Baseline Comparison Group Research Articles

The efficacy of psychoeducation to improve personal skills and well-being among health-care professionals returning to clinical practice: a pilot pre-post study

PurposeMany health-care professionals leave clinical practice temporarily or permanently. Interventions designed to facilitate the return of health-care professionals fail to consider returners’ psychosocial needs despite their importance for patient care. This study aims to evaluate the efficacy of a psychoeducational intervention in improving personal skills and well-being among UK-based health-care professionals returning to clinical practice.Design/methodology/approachIn total, 20 health-care professionals took part in the one-day intervention and completed measures of demographics, self-efficacy, positive attitudes towards work and perceived job resources before and after the intervention. A baseline comparison group of 18 health-care professionals was also recruited.FindingsSignificant associations were detected between return-to-work stage and study group. Following the intervention, participants reported improvements in self-efficacy and, generally, perceived more job resources, whereas positive attitudes towards work decreased. While none of these changes were significant, the intervention was deemed acceptable by participants. This study provides modest but promising evidence for the role of psychoeducation as a tool in supporting the psychosocial needs of returning health-care professionals.Research limitations/implicationsAdditional research is needed to clarify the reliability of intervention effects, its effectiveness compared to alternative interventions, and the impact across different subgroups of returning health-care professionals.Practical implicationsReturn-to-practice interventions should address the psychosocial needs of health-care professionals in terms of their personal skills and well-being. Psychoeducation can increase self-efficacy and perceptions of job resources among returning health-care professionals.Originality/valueThis study sheds light on a relatively understudied, but fundamental area – the psychosocial challenges of health-care professionals returning to clinical practice – and further justifies the need for tailored interventions.

Development and evaluation of a forensic nursing competency-based hybrid simulation education program: A quasi-experimental design

AimThis study aimed to develop and validate the effectiveness of a hybrid simulation education program designed to enhance the forensic nursing competency of emergency department nurses. BackgroundEmergency nurses often bear the responsibility of conducting forensic nursing assessments and interventions, such as patient recognition and evidence collection, to safeguard patients' legal rights, given their frequent encounters with emergency department patients. Simulation methods have proven effective in training for forensic nursing care. However, there is still a need for the development of forensic nursing education using simulation methods. DesignThis study employed a one-group pre-test/post-test quasi-experimental design. A four-hour simulation education program was developed based on the analysis, design, development, implementation, and evaluation model, with a focus on enhancing forensic nursing competency. MethodsNurses with more than six months of clinical experience in the emergency department in South Korea were divided into an experimental group (n=23) and a baseline comparison group (n=24). Both groups completed self-evaluations of their forensic nursing competency through a survey. The experimental group underwent the simulation education program, and their forensic nursing performance was evaluated before and after the program. Following the training, participants completed a questionnaire to assess their forensic nursing competency and satisfaction with the program. ResultsThe initial forensic nursing competency of the experimental and baseline comparison groups was found to be similar. However, the forensic nursing competency and performance of the experimental group exhibited significant improvement after the training. Regarding program evaluation, the average scores on a 5-point scale were as follows: theoretical lecture (4.79 SD 0.27), simulation education (4.78 SD 0.29), simulation design (4.42 SD 0.45), and satisfaction with the educational program (4.82 SD 0.28). ConclusionsThe forensic nursing competency-based simulation education program herein improved the relevant competency and performance of emergency nurses.

Triangulation of evidence on immigration and rates of alcohol use disorder in Sweden: Evidence of acculturation effects.

This study aimed to determine the robustness of the impact of immigration on risk for alcohol use disorder (AUD) using different measures, designs, and immigrant regional cohorts. The analytic sample included all individuals born between 1950 and 1990 and registered in Sweden from 1973 to 2017. Using Cox regression models, we examined the risk for AUD from Swedish nationwide registries in immigrants to Sweden from seven geographical regions: Africa, Asia and Oceania, Eastern Europe, Finland, Latin America and the Caribbean, Middle East/North Africa, and Western countries. We assessed greater exposure to Swedish culture, which we interpreted as increasing acculturation, by (i) comparing first-generation immigrants and their children with no and one native Swedish parent and (ii) examining age at immigration. The baseline comparison group was the native Swedish population. We also examined AUD risk in first-generation sibling pairs discordant for their age at immigration. In nearly all immigrant cohorts in Sweden, increasing degrees of acculturation, as assessed by both our variables, were associated with rates of AUD that approached those of the Swedish population. These findings occurred in both men and women and both regional cohorts whose first-generation immigrants had lower and higher levels of AUD than native-born Swedes. For most cohorts, the rates of change with acculturation were greater in women than in men. In sibling pairs from most regions, the sibling who was younger at immigration had a higher rate of AUD. An examination of both sexes and two different proxies for acculturation provides consistent support for socio-cultural influences on AUD risk. Our co-sibling analyses suggest that a meaningful proportion of this effect is likely to be causal in nature.

Early detection of obstructive sleep apnea in patients with atrial fibrillation.

Obstructive sleep apnea (OSA) is an independent and modifiable risk factor for atrial fibrillation (AF) and correlates with a three-fold higher risk of incident AF. Although OSA is prevalent in patients with AF, it remains underdiagnosed. Guidelines for OSA screening are ambiguous. A small community hospital in the southeast United States lacked standardized OSA screening and consistent sleep clinic referral for hospitalized patients with AF. Over 3 months, an OSA bundle (including screening, education, and referral) was implemented for hospitalized patients with AF. A retrospective electronic health record (EHR) review established a baseline comparison group. Descriptive analyses between the intervention and comparison groups evaluated the effectiveness of the OSA bundle. Eligible patients received OSA screening with the STOP-Bang questionnaire. A STOP-Bang score of 3 or higher triggered patient education about the arrhythmogenic relationship of OSA and AF. At discharge, patients received an ambulatory sleep clinic referral. After 3 months, an EHR review assessed the rate of sleep clinic follow-up, sleep testing, OSA diagnosis, and initiation of positive airway pressure. Of the 68 patients in the comparison group and 33 patients in the intervention group, the rate of OSA screening increased from 4.4% to 100%. Sleep clinic referral increased from 66.7% to 93.5%. Sleep clinic follow-up increased from 0% to 10%. Screening for OSA and sleep clinic referral improved with the OSA bundle; however, sleep clinic follow-up remained low. Further quantitative and qualitative investigation is needed to better understand barriers to sleep clinic follow-up.

Decreasing driveline infections in patients supported on ventricular assist devices: a care pathway approach

BackgroundDriveline infections (DLIs) are a common adverse event in patients on ventricular assist devices (VADs) with incidence ranging from 14% to 59%. DLIs have an impact on patients and the...

Risk Factors for COVID-19 Hospitalization in School-Age Children.

IntroductionWith the recent emergence of the Omicron variant, there has been a rapid and alarming increase in the number of COVID-19 cases among pediatric populations. Yet few US pediatric cohort studies have characterized the clinical features of children with severe COVID-19. The objective of this study was to identify those chronic comorbidities that increase the risk of hospitalization for pediatric populations with severe COVID-19.MethodsA retrospective cohort study that utilized the Texas Inpatient Public Use Data file was conducted. The study included 1187 patients (ages 5 to 19) from 164 acute-care Texas hospitals with the primary or secondary ICD-10CM diagnosis code U07.1 (COVID-19, virus identified). The baseline comparison group included 38 838 pediatric patients who were hospitalized in 2020. Multivariable binary logistic regression, controlling for patient characteristics, sociodemographic factors, and health insurance, was used to estimate the adjusted risk of hospitalization for COVID-19.ResultsObesity and type 1 diabetes increased the risk of hospitalization with COVID-19 among both children (5-12 years) and adolescents (13-19 years). Adolescents with morbid obesity were 10 times more likely to have severe COVID-19 (p < 0.001). Regardless of age, single-parent households (%) for the patient's zip code was associated with an increased risk of hospitalization with COVID-19 (AOR = 1.02, CI: 1.01-1.03, p < 0.01). Other risk factors included chronic kidney disease (p < 0.05), male gender (p < 0.001), Medicaid (p < 0.001), and charity care (p < 0.001).ConclusionPediatric providers and public health officials should consider the need to tailor clinical management and mitigation efforts for pediatric populations with identifiable risk factors for severe COVID-19. These findings can be used to improve risk communication with families of children with underlying medical conditions and to prioritize prevention measures, including vaccinations.

Identifiability and Estimation Under the Test-negative Design With Population Controls With the Goal of Identifying Risk and Preventive Factors for SARS-CoV-2 Infection.

Owing to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, quick public health investigations of the relationships between behaviors and infection risk are essential. Recently the test-negative design (TND) was proposed to recruit and survey participants who are symptomatic and being tested for SARS-CoV-2 infection with the goal of evaluating associations between the survey responses (including behaviors and environment) and testing positive on the test. It was also proposed to recruit additional controls who are part of the general population as a baseline comparison group to evaluate risk factors specific to SARS-CoV-2 infection. In this study, we consider an alternative design where we recruit among all individuals, symptomatic and asymptomatic, being tested for the virus in addition to population controls. We define a regression parameter related to a prospective risk factor analysis and investigate its identifiability under the two study designs. We review the difference between the prospective risk factor parameter and the parameter targeted in the typical TND where only symptomatic and tested people are recruited. Using missing data directed acyclic graphs, we provide conditions and required data collection under which identifiability of the prospective risk factor parameter is possible and compare the benefits and limitations of the alternative study designs and target parameters. We propose a novel inverse probability weighting estimator and demonstrate the performance of this estimator through simulation study.

Social movement strategy (nonviolent vs. violent) and the garnering of third‐party support: A meta‐analysis

AbstractAn emerging literature suggests that the success of social movements depends, partly, on their ability to garner support from third‐party groups. One factor that appears to predict support is social movements’ use of nonviolent (compared to violent) strategies to achieve their goals. However, this literature is not definitive. Herein, we report the results of a meta‐analysis of research that has assessed the effect of the use of nonviolence on third‐party support (k = 16, N = 4598). A small‐to‐moderate positive effect was observed, d = 0.25. Additionally, research that used a control or baseline comparison group suggested that using nonviolent strategies marginally (p = .090) increased people's willingness to help the movement (d = 0.17) while adopting violent strategies did not increase or decrease people's willingness to help the movement (d = −0.03). Publication bias was evidenced by bigger effect sizes of published (vs. unpublished) studies. Target (i.e., state vs. social issues) and location of the protest (i.e., domestic vs. foreign) were not significant moderators, whereas the context (i.e., real vs. hypothetical scenarios) was, although marginally. Results suggest that it behooves social movements to adopt nonviolent strategies if third‐party support is desired.

Waterloo Better Beginnings as a Transformative Prevention Project: Impacts on Children, Parents, and the Community.

Better Beginnings Waterloo (BBW) is an ecological, community-driven, prevention program for children aged 4–8 and their families. BBW was implemented in two low-income communities with high percentages of visible minorities. Data on Grade 1–2 children and their parents (the baseline comparison group) were gathered through parent interviews (n = 34) and teacher reports (n = 68) in 2015, prior to BBW programs, and in the period 2018–2019, the same data were collected through parent interviews (n = 47) and teacher reports (n = 46) for children and parents participating in programs (the BBW group). As well, qualitative, open-ended individual interviews with parents (n = 47) and two focus groups were conducted in the period 2018–2019. Children in the BBW cohort were rated by their teachers as having a significantly lower level of emotional and behavioural problems than those in the baseline sample; parents in the BBW cohort had significantly higher levels of social support than parents in the baseline cohort; BBW parents rated their communities significantly more positively than parents at baseline. The qualitative data confirmed these findings. The quantitative and qualitative short-term findings from the BBW research showed similar positive impacts to previous research on program effectiveness, thus demonstrating that the Better Beginnings model can be successfully transferred to new communities.

Computational Markers of Risky Decision-making for Identification of Temporal Windows of Vulnerability to Opioid Use in a Real-world Clinical Setting

Opioid addiction is a major public health problem. Despite availability of evidence-based treatments, relapse and dropout are common outcomes. Efforts aimed at identifying reuse risk and gaining more precise understanding of the mechanisms conferring reuse vulnerability are needed. To use tools from computational psychiatry and decision neuroscience to identify changes in decision-making processes preceding opioid reuse. A cohort of individuals with opioid use disorder were studied longitudinally at a community-based treatment setting for up to 7 months (1-15 sessions per person). At each session, patients completed a risky decision-making task amenable to computational modeling and standard clinical assessments. Time-lagged mixed-effects logistic regression analyses were used to assess the likelihood of opioid use between sessions (t to t + 1; within the subsequent 1-4 weeks) from data acquired at the current session (t). A cohort of control participants completed similar procedures (1-5 sessions per person), serving both as a baseline comparison group and an independent sample in which to assess measurement test-retest reliability. Data were analyzed between January 1, 2018, and September 5, 2019. Two individual model-based behavioral markers were derived from the task completed at each session, capturing a participant's current tolerance of known risks and ambiguity (partially unknown risks). Current anxiety, craving, withdrawal, and nonadherence were assessed via interview and clinic records. Opioid use was ascertained from random urine toxicology tests and self-reports. Seventy patients (mean [SE] age, 44.7 [1.3] years; 12 women and 58 men [82.9% male]) and 55 control participants (mean [SE] age, 42.4 [1.5] years; 13 women and 42 men [76.4% male]) were included. Of the 552 sessions completed with patients (mean [SE], 7.89 [0.59] sessions per person), 252 (45.7%) directly preceded opioid use events (mean [SE], 3.60 [0.44] sessions per person). From the task parameters, only ambiguity tolerance was significantly associated with increased odds of prospective opioid use (adjusted odds ratio, 1.37 [95% CI, 1.07-1.76]), indicating patients were more tolerant specifically of ambiguous risks prior to these use events. The association of ambiguity tolerance with prospective use was independent of established clinical factors (adjusted odds ratio, 1.29 [95% CI, 1.01-1.65]; P = .04), such that a model combining these factors explained more variance in reuse risk. No significant differences in ambiguity tolerance were observed between patients and control participants, who completed 197 sessions (mean [SE], 3.58 [0.21] sessions per person); however, patients were more tolerant of known risks (B = 0.56 [95% CI, 0.05-1.07]). Computational approaches can provide mechanistic insights about the cognitive factors underlying opioid reuse vulnerability and may hold promise for clinical use.

POISONING DEATHS AMONG LATE-MIDDLE AGED AND OLDER ADULTS: COMPARISON BETWEEN SUICIDES AND DEATHS OF UNDETERMINED INTENT

Introduction In violent deaths, forensic autopsy is often regarded as the means for making the final medical diagnosis of the cause and manner of death; however, without other corroborative evidence (e.g., suicide note, prior history of suicide attempt/intent disclosure), drug intoxication and other poisoning deaths, especially among individuals with pre-existing substance use and/or mental health problems, pose challenges in determining the intent/manner of death. Given the rapid increase in prescription and illicit drug poisoning deaths in the 50+ age group, we examined precipitating/risk factors and toxicology results associated with poisoning deaths classified as suicides compared to intent-undetermined death (UnD) among decedents aged 50+. Methods The National Violent Death Reporting System, 2005-2015, provided data. The 2005-2015 NVDRS contained 56,118 suicide decedents and 7,752 UnDs aged 50+. Of these 50+-year olds’ deaths, poisoning deaths were 18.5% (N=10,363) of suicides and 65.7% (N=5,090) of UnDs. The present study focused on these 15,453 poisoning decedents and stratified them into three groups—suicide decedents who left a suicide note, suicide decedents who did not leave a note, and decedents classified as UnD. Following descriptive statistics using χ2 tests, multinomial logistic regression models were used to test study hypotheses (associations of intent/manner of death with precipitating/risk factors and positive toxicologies) controlling for incident year (time), state, and demographic variables. We chose suicide decedents who did not leave a suicide note as the baseline comparison group to better examine potential differences and similarities between them and UnDs. Results Of all poisoning deaths, 29.4% were classified as suicide decedents who left a note, 37.7% as suicides without a note, and 32.9% as UnDs. Of all NVDRS participating states, Maryland and Utah had the highest proportions of all poisoning deaths (82.8% and 58.9%, respectively) and the highest numbers of UnDs (52.5% of all UnDs in this study). We also found that of all states, Maryland had the highest proportion of Black decedents (34.6% of both poisoning suicides and UnDs). Analysis of time trend showed that the proportions of UnD cases in 2005 and 2015 were 36.5% and 30.0%, respectively, with a generally declining trend over the 11-year period. Multinomial logistic regression analysis showed that compared to suicide decedents without a note, those with a note were more likely to have been depressed and had physical health problems and other life stressors, while UnD cases were less likely to have had mental health problems and other life stressors but more likely to have had substance use and health problems. UnD cases were also more likely to be opioid (RRR=2.65, 95% CI=2.42-2.90) and cocaine (RRR=2.59, 95% CI=2.09-3.21) positive but less likely to be antidepressant positive (RRR=0.79, 95% CI=0.72-0.87). Those who left a note were older and more likely to be non-Hispanic White, but Blacks were more than twice as likely as non-Hispanic Whites to be UnDs. Gender was not a significant factor. Results from separate regression models in the highest UnD states (Maryland and Utah) and in states other than Maryland/Utah were similar. Conclusions The finding that UnDs had a higher likelihood of substance use problems and positive opioid and cocaine toxicology results suggests that their substance use/abuse was largely and directly responsible for their death. We could not compare UnDs to accidental overdose deaths, as the NVDRS does not include the latter, but such research among middle-aged and older adults is needed as many UnDs may be more correctly classified as unintentional overdose deaths. The extremely high UnD rates in Maryland and Utah are also likely reflections of the opioid epidemic that has raged in these two states. The study limitations were that as data on precipitating circumstances were largely collected from decedents’ informal support systems, the validity of these proxy-derived data is a concern as is incomplete/unknown data, and substantial numbers of toxicology-tested decedents had missing test results. However, the findings show that along with more accurate determination processes for intent/manner of death, substance use treatment and approaches to curbing opioid and other drug use problems are needed to prevent intentional and unintentional poisoning deaths. Racial disparities in UnDs also underscore the need for more effective approaches to prevention and curbing drug availability in communities with concentrations of low-income and racial/ethnic minority populations.

Curricular Learning Communities and Retention

Learning communities have been a part of the higher educational landscape since the 1980s. Despite their widespread use, research regarding their effectiveness with enhancing retention is sparse. This study describes a freshmen curricular learning community linking courses required for all business majors. Retention for students taking courses in a curricular learning community is compared to retention for students taking the same courses independent from a learning community. Analysis of the data indicates that students who participated in the learning community were twice as likely to persist to the following semester than the students in the baseline comparison group. The results provide evidence that purposeful structuring of courses in a curricular learning community with support imbedded to help students succeed is associated with improved retention.

Network Disadvantaged Entrepreneurs: Density, Hierarchy, and Success in China and the West

This article is about the network theory of advantage applied to entrepreneurship and an area-probability sample of 700 Chinese entrepreneurs, using 2,193 American and European managers as a baseline comparison group. The article deals with how certain entrepreneurs are disadvantaged by their networks, the contrasting forms that disadvantage takes in China and the West, the role of family in the Chinese networks, and ultimately the robustness of network theory to the cultural, structural, and content variations discussed.

The effect of testing can increase or decrease misinformation susceptibility depending on the retention interval

Research has consistently demonstrated that testing prior to the presentation of misleading post-event information, within the context of a standard eyewitness misinformation paradigm, results in an increase in the misinformation effect. The present study investigated whether changes in misinformation susceptibility in the context of interim testing are affected by retention interval differences between misinformation presentation and final testing. Further, this study tested possible divergences in original and post-event learning between conditions where elaboration in processing of critical details was encouraged either indirectly, via interim testing, or directly, by visually emphasizing critical details. In two experiments, we compared three groups of participants. All participants were exposed to an event, presented with misleading post-event misinformation, and then given a final test on the original event. One group was given an interim test between the original event and the post-event synopsis. A second was presented with a post-event synopsis in which critical details were visually emphasized. A third group served as a baseline comparison group for which synopsis processing was not manipulated. All experimental phases occurred in a single session in Experiment 1. A 48-hour retention interval was inserted between the post-event synopsis and final test in Experiment 2. In Experiment 1, we found that interim testing and emphasizing critical details increased misinformation susceptibility as compared to that found in the standard misinformation group. In Experiment 2, misinformation susceptibility was reduced in the interim testing group. These results suggest that interim testing and emphasizing critical details influence the rate of original detail forgetting. At a longer retention interval, the benefits of testing in learning emerged.

Workplace Satisfaction Before and After Move to an Open Plan Office - Including Interactions with Gender and Introversion

Open plan offices are both popular and controversial. We studied the response of a group moving from shared, but closed offices to an open plan office. The main data source reported here is a workplace satisfaction survey given pre-move, post-move, and to a lab baseline comparison group at the same organization, with some additional data from observations and interviews. Workers moving to the open plan office appreciated the flexible support for collaboration and the space’s appearance. There was lower satisfaction related to space for private concentrated work, temperature control, and ability to have private conversations. There were also some statistical interactions suggesting more positive responses by males and less positive responses by introverts; analysis was limited by small sample size. Observations and interviews gave further insight into open plan “neighborhoods” and the design of ad hoc spaces.

Evaluation of an online training for improving self-reported evidence-based decision-making skills in cancer control among public health professionals

ObjectivesThe purpose of this evaluation was to assess the effect of the online evidence-based cancer control (EBCC) training on improving the self-reported evidence-based decision-making (EBDM) skills in cancer control among Nebraska public health professionals. Study designCross-sectional group comparison. MethodsPreviously developed EBDM measures were administered via online surveys to 201 public health professionals at baseline (comparison group) and 123 professionals who took part in the training. Respondents rated the importance of and their skill level in 18 EBCC skills. Differences were examined using analysis of variance models adjusted for gender, age, years at agency, and years in position, and stratified by respondent educational attainment. ResultsAmong professionals without an advanced degree, training participants reported higher overall skill scores (P = .016) than the baseline non-participant group, primarily driven by differences in the partnerships and collaboration and evaluation domains. No differences in importance ratings were observed. Among professionals with advanced degrees, there were no differences in skill scores and small differences in importance scores in the expected direction (P < .05). Respondents at baseline rated the following facilitators for EBDM as important: expectations from agency leaders and community partners, high priority placed on EBDM by leadership, trainings, and positive feedback. They also reported using a variety of materials for making decisions about programs and policies, though few used individual scientific studies. ConclusionsEBCC led to improved self-reported EBDM skills among public health professionals without an advanced degree, though a gap remained between the self-reported skills and the perceived importance of the skills. Further research on training content and modalities for professionals with higher educational attainment and baseline skill scores is needed.

Short- and Long-term Impact of an Inpatient Quality Improvement Initiative

A significant percentage of patients undergoing coronary artery bypass graft (CABG) surgery leave the hospital without appropriate preventive medications. Little is known about this prevention gap and its solutions. We studied the short- and long-term impacts of a quality improvement (QI) project aimed at reducing this prevention gap. A sequential 3-phase QI project was performed in patients undergoing CABG surgery in Olmsted County, MN, from April 2001 to March 2002. In phase 1 (n = 213), cardiovascular surgery team members were given a pocket reminder card with preventive medication guidelines. In phase 2 (n = 182), monthly team feedback reports were added. In phase 3 (n = 199), a "refrigerator magnet" patient reminder card listing prescribed medications was added. A baseline comparison group (n = 305) was selected randomly from patients undergoing CABG surgery in 2000. Patient receipt of preventive medications and all-cause mortality were compared. Prescription of lipid-lowering medications (LLM) increased with each incremental QI tool as compared with baseline (P < .001). Nonsignificant trends were noted for aspirin, angiotensin-converting enzyme inhibitors, and β-blockers. At 1 year, the use of LLM was similarly high in all groups and was associated with cardiac rehabilitation use. Short- and long-term mortality rates did not differ between study groups. Our inpatient QI tools resulted in early, high LLM use, but the treatment advantage of the interventions was erased by 1 year and no survival benefit was noted. Our study illustrates the importance of tracking long-term outcomes in QI projects and suggests that outpatient cardiac rehabilitation is associated with long-term use of LLM.

Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization At A VA Hospital

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively small amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.

Implementing a Continuous Quality Improvement Program for Reducing Pressure Prevalence in a Teaching Hospital in China

The purpose of this study was to determine whether a continuous quality improvement program would reduce pressure ulcer prevalence. The study sample comprised 2913 patients who were used as a baseline comparison group and 3019 patients who acted as the intervention group. The research setting was a 3000-bed teaching hospital with 61 nursing units located in Wuhan, China. This prospective study compared pressure ulcer prevalence of patients admitted to hospital before and after implementation of a continuous quality improvement program designed to reduce the incidence of hospital-acquired pressure ulcers. The program was implemented after baseline data were collected in April and the comparison prevalence survey was completed in October of the same year. Pressure ulcer prevalence data were collected on a single day. The overall pressure ulcer prevalence (combining ulcers that were hospital acquired and present on admission) was 1.8% at baseline as compared to 1.4% following implementation of the quality improvement program. The prevalence of hospital-acquired pressure ulcers was 1.5% at baseline; it was 1.1% following the intervention. Excluding stage 1 pressure ulcers, the prevalence was 0.8% and 0.6%, respectively. No stage 4 pressure ulcers were identified when prevalence was measured after initiation of the prevention project. Pressure ulcer prevalence, which was low at baseline measurement, did not statistically significantly decrease, despite a comprehensive quality improvement program.

Accuracy of Primary Care and Hospital-Based Physicians' Predictions of Elderly Outpatients' Treatment Preferences With and Without Advance Directives

Past research has documented that primary care physicians and family members are often inaccurate when making substituted judgments for patients without advance directives (ADs). This study compared the accuracy of substituted judgments made by primary care physicians, hospital-based physicians, and family surrogates on behalf of elderly outpatients and examined the effectiveness of ADs in improving the accuracy of these judgments. Participants were 24 primary care physicians of 82 elderly outpatients, 17 emergency and critical care physicians who had no prior experience with the patients, and a baseline comparison group of family surrogates. The primary outcome was accuracy of physicians' predictions of patients' preferences for 4 life-sustaining treatments in 9 hypothetical illness scenarios. Physicians made substituted judgments after being provided with no patient AD, patient's value-based AD, or patient's scenario-based AD. Family surrogates' judgments were more accurate than physicians'. Hospital-based physicians making predictions without ADs had the lowest accuracy. Primary care physicians' accuracy was not improved by either AD. Accuracy and confidence in predictions of hospital-based physicians was significantly improved for some scenarios using a scenario-based AD. Although ADs do not improve the accuracy of substituted judgments for primary care physicians or family surrogates, they increase the accuracy of hospital-based physicians. Primary care physicians are withdrawing from hospital-based care in growing numbers, and emergency medicine and critical care specialists most often are involved in decisions about whether to begin life-sustaining treatments. If ADs can help these physicians better understand patients' preferences, patient autonomy more likely will be preserved when patients become incapacitated.