members and partners, via newsletters, websites, e-mails and social media. ResultsRespondents (n = 372) were mainly physicians (74.5 %), practicing in government funded (59.4 %), paediatric (54.0 %), metropolitan settings (85.8 %) in Europe (44.9 %); 37.1 % in low and middle-income countries (LMICs). Few centers used a transition readiness checklist (32.8 %), provided written transition information (29.6 %), or had a dedicated staff member (23.7 %). Similarly, few involved a psychologist (25.8 %), had combined (35.2 %) or transition/young person-only clinics (34.9 %), or a structured transition education program (22.6 %); 49.8 % advised youth to use technology to assist the transfer.Most (91.9 %) respondents reported barriers in offering a good transition experience. Proportionally, more respondents from LMICs prioritised more funding (p = 0.01), a structured protocol (p < 0.001) and education (p < 0.001). ConclusionHCPs’ experiences and perceptions related to transition vary widely. There is a pressing need for an international consensus transition guideline.

Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization

BackgroundLaboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada.MethodsWe have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2–3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes.DiscussionThe study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work.Trial RegistrationThis study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic.clinicaltrials.gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1

Coupled changes between ruminating thoughts and resting-state brain networks during the transition into adulthood.

Perseverative negative thoughts, known as rumination, might arise from emotional challenges and preclude mental health when transitioning into adulthood. Due to its multifaceted nature, rumination can take several ruminative response styles, that diverge in manifestations, severity, and mental health outcomes. Still, prospective ruminative phenotypes remain elusive insofar. Longitudinal study designs are ideal for stratifying ruminative response styles, especially with resting-state functional MRI whose setup naturally elicits people's ruminative traits. Here, we considered self-rated questionnaires on rumination and psychopathology, along with resting-state functional MRI data in 595 individuals assessed at age 18 and 22 from the IMAGEN cohort. We conducted independent component analysis to characterize eight single static resting-state functional networks in each subject and session and furthermore conducted a dynamic analysis, tackling the time variations of functional networks during the entire scanning time. We then investigated their longitudinal mediation role between changes in three ruminative response styles (reflective pondering, brooding, and depressive rumination) and changes in internalizing and co-morbid externalizing symptoms. Four static and two dynamic networks longitudinally differentiated these ruminative styles and showed complemental sensitivity to internalizing and co-morbid externalizing symptoms. Among these networks, the right frontoparietal network covaried with all ruminative styles but did not play any mediation role towards psychopathology. The default mode, the salience, and the limbic networks prospectively stratified these ruminative styles, suggesting that maladaptive ruminative styles are associated with altered corticolimbic function. For static measures, only the salience network played a longitudinal causal role between brooding rumination and internalizing symptoms. Dynamic measures highlighted the default-mode mediation role between the other ruminative styles and co-morbid externalizing symptoms. In conclusion, we identified the ruminative styles' psychometric and neural outcome specificities, supporting their translation into applied research on young adult mental healthcare.

The pervasive influence of systems of power on transition readiness for adult care in sickle cell disease: A qualitative study.

Adolescence and young adulthood are vulnerable developmental periods for individuals with sickle cell disease (SCD), particularly given the impact of social inequities, challenges with transitioning to adult healthcare services, and increased risk for morbidity and mortality. Systems of power, such as institutionalized and interpersonal manifestations of bias, could impact SCD transfer and engagement in adult care through their influence on healthcare transition readiness; yet research in this area is limited. To characterize how systems of power impact transition readiness factors described in the Social-ecological Model of AYA Readiness for Transition to Promote Health Equity (SMART-E) framework at the patient, caregiver, and practitioner levels. Pediatric adolescents and young adults (AYA), transferred AYA, caregivers, and practitioners participated in semi-structured focus groups and individual interviews examining health equity and systems of power during healthcare transition. Focus groups/interviews were transcribed and coded using a deductive approach via the updated SMART-E framework. Ten pediatric AYA with SCD, nine transferred AYA with SCD, eight caregivers, and nine practitioners participated in a focus group or interview. Qualitative findings across reporters emphasize the impact of systems of power (e.g., racial bias and disease stigma) on knowledge, skills and self-efficacy, beliefs and expectations, goals and motivation, and emotions and psychosocial functioning at the patient, caregiver, and practitioner levels. Systems of power are prevalent with respect to transition barriers for AYA with SCD and their supports. Structural, institutional, and individual factors with potential to reduce the influence of systems of power should be further identified and targeted for intervention.