Care Planning Research Articles

Balanced chaos: A 55-year journey with unrepaired D-transposition of great arteries, ventricular septal defect, subvalvular and valvular pulmonary stenosis

Abstract We report a rare case of unoperated D-transposition of the great arteries (d-TGA) in a 55-year-old homeless patient presenting with exertional dyspnea and cyanosis. Echocardiographic findings revealed d-TGA with an outlet ventricular septal defect and concurrent subvalvular and valvular pulmonary stenosis. Due to delayed age of diagnosis, limited data on adult d-TGA outcomes, and socioeconomic factors, surgical intervention was not pursued. Instead, palliative care measures were implemented, underscoring the importance of early diagnosis, tailored care plans, and comprehensive support structures to optimize outcomes.

Rural tourism: Nurturing prosperity and community resilience

Rural tourism entails visiting rural regions for leisure, recreation and cultural immersion. It is valued for its potential to generate economic opportunities, preserve cultural heritage and conserve natural resources while empowering local communities. It offers potential for economic development by creating employment opportunities and generating income for rural residents through various tourism-related activities. This paper investigates the benefits to local communities of rural tourism development through a comprehensive review and insights from community stakeholders. The research was based on existing literature and employed a survey using a structured questionnaire and rigorous data analysis techniques. The survey included three well-known villages for their tourism experiences in the Korça region located in the southeastern part of Albania. The primary research targeted 200 members of the local communities aiming to analyze their perceptions of the benefits that rural tourism brings to their communities both in terms of income generation and socio-economic benefits. The study revealed that rural tourism has positively contributed to the economic development of these communities through revenue growth, the generation of employment and self-employment opportunities as well as the improvement of infrastructure through the lens of community perspectives. Rural tourism holds considerable promise for advancing sustainable development by offering economic, social and environmental benefits to rural regions. However, careful planning, community involvement and adherence to sustainable tourism principles are required.

Measuring Physical Activity in Children Who Do Not Walk and With Cerebral Palsy: An Exploratory Case Series.

The purpose of this case series was to describe physical activity (PA) amount and intensity in the home and school environment. Accelerometers and heart rate (HR) monitors are reliable and valid measures of PA in children with cerebral palsy (CP) who can walk. There is limited research on PA measures in children with CP who cannot walk. Three 9-year-old boys with CP, Gross Motor Function Classification System levels IV and V, participated in a 1-week measurement period wearing waist- and wrist-worn triaxial accelerometers to measure PA counts and a wrist-worn HR monitor to measure PA intensity. PA intensity was calculated using an estimated HR max. Accelerometer counts were reported. Parents and school staff completed activity and eating journals. Six days of PA and HR data were analyzed. Two participants spent more time in moderate/vigorous PA intensity during school compared to at home. Activities with greatest PA intensity included oral eating, communication, and social engagement. Higher activity counts were recorded from the wrist compared with the waist accelerometers. PA and eating journal adherence were high in both settings. The findings provide preliminary data to evaluate PA amount and intensity in children with CP who have little walking ability. It is important to consider PA levels in daily activity for youth with CP when designing plans of care.

Use of the supportive and palliative care indicators tool (SPICT™) for end-of-life discussions: a scoping review

BackgroundIn order to mitigate the distress associated with life limiting conditions it is essential for all health professionals not just palliative care specialists to identify people with deteriorating health and unmet palliative care needs and to plan care. The SPICT™ tool was designed to assist with this.AimThe aim was to examine the impact of the SPICT™ on advance care planning conversations and the extent of its use in advance care planning for adults with chronic life-limiting illness.MethodsIn this scoping review records published between 2010 and 2024 reporting the use of the SPICT™, were included unless the study aim was to evaluate the tool for prognostication purposes. Databases searched were EBSCO Medline, PubMed, EBSCO CINAHL, APA Psych Info, ProQuest One Theses and Dissertations Global.ResultsFrom the search results 26 records were reviewed, including two systematic review, two theses and 22 primary research studies. Much of the research was derived from primary care settings. There was evidence that the SPICT™ assists conversations about advance care planning specifically discussion and documentation of advance care directives, resuscitation plans and preferred place of death. The SPICT™ is available in at least eight languages (many versions have been validated) and used in many countries.ConclusionsUse of the SPICT™ appears to assist advance care planning. It has yet to be widely used in acute care settings and has had limited use in countries beyond Europe. There is a need for further research to validate the tool in different languages.

ENDOCARDITIS TEAM? DESIGNING AN ORIGINAL AND TAILORED CLINICAL PATHWAY

Abstract Infective endocarditis (IE) remains a poorly understood disease that primarily affects either native or prosthetic heart valves. Its incidence has increased over the past two decades, now affecting 3 to 10 individuals per 100.000/year in the general population. Despite advances in early diagnosis and surgical intervention, IE continues to pose a significant challenge, often leading to severe complications and carrying a substantial burden of morbidity and mortality. Data from the EURO–Endo registry show a drastic change in IE and provide an accurate picture of IE disease today. In European countries, it tends to affect older patients with a remarkable 12% of cases occurring in those aged ≥ 80 years. The traditional care pathway is often fragmented into multiple and potentially dangerous steps, resulting in delayed diagnosis and treatment. Such a “patchy” approach may cause suboptimal patient management, especially in the subset of frail patients with important concomitant diseases and high surgical risk. Clinical pathways (CPs) are an evidence–based multidisciplinary care plans involving diagnosis, treatment and rehabilitation phases, through which to follow patients from hospital admission to discharge, in order to manage a specific health condition, aiming to optimize patient and hospital/team outcomes, while contributing to a better organized care processes. In 2018, a working group composed by healthcare managers, infectious disease specialists, cardiac surgeons, cardiologists, anesthesiologists, geriatricians and other professionals involved in the care of IE patients have engineered a dedicated CP for IE at our institution. The CP introduced significant changes in the management of patients with IE. As a result, the quality of care and services offered increased, a faster and more appropriate diagnosis and treatment were achieved, patient outcomes and safety improved and a better coordination and continuity of care between different settings was guaranteed. The growing burden of IE in western countries demands an evidence–based multidisciplinary care plan. The creation of a territorial network ensures continuity and appropriateness of care in conjunction with the referring physicians/hospital and rationalization of resources. Although some controversies still exist, we believe that CP will have a positive impact on quality in health care.

Trajectory patterns and influencing factors of supportive care needs in stroke patients: A longitudinal study.

To investigate the trajectory patterns and influencing factors of supportive care needs in stroke patients. A longitudinal study. In total, 207 stroke patients who received treatment at the Department of Neurology in a hospital in Xuzhou between July 2022 and July 2023 were recruited using convenience sampling. Questionnaires including supportive care needs, hospital anxiety and depression scale, and the Barthel index were investigated at baseline and at 1, 3, and 6 months. A latent class growth model was applied to identify the supportive care needs trajectories. Multiple logistic regression was used to determine the predictors for membership. This study adheres to STROBE reporting guidelines. Three patterns of supportive care needs trajectories were identified: A high needs slow decline group (20.8%), a medium needs stable group (56.5%) and a medium needs rapid decline group (22.7%). Based on further analysis, the findings indicated that age, education level, monthly income, comorbidity, activities of daily living, anxiety and depression were associated with the trajectory categories of supportive care needs with stroke patients. This study demonstrates heterogeneity in changes in supportive care needs among stroke patients. Healthcare providers need to consider these different categories of needs and develop individualized care measures based on the characteristics of different patients. Healthcare providers should be aware of the fluctuations in care needs of stroke patients at various stages. Additionally, the study aimed to identify patients' specific needs based on their circumstances, monitor the rehabilitation process and establish a more personalized and optimized care plan through multidisciplinary collaboration. The ultimate goal was to alleviate symptomatic distress and address the long-term care needs of patients. No patient or public contribution.

Educating the next generation of psychiatrists in the use of clinical neuromodulation therapies: what should all psychiatry residents know?

A variety of neuromodulation treatments are available today and more are on the way, but are tomorrow’s psychiatrists prepared to incorporate these tools into their patients’ care plans? This article addresses the need for training in clinical neuromodulation for general psychiatry trainees. To ensure patient access to neuromodulation treatments, we believe that general psychiatrists should receive adequate education in a spectrum of neuromodulation modalities to identify potential candidates and integrate neuromodulation into their multidisciplinary care plans. We propose curricular development across the four FDA-cleared modalities currently available in psychiatric practice: electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). With a focus on psychiatry residency training, the article delineates core learning components for each neuromodulation technique. For each modality, we review the clinical training status, the respective FDA-cleared indications, mechanisms of action, clinical indications and contraindications, adverse effects, informed consent process, dosing considerations, and clinical management guidelines. The approach outlined in this article aims to contribute to the development of a well-rounded generation of psychiatry trainees with the capacity to navigate the growing field of neuromodulation. Whether or not a psychiatrist specializes in delivering neuromodulation therapies themselves, it is incumbent on all psychiatrists to be able to identify patients who should be referred to neuromodulation therapies, and to provide comprehensive patient care before, during and after clinical neuromodulation interventions to optimize outcomes and prevent relapse.

The Divergence between Self- and Preceptor-Assessments of Student Performance during Advanced Pharmacy Practice Experiences.

(1) Objectives: A divergence in self- and preceptor-evaluations of clinical skills has been noted during Advanced Pharmacy Practice Experiences (APPEs). The goal of this study was to determine the domains of overestimation of clinical skills by students during their APPE rotations. (2) Methods: Preceptor-assigned grades for APPE rotations from 2017-2022 were analyzed to identify instances of letter grade B or lower. The self- and preceptor-evaluations of APPE rotation were compared to determine the domains of divergence in evaluation between students and preceptors. (3) Results: Between 2017 and 2022, 305 student APPE rotations were graded as B or lower (~14%) by the preceptors. A statistically significant difference was noted between self- and preceptor-assigned letter grades across all practice settings including ambulatory patient care, community pharmacy, general medicine patient care, hospital/health system pharmacy, and special population patient care APPE rotations. In addition, examining the self- and preceptor evaluation rubric for these rotations revealed a statistically significant overestimation of clinical skills by students in all 9 domains of APPE evaluation. Finally, the divergence in the rating of clinical skills between student- and preceptor evaluation was found to be highest in the domains of planning and follow-up of patient care, disease knowledge, and communication with patients. (4) Conclusions: Students who fail to exhibit exemplary practice readiness during APPEs tend to overestimate their clinical skills in all domains of APPE evaluation. The results from our study support the need for additional avenues to assist in the identification of deficits in student learning before APPEs to increase their self-awareness (metacognition).

Understanding Pediatric Physical Therapists' Experiences With Middle Eastern Patients and Arabic Interpreters: A Qualitative Study.

The purpose of this study was to explore pediatric physical therapists' (PTs') experiences including successes, challenges, and barriers with cross-cultural communication with Arabic-speaking Middle Eastern children and their families who require interpreter services. Eight PTs consented to participate in qualitative dyadic interviews. Transcription and interviews were conducted virtually in Microsoft Teams. Quality criteria included member checking for validity and trustworthiness and bracketing to minimize investigator bias. Inductive thematic analysis was used to identify meaning units and major themes. The 6 themes that emerged were: fostering therapeutic relationships, practicing culturally sensitive care, communicating intentionally, experiencing successes, recognizing challenges, and tailoring a physical therapy plan of care. Representative quotations support each theme. Therapists perceive their experiences with Arabic-speaking children, families, and interpreters positively despite challenges related to cultural and language barriers. In sharing their experiences, therapists demonstrated self-reflection, openness to learning, and desire to build strong therapeutic alliances.

Long-Term Course of Remission and Recovery in Psychotic Disorders.

Understanding prognosis is critical to anticipating public health needs and providing care to individuals with psychotic disorders. However, the long-term course of remission and recovery remains unclear. In this study, the most common trajectories of illness course are described for a cohort of individuals followed for 25 years since first admission for psychosis. Participants are from the Suffolk County Mental Health Project, an epidemiological study of first-admission psychosis. Data for the present study was collected from six follow-ups, with 311 individuals assessed at the 25-year follow-up. Common patterns of remission and recovery were assessed in the baseline cohort of 591 individuals and the subsample from the 25-year follow up. In the baseline cohort and the 25-year subsample, the most common trajectory for individuals with schizophrenia spectrum disorders was no remission and no recovery. Among individuals with other psychotic disorders, in both the baseline and 25-year cohorts, the modal pattern was one of intermittent remission and recovery. Individuals with other psychotic disorders were more likely to experience stable remission (15.1%) and stable recovery (21.1%), outcomes that were rare among individuals with schizophrenia spectrum disorders (0% and 0.6%, respectively). The modal longitudinal pattern for individuals with other psychoses is one of multiple transitions into and out of symptomatic and functional recovery. Engagement in a long-term health care plan may help individuals detect and respond to these changes. Sustained remission and recovery are rare among people with schizophrenia spectrum disorders. Efforts should be directed toward developing more effective treatments for this population.

It is Not a Curse! It is Neurofibromatosis 1 (NF1): A Case Report from Rural Kenya

Neurofibromatosis 1 (NF1) is an autosomal dominant genetic disorder caused by mutations in the NF1 gene, with near complete penetrance and variable clinical presentation. Patients classically have café-au-lait macules, neurofibromas, skin freckles, and Lisch nodules, among other multisystemic features. Long-term management in a multidisciplinary team focuses on surveillance and treating complications. NF1 is a rare disease in Kenya, often leading to myths and misconceptions about its nature, especially among rural communities. We present a classical case from rural Kenya whose diagnosis was delayed by a belief that it was the result of a curse. We aim to highlight the importance of making this diagnosis and its linkage to a long-term care plan within a primary health care setting.

Dietary supplement intake in women with breast cancer before and after diagnosis: results from the SUCCESS C trial

BackgroundThere is little evidence that dietary supplements are beneficial for patients with breast cancer; therefore, they are usually not recommended by treatment guidelines. The aim of the present analysis was to assess the prevalence of dietary supplement (DS) intake among women before and after a breast cancer diagnosis.MethodsParticipants in the SUCCESS C lifestyle intervention study, a randomized controlled trial in women with newly diagnosed intermediate- to high-risk breast cancer, completed two questionnaires on dietary supplement intake 24 months (QS1) and 48 months (QS2) after beginning the lifestyle intervention. The study was registered on 12.17.2008 under the EU Clinical Trials Register https://www.clinicaltrialsregister.eu/, trial registration number: 2008-005453-38. The questionnaires collected data on DS intake during the 5-year period prediagnosis (QS1) and in the period postdiagnosis (QS2). Multivariate logistic regression models were fitted to examine differences in DS intake between the two intervention groups. The groups were then pooled to examine differences in DS use between the prediagnostic and postdiagnostic period.ResultsA total of 320 questionnaires from 58.5% of intervention group completers and 416 questionnaires from 46.6% of low-level intervention group completers were included in the analysis. Overall, 20.2% of all respondents reported taking DS prior to their diagnosis. After a cancer diagnosis, the percentage of women taking DS significantly increased to 56.4% (p for time effect < 0.0001). No differences in DS intake between the intervention groups were observed. Single or combined preparations of vitamins and minerals/trace elements were the most frequently reported supplements. Notably, a 9-fold increase in vitamin D intake was reported postdiagnosis, where the proportion of women increased from 3.8 to 34.5%.ConclusionA 3-fold increase in the reported intake of dietary supplements was seen in women after a breast cancer diagnosis. These observations underscore the need to incorporate patient education surrounding the use of dietary supplements in a treatment care plan, particularly addressing the negligible benefits as well as the potential risks and treatment interactions.

Individualized Care Delivery for Children With Autism and Related Disabilities Undergoing Overnight Video Electroencephalography (EEG): One Hospital's Experience With a Coordinated Team Approach.

Background and Purpose: Children with developmental disabilities have increased risk of epilepsy and need for overnight video electroencephalographic (EEG) monitoring. However, video EEGs have historically been considered difficult to complete for this population. An autism support service at a pediatric tertiary care hospital implemented a coordinated team approach to help children with developmental disability tolerate overnight video EEGs. The project included completion of a caregiver-report preprocedure questionnaire that then was shared with the multidisciplinary team and used to create individualized care plans. The current study aims to describe rates of video EEG completion and need for lead placement under general anesthesia among children with autism and related disabilities who received these supports. Methods: Rates of video EEG completion and general anesthesia use were analyzed for children referred to the support service between April 2019 and November 2021. Results: A total of 182 children with developmental disability (mean age = 10.3 years, 54.9% diagnosed with autism) met inclusion criteria. 92.9% (n = 169) of children successfully completed EEG (leads on ≥12 hours). Only 19.2% (n = 35) required general anesthesia for video EEG lead placement. The majority (80.2%) of parents (n = 146) completed the preprocedure questionnaire. Video EEG outcomes did not differ based on completion of the questionnaire. Parent-reported challenges with communication and cooperation were associated with shorter video EEG duration and greater use of general anesthesia. Conclusions: These findings suggest that most children with developmental disability can complete video EEG with sufficient support. Preprocedure planning can identify children who would benefit from additional accommodations. Further research is necessary to clarify which supports are most helpful.

Perceptions of vision care following neurological impairment: a qualitative study

BackgroundVisual impairment is a common consequence of neurological impairments, and can impact a person’s ability to undertake everyday tasks, affecting their confidence and mental health. Previous qualitative research in the UK has shown inequalities to exist where patients are accessing vision care after stroke, but little is known around the experiences of accessing vision care following other neurological impairments, and a lack of national guidelines prevent standardised care planning. The aim of this qualitative study is to explore the perceptions of vision care after neurological impairment, and to identify possible inequalities and support mechanisms, where it has been possible to access vision care.MethodsUniversity ethical approval was obtained, and adults with a visual impairment as a result of a neurological impairment were offered an in-depth interview to explore their vision care experiences. Data were collected between April and November 2021 and analysed using iterative, thematic analysis (TA), informed by a social constructionist ideology.ResultsSeventeen participants were recruited. Three overarching themes were conceptualised in relation to the participants’ perception of vision care: Making sense of the visual impairment; The responsibility of vision care; and Influential factors in care quality perception.ConclusionInequalities were noted by participants, with most reporting a lack of suitable vision care offered as part of their neurological rehabilitation. Participants were thus burdened with the task of seeking their own support online, and encountered inaccurate and worrying information in the process. Participants noted changes in their identity, and the identity of their family carers, as they adjusted to their vision loss. The findings from this research highlight a need for clinicians to consider the long-term impact of vision loss after neurological impairment, and ensure patients are provided with adequate support and information, and appropriate referral pathways, alleviating this patient burden.

Palliative care in kidney transplant recipients with graft failure.

Kidney transplantation is the best renal replacement therapy for patients with end stage kidney disease. It provides longer patient survival and better quality of life than dialysis. The clinical course after kidney transplantation could be complex and variable. Patients may develop various complications or even kidney graft failure. Symptom burden related to uraemia in patients with graft failure, and the side-effects of immunosuppression, cause psychological distress and adversely affect the quality of life of patients. Treatment decisions in patients with graft failure can be challenging to patients and their caregivers. Renal palliative care is an emerging field, but its adoption remains relatively low among kidney transplant recipients with progressive graft failure. In this context, timely consideration and referral for palliative care can improve symptom burden, reduce stress in patients and their caregivers, and facilitate treatment goal setting and advanced care planning. Common barriers to bring palliative care to suitable patients include: (I) misconception in patients, caregivers and healthcare providers that palliative care means abandonment of life sustaining treatment; (II) over-optimistic prognostic assessment and over-aggressive management approach; (III) insufficient awareness and training in palliative care of healthcare professionals; (IV) inadequate access to and insufficient resources in palliative care. Enhanced training and awareness, and further studies, would be needed to optimize the decision process and delineate the benefit of palliative care, and to guide evidencebased practice in the transplant population.

Health Service Use and Costs During Pregnancy Among Privately Insured Individuals With Congenital Heart Disease

Individuals with congenital heart disease (CHD) are increasingly reaching childbearing age, are more prone to adverse pregnancy events, and uncommonly undergo recommended cardiac evaluations. Data to better understand resource allocation and financial planning are lacking. To examine health care use and costs for patients with CHD during pregnancy. This retrospective cohort study was performed from January 1, 2010, to December 31, 2016, using Merative MarketScan commercial insurance data. Participants included patients with CHD and those without CHD matched 1:1 by age, sex, and insurance enrollment year. Pregnancy claims were identified for all participants. Data were analyzed from September 2022 to March 2024. Baseline characteristics (age, US region, delivery year, insurance type) and pregnancy-related events (obstetric, cardiac, and noncardiac conditions; birth outcomes; and cesarean delivery). Health service use (outpatient physician, nonphysician, emergency department, prescription drugs, and admissions) and costs (total and out-of-pocket costs adjusted for inflation to represent 2024 US dollars). A total of 11 703 pregnancies (mean [SD] maternal age, 31.5 [5.4] years) were studied, with 2267 pregnancies in 1785 patients with CHD (492 pregnancies in patients with severe CHD and 1775 in patients with nonsevere CHD) and 9436 pregnancies in 7720 patients without CHD. Compared with patients without CHD, pregnancies in patients with CHD were associated with significantly higher health care use (standardized mean difference [SMD] range, 0.16-1.46) and cost (SMD range, 0.14-0.55) except for out-of-pocket inpatient and ED costs. After adjustment for covariates, having CHD was independently associated with higher total (adjusted cost ratio, 1.70; 95% CI, 1.57-1.84) and out-of-pocket (adjusted cost ratio, 1.40; 95% CI, 1.22-1.58) costs. The adjusted mean total costs per pregnancy were $15 971 (95% CI, $15 480-$16 461) for patients without CHD, $24 290 (95% CI, $22 773-$25 806) for patients with any CHD, $26 308 (95% CI, $22 788-$29 828) for patients with severe CHD, and $23 750 (95% CI, $22 110-$25 390) for patients with nonsevere CHD. Patients with vs without CHD incurred $8319 and $700 higher total and out-of-pocket costs per pregnancy, respectively. This study provides novel, clinically relevant estimates for the cardio-obstetric team, patients with CHD, payers, and policymakers regarding health care and financial planning. These estimates can be used to carefully plan for and advocate for the comprehensive resources needed to care for patients with CHD.

Clinimetric properties of the "FIND-NEEDS" to screen geriatric conditions.

Comprehensive geriatric assessment (CGA) is used to thoroughly assess and identify complex healthcare problems among older adults. However, administration of CGA is time-consuming and labor intensive. A simple screening tool with the mnemonic "FIND-NEEDS" was developed to quickly identify common geriatric conditions. The present study was to evaluate the clinimetric properties of the FIND-NEEDS. First-visiting older adults aged 65 years and above (and who were able to communicate by themselves or with the help of a caregiver) were assessed (October to December, 2021) using the FIND-NEEDS and CGA at geriatric outpatient clinics of a tertiary, referred medical center. The FIND-NEEDS was examined for its criterion-related validity and compared with the CGA results. Two types of scoring (summed score and binary score) of FIND-NEEDS and CGA were analyzed using Spearman correlation, sensitivity and specificity, and area under receiver operating characteristic curve (AUC). The mean age of the 114 outpatients was 78.3±7.6 years, and 79(69.3%) were female. The internal consistency was excellent when using all FIND-NEEDS items, and was acceptable when using domain scores. Exploratory factor analysis showed that most of the FIND-NEEDS domain scores had factor loadings higher than 0.3. Intercorrelations of binary scores between domains of FIND-NEEDS and CGA showed most domains were moderately correlated. The overall correlation of summed scores between FIND-NEEDS and CGA was high. The FIND-NEEDS summed score was moderately correlated with CGA score (r=0.494; p&lt;0.001), and the binary score showed excellent correlation (r=0.944; p&lt;0.001). When using the CGA score as the gold standard, the FIND-NEEDS showed excellent AUC (0.950), sensitivity (1.00), and specificity (0.90). The present study demonstrated that the FIND-NEEDS had acceptable clinimetric properties to screen for geriatric problems among older adults. Further in-depth assessment and care plan can then be conducted afterwards.

The feasibility, acceptability and appropriateness of screening for frailty in Australians aged 75 years and over attending Australian general practice

Background Globally, frailty is associated with a high prevalence of avoidable hospital admissions and emergency department visits, with substantial associated healthcare and personal costs. International guidelines recommend incorporation of frailty identification and care planning into routine primary care workflow to support patients who may be identified as pre-frail/frail. Our study aimed to: (1) determine the feasibility, acceptability, appropriateness and determinants of implementing a validated FRAIL Scale screening Tool into general practices in two disparate Australian regions (Sydney North and Brisbane South); and (2) map the resources and referral options required to support frailty management and potential reversal. Methods Using the FRAIL Scale Tool, practices screened eligible patients (aged ≥75 years) for risk of frailty and referred to associated management options. The percentage of patients identified as frail/pre-frail, and management options and referrals made by practice staff for those identified as frail/pre-frail were recorded. Semi-structured qualitative interviews were conducted with practice staff to understand the feasibility, acceptability, appropriateness and determinants of implementing the Tool. Results The Tool was implemented by 19 general practices in two Primary Health Networks and 1071 consenting patients were assessed. Overall, 80% of patients (n = 860) met the criterion for frailty: 33% of patients (n = 352) were frail, and 47% were pre-frail (n = 508). They were predominantly then referred for exercise prescription, medication reviews and geriatric assessment. The Tool was acceptable to staff and patients and compatible with practice workflows. Conclusions This study demonstrates that frailty is identified frequently in Australians aged ≥75 years who visit their general practice. It’s identification, linked with management support to reverse or reduce frailty risk, can be readily incorporated into the Medicare-funded annual 75+ Health Assessment.

Developing machine learning models to predict multi-class functional outcomes and death three months after stroke in Sweden.

Globally, stroke is the third-leading cause of mortality and disability combined, and one of the costliest diseases in society. More accurate predictions of stroke outcomes can guide healthcare organizations in allocating appropriate resources to improve care and reduce both the economic and social burden of the disease. We aim to develop and evaluate the performance and explainability of three supervised machine learning models and the traditional multinomial logistic regression (mLR) in predicting functional dependence and death three months after stroke, using routinely-collected data. This prognostic study included adult patients, registered in the Swedish Stroke Registry (Riksstroke) from 2015 to 2020. Riksstroke contains information on stroke care and outcomes among patients treated in hospitals in Sweden. Prognostic factors (features) included demographic characteristics, pre-stroke functional status, cardiovascular risk factors, medications, acute care, stroke type, and severity. The outcome was measured using the modified Rankin Scale at three months after stroke (a scale of 0-2 indicates independent, 3-5 dependent, and 6 dead). Outcome prediction models included support vector machines, artificial neural networks (ANN), eXtreme Gradient Boosting (XGBoost), and mLR. The models were trained and evaluated on 75% and 25% of the dataset, respectively. Model predictions were explained using SHAP values. The study included 102,135 patients (85.8% ischemic stroke, 53.3% male, mean age 75.8 years, and median NIHSS of 3). All models demonstrated similar overall accuracy (69%-70%). The ANN and XGBoost models performed significantly better than the mLR in classifying dependence with F1-scores of 0.603 (95% CI; 0.594-0.611) and 0.577 (95% CI; 0.568-0.586), versus 0.544 (95% CI; 0.545-0.563) for the mLR model. The factors that contributed most to the predictions were expectedly similar in the models, based on clinical knowledge. Our ANN and XGBoost models showed a modest improvement in prediction performance and explainability compared to mLR using routinely-collected data. Their improved ability to predict functional dependence may be of particular importance for the planning and organization of acute stroke care and rehabilitation.

Factors associated with family decision-making self-efficacy among family members of patients with advanced cancer in mainland China.

In Chinese culture, family members are the main decision maker on end-of-life (EoL) issues for patients with advanced cancer. Yet little is known about Chinese families' confidence in making EoL decisions and its associated factors. This study aims to investigate the status and associated factors of Chinese family members' confidence in making EoL decisions for patients with advanced cancer. This cross-sectional study used a convenience sample of 147 family members of patients with stage III or stage IV cancer from a tertiary cancer center in Guangzhou, China. The questionnaires included demographic information of patients and their family members, patients' EoL preferences, and the Chinese version of the Family Decision-Making Self-Efficacy (FDMSE) Scale. A total of145 family members (98.64%) completed the questionnaires. The average score of FDMSE was 3.92 ± 0.53. A multiple regression analysis showed that the factors associated with FDMSE included patients' duration of disease, health insurance, participation in EoL decision-making, the expression of unfilled wishes, and family members' employment status. Chinese family members were not confident enough in making EoL decisions for patients with advanced cancer. It is recommended to develop cultural-tailored advanced care planning models to clarify patient preferences and to enhance the family members' self-efficacy in making EoL decisions with or for patients with advanced cancer.