Clinical Quality Improvement Research Articles

Long-term results of radiofrequency ablation for unilateral great saphenous vein insufficiency and hemodynamic changes in the contralateral leg.

Long-term results of radiofrequency ablation for unilateral great saphenous vein insufficiency and hemodynamic changes in the contralateral leg.

Unveiling Critical Awareness: Development and Validation of a Situation Awareness Questionnaire for Emergency Rooms

Situation awareness is vital for effective decision-making in emergency rooms. This study developed and validated the “Situation Awareness in the Emergency Room” questionnaire using a 6-month mixed-methods approach. Initial qualitative methods identified key components through interviews and focus groups, followed by quantitative validation with 569 respondents across 77 hospitals in Bali. Confirmatory factor analysis demonstrated excellent model fit (Root Mean Square Error of Approximation = 0.045, Comparative Fit Index = 0.96, Tucker-Lewis Index = 0.95) and strong factor loadings (>0.60). The questionnaire effectively measures General Awareness, Perception of Environment, Understanding of Situation, and Projection of Events, providing a reliable tool for clinical assessments and quality improvement.

Development of the Pediatric Scale for Quality of Recovery (PedSQoR).

Measuring the quality of a patient's recovery is vital, and reliable patient-centered outcome metrics are needed for clinical investigations and quality improvement. Currently, assessment tools to measure quality of recovery in pediatric patients are lacking. This study aimed to develop a scale to assess the quality of recovery (QoR) construct in pediatric patients. Using a mixed-methods investigative model, item generation was achieved using two complementary approaches. First, a comprehensive review of the literature identified tools and questions that assessed the endpoints relevant to recovery in children. Questions were categorized and then assessed by an expert Delphi panel who determined the most significant domains and items to be included. Concurrently, semi-structured interviews were conducted with patients and their families to identify themes related to recovery that were important to patients and families. The resulting pilot questionnaire was administered to patients and their families presenting for elective surgery in the US and Australia. The literature search identified 41 instruments, comprising 216 questions relevant to recovery. After the initial Delphi round, the item list was reduced to 91 questions, and then to 50 questions after the second round. The themes identified in the semi-structured interviews aligned with domains considered important by a panel of experts. A 50-item questionnaire was administered to 1162 children, at multiple time points post-surgery. Item reduction and factor analysis resulted in the 20-item Pediatric Scale for Quality of Recovery (PedSQoR) that assesses the domains relevant to physical and psychological recovery. The PedSQoR scale is a 20-item questionnaire designed to provide a holistic representation of a child's physical, emotional, and psychological recovery after surgery and anesthesia. It was developed and validated with consumer involvement and a strong patient-centered focus. Once further validation has been established, it is expected to become a standardized endpoint in pediatric perioperative trials and quality improvement projects.

Revising sepsis definitions to better target and tailor sepsis care.

How we define sepsis has significant implications for clinical care, quality improvement, and regulatory policies. Current sepsis criteria identify heterogenous patients that vary widely in their clinical syndromes, triggering pathogens, and prognoses; one-third have viral or non-infectious processes and crude mortality rates vary 30-fold. Nonetheless, clinicians have been trained to treat all patients with possible sepsis immediately, aggressively, and uniformly with broad-spectrum antibiotics. Evidence continues to mount, however, that immediate antibiotics are critical for patients with septic shock or multiorgan dysfunction but short delays can safely be tolerated by patients with single organ dysfunction without shock. This allows time to clarify whether these patients are infected or not. We suggest modifying sepsis operational definitions to flag just those patients in whom short antibiotic delays are associated with worse outcomes. This will help focus sepsis care where it is needed, aid antibiotic stewardship, and increase the validity of sepsis quality measures.

Evaluating Risk-Adjusted Associations between Prenatal Care Utilization and Obstetric Outcomes in a Commercially Insured Patient Population.

Office prenatal care has followed a similar structure for the past century. It is largely unknown whether attendance at routine outpatient antenatal visits prevents major adverse maternal outcomes. This study examined associations between prenatal care utilization and adverse obstetric outcomes including severe maternal morbidity (SMM), preterm birth, and stillbirth in a large, commercially insured US patient population.This is a retrospective cohort study using an insurance claims database evaluating associations between prenatal care utilization and obstetric outcomes over 4 years (2017-2020). Prenatal care utilization was characterized based on the adequacy of prenatal care utilization (APNCU) index. The primary outcome was SMM (as per Centers for Disease Control). Secondary outcomes included preterm birth <37 weeks and stillbirth. Associations between exposure and outcome were investigated using logistic regression models in designated "low" and "medium" maternal risk groups, defined based on obstetric co-morbidity index (OB-CMI) scores modeled at the time of the first trimester and at delivery.A total of 297,453 patients were included: 78,100 in the sub-group who remained low-risk throughout pregnancy and 49,920 in the sub-group who remained medium-risk. The largest number of patients overall (29.9%) received "adequate plus" care, as defined by the APNCU index, while a plurality of low- and medium-risk patients received "intermediate" care (35.6 and 29.9%, respectively). One point seventy seven percent of patients experienced SMM, 8.63% delivered preterm, and 0.88% had stillbirth. Adjusted analysis comparing volume of prenatal care with these outcomes demonstrated no statistically significant associations, with the exception of preterm birth, which was positively associated with "adequate" and "adequate plus" care in low- and medium-risk patients. "Inadequate care" was not associated with any of the studied outcomes.Overall volume of prenatal care was not associated with a reduction in adverse obstetric outcomes. Clinical quality improvement and health policy efforts to improve prenatal care delivery models may need to bypass adherence to established guidelines in terms of gross visit number as a key metric and instead work to revise practices based on more meaningful clinical outcomes. · It is unknown whether receipt of routine prenatal care is associated with better pregnancy outcomes.. · There were no associations between amount of prenatal care and SMM or stillbirth.. · Preterm birth was associated with "adequate" and "adequate plus" care in low- and medium-risk patients.. · Likely suggesting higher utilization in the setting of concerning symptoms.. · "Inadequate" care was not associated with any of the studied adverse outcomes..

Nurse‐led evidence‐based quality improvement programme to improve intensive care unit patient sleep quality

AbstractBackgroundPatients in the intensive care unit (ICU) suffer from significant sleep disturbances, which can negatively impact their healing and overall health. Nurses, as the primary caregivers, need to have expertise in sleep management to ensure better patient outcomes. Implementing nurse‐led, evidence‐based sleep protocols in ICUs is crucial.AimThis study aimed to improve ICU patients' sleep quality by developing and implementing a nurse‐led, evidence‐based SLEEP Bundle, including Sleep initiative, Light control, Eye mask and earplugs usage, Environment noise cancellation and Provision of non‐pharmacological (aromatherapy and music therapy) and pharmacological (dexmedetomidine and painkillers) support.MethodsThe Framework of Evidence‐based Continuous Quality Improvement and the Ottawa Model of Research Use framework were used to guide the development, implementation and assessment of the SLEEP Bundle. A quasi‐experimental study was conducted in a 12‐bed surgical intensive care unit (SICU), assessing patient‐perceived sleep quality, nurses' self‐report knowledge, attitudes and actions regarding patient sleep conditions and nurses' adherence to the interventions.InterventionsIn order to successfully translate evidence into clinical practice, the protocol was crafted with significant nurse involvement, input in sleep promotion materials and a flexible continuing education component, which provided credits to encourage nurse participation. A sleep‐aid kit, complete with non‐pharmacological tools, and a system of regular quality control and feedback were integral to the clinical application of the protocol.ResultsThe intervention significantly enhanced ICU patients' sleep quality, as evidenced by a significant increase in Richards‐Campbell Sleep Questionnaire scores from 62 (IQR = 48–72) to 70 (IQR = 62–76) (95% CI [−10.000, −6.000], Z = −6.100, p &lt; .001). Nurses demonstrated a 100% agreement in knowledge items and a significant upsurge in action items following the intervention. Concurrently, adherence to practice standards showed notable improvements in sleep management practices, including enhanced sleep quality assessment, daytime functional exercise support and compliance with environmental regulations, along with increased use of earplugs, eye masks and aromatherapy/music therapy.ConclusionsThe study highlights the effectiveness and feasibility of a nurse‐led sleep management strategy, as demonstrated by improved patient outcomes and increased nurse adherence to sleep promotion interventions.Relevance to Clinical PracticeThe significant improvements in sleep quality as well as the increased adherence to evidence‐based interventions by nurses suggest that this SLEEP Bundle could be effectively translated to other clinical settings.

Importance of Limitation Sections in Clinical Research and Quality Improvement Manuscripts.

Importance of Limitation Sections in Clinical Research and Quality Improvement Manuscripts.

Mepolizumab: Which condition benefits more: Nasal polyps or eosinophilic asthma?

The negative effects of eosinophilic severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) on quality of life are well known. The present study aimed to evaluate the impact of mepolizumab treatment on the quality of life of patients diagnosed with eosinophilic severe asthma and CRSwNP. Patients with CRSwNP and eosinophilic severe asthma who had been receiving mepolizumab 100 mg/month for at least six months as treatment were eligible for the study. Patients were assessed using quality of life and disease control questionnaires for both diseases before and during the sixth month of treatment. Forty-nine patients were included in the present study. Compared to the pre-treatment period, there was significant clinical improvement in quality of life for both rhinitis and asthma following mepolizumab treatment. The changes before and after the treatment were found as follows: Rhinitis Quality of Life Scale [44 (23-72); 25 (6-57); p< 0.001], Nasal Congestion Symptom Assessment Scale [13.0 (8-20); 9.0 (0-20); p< 0.001], Sino-Nasal Outcomes Test-22 (63.16 ± 17.9; 44.16 ± 21.33; p< 0.001), Asthma Quality of Life Questionnaire (111.06 ± 25.17; 142.67 ± 28.04; p< 0.001), Asthma Control Test [16 (6-21); 22 (14-25); p< 0.001]. Before mepolizumab treatment, 20 patients defined that CRSwNP and 29 patients defined that asthma affected their quality of life primarily. After six months of mepolizumab treatment, 38 patients defined that CRSwNP and 11 patients defined that asthma affected their quality of life primarily. Our results showed that mepolizumab is an effective treatment option for eosinophilic severe asthma and CRSwNP in patients having both diseases. Before mepolizumab, most patients' quality of life was affected by asthma symptoms, but this changed, and their quality of life began to be affected primarily by CRSwNP symptoms. This suggests that mepolizumab treatment is more effective in suppressing asthma symptoms than suppressing nasal polyp symptoms.

Clinical Practice Guideline for Management of Tinnitus

ImportanceThe most recent US clinical practice guideline (CPG) for tinnitus was published in 2014. The US Department of Veterans Affairs (VA)/US Department of Defense Tinnitus Clinical Practice Guideline Work Group recently completed a new guideline. The work group consisted of experts across disciplines who were supported by the VA Office of Quality and Patient Safety and the Defense Health Agency Clinical Quality Improvement Program. This article summarizes the first VA/US Department of Defense CPG for tinnitus management.Methods and ObservationsThe guideline was based on a systematic review of clinical and epidemiological evidence. Rigorous methods determined the strength of the recommendations. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical associations between various care options and health outcomes while rating the quality of the evidence and strength of the recommendations for 20 questions focused on evaluating and managing care for adults with bothersome tinnitus. The guideline provides an evidence-based framework for evaluating and managing care for adults with bothersome tinnitus.Conclusions and RelevanceThe CPG offers patients with tinnitus and clinicians an overview of evidence-based education and self-management, care options, and recommended outcome measures to monitor effectiveness and potentially improve patient health and well-being. Findings of a lack of sufficient evidence resulted from evaluating the quality of the body of evidence and emphasize the gaps in knowledge that need further study. Addressing these gaps may enable a comprehensive evaluation of the potential benefits and limitations of various tinnitus care options, ultimately improving patient care and clinical practice.

Janus kinase inhibitors for the treatment of lichen Sclerosus: A systematic review.

The current treatment options for lichen sclerosus (LS) remain limited. We aimed to systematically assess the evidence on the effects of Janus kinase (JAK) inhibitors in treating LS. We performed a systematic review and searched PubMed, Cochrane, Embase and the Airiti Library from inception to 16 January 2025. As we expected a lack of relevant randomized trials, we also included relevant single-arm trials, case reports and case series. The risk of bias of included case reports and case series was evaluated using Murad's tool, while single-arm trials were assessed using Alsinbili's tool. This systematic review included a total of nine studies, with one single-arm trial and three case reports on baricitinib, one single-arm trial and one case report on abrocitinib, two case reports on topical ruxolitinib and one case report on tofacitinib. A total of 43 LS patients (31 females and 12 males) were included, with four presenting with extragenital LS and one with bullous type affecting both genital and extragenital areas. The overall risk of bias of the included studies was low to unclear. Improvements in clinical symptoms, lesion characteristics and quality of life were observed for both genital and extragenital LS, with adverse events being tolerable. Single-arm trials with baricitinib and abrocitinib provide the highest current evidence for JAK inhibitors in treating genital LS. While evidence for extragenital LS remains limited to case reports, baricitinib shows therapeutic potential. These findings support baricitinib and abrocitinib as potential candidates for future randomized controlled trials.

Abstracts of the 10th Libyan Cardiac Society Congress, October 10–13, 2024, Misrata, Libya

AbstractThe 10th Annual Scientific Meeting of the Libyan Cardiac Society Congress (CARDIOLIBYA 10) was held between October 10 and 13, 2024, at Misrata University, Misrata, Libya. Abstracts were received in three categories: clinical vignette, research, and quality improvement. All abstracts underwent a peer-review process by the scientific committee and independent reviewers. A grading system was used based on the abstract’s quality, novelty, and clinical significance. Here, we present the oral and poster abstracts submitted by the authors after minimal restyling to suit publication purposes. They are published here for rapid communication and to benefit those who could not attend the congress physically.

Insights into the Novel Biomarkers Expressed in Diabetic Nephropathy: Potential Clinical Applications.

Diabetic nephropathy (DN) is increasing worldwide in parallel with type 2 diabetes mellitus. Identifying diagnostic biomarkers for DN at an early stage is crucial due to the considerable societal and economic burden associated with diabetes mellitus (DM) and its risk factors. In the past, early indicators of microvascular problems, such as microalbuminuria (MA), have been used to predict the possibility of developing advanced chronic kidney disease (CKD). However, because of the incapacity of MA to appropriately estimate DN, particularly, non-albuminuric DN, additional markers have been suggested for recognizing the early renal abnormalities and structural lesions, even before MA. This study aims to assess the existing and future biomarkers used to diagnose or predict early DN. This review provides comprehensive insight into diagnostic approaches for early detection of CKD, addressing the following areas: (i) markers of glomerular damage, (ii) markers of tubular damage, (iii) oxidative stress biomarkers, (iv) inflammatory biomarkers and (v) futuristic biomarkers such as micro-ribonucleic acids (miRNAs), proteomics, metabolomics and genomics and gut microbiota. Early detection of DN may lead to improvement in clinical management and quality of life, emphasizing the importance of identifying a specific and reliable predictive biomarker. Emerging serum and urinary biomarkers offer promise for early DN diagnosis, potentially reducing prevalence and preventing progression to end-stage renal disease (ESRD). Further advancements in miRNAs, proteomics, metabolomics genomics and gut microbiota offer prospects for even earlier and more precise DN diagnosis.

DEFINING RADIOLOGICAL HEALING IN PERIANAL FISTULISING CROHNS DISEASE A GLOBAL MODIFIED DELPHI CONSENSUS FROM THE TREATMENT OPTIMISATION AND CLASSIFICATION OF PERIANAL CROHNS DISEASE CONSORTIUM

Abstract BACKGROUND Perianal fistulizing Crohn’s disease (pfCD) presents a complex challenge, requiring precise endpoints in clinical trials to assess the efficacy of medical and surgical therapies. Magnetic Resonance Imaging (MRI) is the gold standard for evaluating fistula healing; however, variability in radiological definitions of fistula improvement and healing has hampered clinical trial design and real-world therapy effectiveness analyses. This study aimed to establish an international consensus on the definition of radiological healing in pfCD. METHODS The study was conducted in two phases through the Treatment Optimisation and CLASSification of perianal Crohn’s Disease (TOpCLASS) consortium (Figure 1). Phase 1 involved a systematic literature review to identify MRI-based variables and indices used to define radiological healing in pfCD. The protocol was prospectively registered on PROSPERO (CRD42024504334). The methodological quality of these indices was assessed using the COSMIN framework, following PRISMA-COSMIN guidelines. This phase generated a comprehensive long list of relevant variables, which international experts assessed and refined during the Delphi process. Phase 2 utilized an online modified Delphi consensus process with international experts in pfCD. Two rounds of surveys were conducted, followed by a final stakeholder meeting to achieve consensus. An agreement threshold of &amp;gt;80% was set for consensus items, and results were reported per Accurate Consensus Reporting Document (ACCORD) guidelines. RESULTS Eighty-four international experts from 16 countries participated in the modified Delphi process with key findings in Figure 2. A strong consensus (&amp;gt;95%) was reached, defining a radiologically healed fistula by the absence of T2-weighted hyperintensity and, when contrast is used, the absence of contrast enhancement on post-contrast T1-weighted images. Radiological improvement of a fistula was defined (80% consensus) by an unequivocal reduction in one or more of the following: T2-weighted hyperintensity, fistula diameter, length, abscess size; or a predominantly fibrous fistula tract. An unequivocal reduction in hyperintensity of the fistula tract on contrast-enhanced T1-weighted images also indicated improvement. Other key findings on the timing of MRIs with surgery and/or advanced therapy usage as well as MRI sequences, timing and need for central reading are shown in Figure 2. CONCLUSION This internationally modified Delphi consensus is a major step toward standardizing radiological endpoints in pfCD. Adoption of this consensus definition will enhance the consistency and reliability of pfCD assessments in both clinical care and research settings. Future studies are underway to validate this definition and assess how changes in variables predict long-term clinical outcomes and improvements in quality of life. Figure 1. Study Flowchart Figure 2. Key findings

Deaths and cardiac arrests during anesthesia - An analysis of 361,152 procedures in a major US health system.

The aim was to analyze the factors associated with intraoperative cardiac arrests at a major US academic center. In this single-center university hospital setting retrospective study, perioperative cardiac arrest data obtained from the clinical quality improvement and local registry from June 1, 2013 to November 19, 2019 was analyzed. Descriptive statistics were used to analyze the findings. A total of 361,152 anesthesia-requiring procedures were performed. At least 49 cardiac arrests occurred in the operating room (at a rate of 1.3 cardiac arrests for every 10,000 surgeries), of which 23 resulted in death (at a rate of 0.6 deaths for every 10,000 surgeries). Twenty-eight cardiac arrests occurred during elective procedures and the remaining were emergencies. Among the causes, hyperkalemia was seen as a likely contributory cause in six patients. PEA (Pulseless electrical activity) was the dominant rhythm and often did not precede other life-threatening arrhythmias. In terms of subspecialty, cardiac surgery witnessed the highest number of cardiac arrests followed by solid organ transplant. Nurse anesthetist/physician anesthesiologist team-delivered care was associated with intraoperative cardiac arrests, with a rate similar to that of all-physician care teams (21 vs. 28), and the death rates were similar (11 vs. 12). Highest number of cardiac arrests belonged to American Society of Anesthesiologists (ASA) 3 category. All patients who sustained cardiac arrests in ASA 2 category also died. Patients with a BMI >30.0 had the highest number of cardiac arrests, although the number of deaths was low. Hyperkalemia is a major factor in intraoperative cardiac arrests. Majority of the cardiac arrests occur during emergency procedures. Solid organ transplant and cardiac surgery carry the highest risk of cardiac arrests.

Patterns of hospital admissions and readmissions due to immune-related adverse events in patients with genitourinary cancers.

462 Background: Immune checkpoint therapies (ICTs) improve survival in patients with genitourinary (GU) cancers, specifically renal cell carcinoma (RCC) and urothelial carcinoma (UC). However, they also lead to inflammation of normal host organs: immune-related adverse events (irAEs). Severe irAEs may lead to repetitive hospitalizations especially if refractory which affects patients’ ability to receive further anti-cancer therapy. We reasoned that identifying such irAEs may enable clinical quality improvement interventions to improve outcomes. Methods: All consecutive patients hospitalized under the Genitourinary Medical Oncology inpatient service at The University of Texas MD Anderson Cancer Center with irAEs over a 14-month period (June 2023 to August 2024) were evaluated. Readmission was defined as re-entry to any hospital within 30 days of an initial discharge. Patient characteristics, ICT regimens, irAE types, treatment strategies, time to outpatient follow-up, and clinical outcomes were analyzed. Results: Sixty-seven patients (n=53 male; n=14 female) were admitted at least once for an irAE. The median age was 69 years (IQR: 62.0-75.5). Male predominance was consistent with the sex distribution of the cancers included (RCC, n=42, 63%; UC, n=11, 16%; prostate cancer, n=11, 16%). Gastroenterology-related irAEs were the most common cause of hospitalization, accounting for 45% (30/67) of admissions, primarily due to colitis (n=18) and hepatitis (n=9). Among these cases, 7% (2/30) were classified as grade 4, 80% (24/30) as grade 3, and 13% (4/30) as grade 2. Readmission occurred in 28% (19/67) of patients. Of the readmissions, 42% (8/19) were due to irAEs, 37% (7/19) to non-ICT-related reasons (e.g., disease progression, edema, pulmonary embolism), and 21% (4/19) to infection. Among the 8 readmissions for irAEs, 75% (6/8) were classified as grade 3 and 25% (2/8) as grade 2. Of these, 5 readmissions were attributed to the recurrence of the same irAE (colitis, n=3; hepatitis, n=2). These cases of recurrent irAEs resulted in delayed anti-cancer therapy for a median of 49 days (IQR: 42-57.5). Furthermore, readmissions were potentially preventable in 3 cases (colitis, n=2; hepatitis, n=1) due to delays in initiating biologic therapy, while the remaining 2 cases were associated with delays in outpatient follow-up. Conclusions: In this single-department, single-center case series, gastroenterology-related irAEs were the most common cause of irAE-related admissions and readmissions in patients undergoing ICT therapy for GU cancers. Quality improvement efforts to reduce readmission are ongoing at our institution including: (1) Improving clinical education for early detection of symptoms; (2) Shortening time to post-discharge outpatient follow-up; and (3) Optimizing timing and usage of steroid-sparing biologic therapies.

Developing a Quality Improvement Framework to Enhance the Health System User Experience for Individuals Living With Type 1 Diabetes: The Reshape T1D Study.

User experience design aims to create products and services that are accessible, usable, and enjoyable. The Reshape T1D study aims to apply these principles to understand how individuals living with T1D interact with and experience healthcare to inform T1D clinical quality improvement. Using a community-based participatory research design, we involved four patients and four clinicians as co-researchers throughout the research. A questionnaire and virtual semi-structured interview were applied across a purposeful sample of 41 adults living with T1D across Alberta, Canada, between September 2021 and May 2022. Audio recordings were transcribed verbatim and de-identified before coding. Thematic analysis was conducted on coded participant discourse through multiple coders. Participants indicated the need for a centralized hub that provides consistent, reliable, and up-to-date T1D education and resources and an emphasis on access to mental health resources within T1D care settings. Providing greater flexibility for appointment types (ie. in-person, virtual, etc.) and after-hours access contributed to better self-management and prevented emergency room visits. Participants desired a choice as to who comprises their T1D care team and for teams to address patient needs specific to their reality. We identified that medical trauma had long-term impacts on perceptions of healthcare and contributed to a reluctance to seek future care. Women expressed challenges in discussing reproductive health with their clinicians. Diabetes online communities provide an adjunct to clinical care through peer support. Cost and access to the latest technology are ongoing barriers for many participants, especially concerning publicly funded programmes that use advanced insulin pump therapy, continuous glucose monitoring, and automated insulin delivery systems. A quality improvement framework emerged through data analysis, and findings were synthesized into actionable recommendations for ongoing clinical quality improvement. Our findings highlight how important health system user suggestions are for more equitable, accessible, and empathetic healthcare for individuals living with T1D. Further work is needed to explore health system user experiences with clinicians and healthcare administrators to effectively carry out T1D clinical quality improvement.

Clinical outcomes of all-inside arthroscopic lateral ankle ligament reconstruction for chronic lateral ankle instability: A prospective series with minimum 12 month outcomes.

Clinical outcomes of all-inside arthroscopic lateral ankle ligament reconstruction for chronic lateral ankle instability: A prospective series with minimum 12 month outcomes.

Evaluation of a peer support group programme for vulnerable host population and refugees living with diabetes and/or hypertension in Lebanon: a before-after study

BackgroundNon-communicable diseases (NCDs) are the leading cause of death globally, and many humanitarian crises occur in countries with high NCD burdens. Peer support is a promising approach to improve NCD care in these settings. However, evidence on peer support for people living with NCDs in humanitarian settings is limited. We evaluated the implementation of peer support groups (PSGs) for people with diabetes and/or hypertension as part of an integrated NCD care model in four primary care centers in Lebanon.MethodsOur objectives were to: (1) evaluate the reach of the PSGs; (2) evaluate the association of PSGs with patient-reported outcomes; and (3) evaluate the association of PSGs with clinical outcomes (blood pressure, HbA1c, and BMI). We used a before-after study design and included a control group for clinical outcomes. The PSG intervention began in December 2022 and was carried out in two waves. The first wave was implemented from December 2022 to July 2023, and the second wave from July 2023 to January 2024. For the control group on clinical outcomes, we used data collected from January 2023 to January 2024. We used routinely collected programmatic and administrative data. The patient reported outcomes (PROMs) were collected at baseline and at six months by trained volunteers for all PSG participants. We performed a before-after analysis of PROMs for all patients who completed the PSG sessions. T-tests were used to analyze the differences in PROMs from baseline. Change in PROMs, together with 95% confidence intervals (CIs), and p-values for the changes were reported. To assess the association between the implementation of the PSG strategy and changes in clinical outcomes, including systolic blood pressure (SBP), glycated hemoglobin A1c (HbA1c), and body mass index (BMI), analysis of covariance (ANCOVA) models were used, adjusting for age, sex, and the baseline values of the outcome being analyzed (baseline SBP and baseline HbA1c, respectively).ResultsA total of 445 patients were approached for enrolment in wave 1, 259 (58%) consented, of whom 81 were enrolled. In wave 2, 169 patients were approached, 92 (54%) consented of whom 91 were enrolled. We found some statistical evidence that PSG improved certain PROMs, including potentially clinical meaningful improvements in overall quality of life (wave 1), physical quality of life (wave 1), social quality of life (wave 2), environmental quality of life (wave 1), adherence (wave 2), patient centeredness (wave 1), and exercise (wave 1). However, we did not find strong statistical evidence of an improvement in clinical outcomes (SBP, HbA1c, or BMI) in participants of the PSGs compared to the control group. We found differences in the association of PSGs and outcomes between the two waves.ConclusionOur study showed mixed results. In terms of reach, over 50% of those approached consented to participate. Regarding the impact on PROMs, we observed improvements in most outcomes; however we found some statistical evidence only for some. We did not find strong statistical evidence of improvement in clinical outcomes compared to the control group. Differences between the two waves may be due to differences in the populations, the way the intervention was delivered, or the individuals implementing it. Additionally, as multiple outcomes were measured, some observed differences may be due to chance. We demonstrated that it is feasible to implement PSGs in humanitarian settings and found some statistical evidence of improvement in quality of life. Further studies should assess the implementation and impact of PSGs in ways that are well accepted by local stakeholders (including humanitarian actors and people living with NCDs) and are potentially amenable to scale-up.

Linking American Spine Registry (ASR) and Medicare Data:an analysis of 8,755 Lumbar Fusion Cases.

Retrospective observational study. To evaluate whether the combined American Spine Registry and Medicare (ASR/CMS) data yields substantially different findings versus ASR data alone with regard to key parameters such as risk stratification, complication rates and readmission rates in lumbar surgery investigated through an analysis of 8,755 spondylolisthesis cases. Medicare data correlation has been effective for determining revision rates for other procedures such as total hip replacement. Our aim is to determine whether these findings are translatable in the realm of lumbar spinal surgery investigated through an analysis of 8,755 spondylolisthesis cases. The American Spine Registry (ASR) was queried for Medicare-eligible patients who underwent lumbar spinal fusion for lumbar spondylolisthesis. This cohort was analyzed based upon ASR data alone in comparison to the same patients in the combined ASR/Medicare (ASR/CMS) dataset. The primary outcome of interest was readmission at 30 and 90 days postoperatively. There were 8,755 Medicare-eligible cases with a diagnosis of spondylolisthesis within the ASR. The mean age was 72.7 years, 60.8% were female. Medical comorbidities were more frequently detected in the combined ASR/CMS dataset, reflected by a higher mean Charlson Comorbidity Index score (3.49 vs. 3.27, P<0.001). Hospital readmission rates were significantly higher in the combined ASR/CMS dataset at both 30 days (4.89% vs. 1.83%, P<0.001) and 90 days (7.68% vs. 2.66%, P<0.001), with notable increases in readmissions for infections and medical complications. Discharge disposition remained comparable across datasets, with most patients discharged to home or home health care. This study demonstrates that integrating patient-identified Medicare data with the ASR provides a more comprehensive assessment of outcomes for lumbar spinal fusion surgery as demonstrated through an analysis of 8,755 spondylolisthesis cases. These findings, establish the importance of multi-source data linkage to overcome the limitations of single-source registries, thereby enhancing data quality for clinical decision-making and quality improvement in spinal surgery.

Improved Risk Adjustment for Comorbid Diagnoses in Administrative Claims Analyses of Orthopaedic Surgery.

The accurate inclusion of patient comorbidities ensures appropriate risk adjustment in clinical or health services research and payment models. Orthopaedic studies often use only the comorbidities included at the index inpatient admission when quantifying patient risk. The goal of this study was to assess improvements in capture rates and in model fit and discriminatory power when using additional data and best practices for comorbidity capture. Hip fracture care was used as an exemplary case of an inpatient condition in a population typically having multiple comorbidities. Cohorts were built from 3 administrative resources: (1) Medicare, (2) all-payer, and (3) private-payer. Elixhauser comorbidities were calculated first using only the index admission and subsequently by adding inpatient and outpatient data from the previous year. Comorbidities identified on outpatient records required 2 instances occurring ≥30 days apart. Model fit and discriminatory power for in-hospital metrics (death, length of stay, and costs or charges) and post-discharge metrics (90-day readmission and surgical site infection, and 90-day and 1-year death) were compared among capture strategies. The index admission missed 9.3% to 65.6% of individual Elixhauser comorbidities for the Medicare cohort, 2.9% to 39.0% for the all-payer cohort, and 14.1% to 57.9% for the private-payer cohort compared with data from the index admission plus the previous year. Using prior inpatient and outpatient data provided substantial improvements in model fit and explanatory power for post-discharge outcomes, whereas information from the index admission was sufficient for in-hospital death and length of stay. The utility of outpatient data was greatest when complete outpatient claims were captured compared with only ambulatory surgery claims. The comorbidity capture strategies demonstrated in this study, namely including all available data for post-discharge outcomes, using a 1-year lookback period, and requiring outpatient codes to appear on 2 claims ≥30 days apart, are relevant for improved risk adjustment in orthopaedic clinical or health services research and quality improvement and payment models. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.