Comparison Of Care Research Articles

Association of Foster Care and its Duration with Clinical Symptoms and Impairment: Foster Care versus Non-Foster Care Comparisons with Spanish Children

ObjectiveThe objective was to determine if Spanish foster care children and Spanish non-foster children differ on sluggish cognitive tempo (SCT), ADHD-inattention (IN), ADHD-hyperactivity/impulsivity (HI), oppositional defiant disorder (ODD), limited prosocial emotions (LPE), anxiety, depression, social and academic impairment measures and if the duration of foster care predicts a reduction in symptom and impairment differences between foster and non-foster care children.MethodFoster care parents of 49 children (8 to 13 years, 57% girls) and non-foster care mothers and fathers of 1776 children (8 to 13 years, 49% girls) completed the Child and Adolescent Behavior Inventory (CABI).ResultsFoster care children had significantly higher scores on all symptom and impairment measures than non-foster care mother and father groups (d values from 0.37 to 1.53). A longer duration in foster care (range 8 to 86 months) was also associated with significant lower scores on SCT, ADHD-IN, anxiety, depression, and academic impairment. In addition, while foster care children with a shorter duration in foster care (less than medium months) had significantly higher scores than the non-foster care groups on all measures (d values from 0.66 to 2.25), children with a longer duration in foster care did not differ from the non-foster care groups on anxiety, depression, ADHD-IN, ADHD-HI, LPE, social and academic impairment.ConclusionsAlthough foster care children had elevated psychopathology and impairment scores relative to non-foster care children, a longer stay in foster care was associated with the elimination of the difference on most symptom and impairment measures.

Development and assessment of the inter-rater and intra-rater reproducibility of a self-administration version of the ALSFRS-R

ObjectiveThe Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) is widely applied to assess disease severity and progression in patients with motor neuron disease (MND). The objective of the study is...

Effects of message-framed informational videos on diabetes management knowledge and self-efficacy.

Nurses play an essential role in improving health-related knowledge and self-efficacy of patients through health education. This study aimed to investigate the effects of message-framed informational videos on diabetes management knowledge and self-efficacy in patients with type 2 diabetes. A quasi-experimental pretest and posttest design with two experimental and one standard care comparison groups was carried out to examine the effects of the message-framed videos. The two message-framed informational videos were developed to provide health teachings about diabetes self-care. The knowledge and self-efficacy of the two video groups and lecture comparison group were measured before and after the intervention using valid and reliable instruments established by the authors. After the intervention, the knowledge and self-efficacy of the two experimental groups were significantly higher than the comparison group. No significant difference was found in the knowledge scores between the two experimental groups, but a significant difference was noted in the average increase in their self-efficacy. Message-framed informational videos can be effective in increasing the diabetes management knowledge and self-efficacy, and a gain-framed rather than loss-framed approach can be superior in increasing self-efficacy.

Housing Design and Community Care: How Home Modifications Reduce Care Needs of Older People and People with Disability.

The extent to which housing design can minimise levels of community caregiving has remained largely unmeasured. This paper reports the potential for home modifications to reduce caregiving in the peoples’ homes, particularly older people and people with a disability. It contributes to new knowledge in understanding how housing can play a role in community caregiving and acknowledges the role of the built environment in managing care levels in ageing societies. This paper analyses self-reported care data from 157 Australian community care recipients (average age: 72 years) who had received home modifications within the past 6 months. A before/after comparison of care provided revealed that home modifications reduced hours of care provided by 42% per week. More detailed analysis revealed that the positive association of home modifications with care reduction is stronger with informal care (46% reduction) followed by formal care (16% reduction). These results suggest the role that home modifications, and housing design in general, play in reducing care needs in a community setting.

Incidence of hip fracture among long-term care insurance beneficiaries with dementia: comparison of home care and institutional care services

BackgroundHip fracture among older adults is not only a major health issue but also preventable by providing proper care, but there is a lack of studies on the association between type of long-term care (LTC) service and hip fracture. This study aimed to investigate the association between the type of LTC service and the incidence of hip fracture among older adults with dementia receiving long-term care insurance (LTCI), and to investigate how such association differs according to characteristics of beneficiaries and structural characteristic of institutional care.MethodIn this retrospective cohort study, data from 2008 to 2013 were collected from 7112 LTCI beneficiaries having benefit level 1 or 2 with dementia aged 60 years or over in the Korean elderly cohort data set. Type of LTC service was categorized into institutional or home care using the LTCI Claims Database, and the incidence of hip fracture was used as the outcome variable. A survival analysis using a time-dependent Cox regression analysis was performed to examine the association between time-varying LTC service type and hip fracture.ResultsOf the 7112 older adults, 115 (1.6%) had hip fracture during a total of 16,540 person-years. Compared to LTC beneficiaries with home care, those with institutional care had a higher adjusted hazards ratio of incidence of hip fracture (hazards ratio = 4.33, 95% confidence interval, 2.84–6.59). This association was particularly strong among beneficiaries who did not have a danger of hip fracture during the mandatory assessment for benefit eligibility, who were partially ambulatory, who were from rural areas, and females.ConclusionsInstitutional care was more likely associated with a higher incidence of hip fracture than home care. The government need to watch the institutional LTC services quality and promote improvements of the institutional care quality.

The Impact of Integrated Psychiatric Care on Hospital Medicine Length of Stay: A Pre-Post Intervention Design With a Simultaneous Usual Care Comparison

Psychiatric comorbidity is highly prevalent in general medicine inpatient settings and is associated with increased duration and cost of hospitalization. To evaluate the impact of integrated, proactive psychiatric care on hospital medicine length of stay (LOS), expanding upon methods from earlier studies. A full-time psychiatrist was dedicated to a single hospital medicine unit to focus on early case finding and intensified treatment, interdisciplinary communication, and discharge planning. To a pre-post intervention design, we added a simultaneous usual care comparison. We also added adjustments for age, sex, insurance type, and whether the patient was discharged home or to a facility. We included a sensitivity analysisto remove outliers for whom LOS was ≤30 days. Statistically significant differences in LOS occurred on the pilot unit in the pre-post analysis (-1.66 d, P= 0.04) and on the pilot versus control units in the intervention year (-1.91 d, P= 0.003). The differential pre-post change in LOS on the pilot versus control units revealed a positive trend but was not statistically significant (-1.59 d, P= 0.14). This more rigorous test approached statistical significance when patients with LOS >30 days were excluded (-1.15 d, P= 0.07). This analysis strengthens existing evidence that dedicated, proactive psychiatric services integrated into hospital medicine units lower LOS more than does usual psychiatric consultation upon request, particularly in patients with an LOS ≤30 days.

Corrie Health Digital Platform for Self-Management in Secondary Prevention After Acute Myocardial Infarction.

Unplanned readmissions after hospitalization for acute myocardial infarction are among the leading causes of preventable morbidity, mortality, and healthcare costs. Digital health interventions could be an effective tool in promoting self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction. A digital health intervention developed at Johns Hopkins-the Corrie Health Digital Platform (Corrie)-includes the first cardiology Apple CareKit smartphone application, which is paired with an Apple Watch and iHealth Bluetooth-enabled blood pressure cuff. Corrie targets: (1) self-management of cardiac medications, (2) self-tracking of vital signs, (3) education about cardiovascular disease through articles and animated videos, and (4) care coordination that includes outpatient follow-up appointments. The 3 phases of the MiCORE study (Myocardial infarction, Combined-device, Recovery Enhancement) include (1) the development of Corrie, (2) a pilot study to assess the usability and feasibility of Corrie, and (3) a prospective research study to primarily compare time to first readmission within 30 days postdischarge among patients with Corrie to patients in the historical standard of care comparison group. In Phase 2, the feasibility of deploying Corrie in an acute care setting was established among a sample of 60 patients with acute myocardial infarction. Phase 3 is ongoing and patients from 4 hospitals are being enrolled as early as possible during their hospital stay if they are 18 years or older, admitted with acute myocardial infarction (ST-segment-elevation myocardial infarction or type I non-ST-segment-elevation myocardial infarction), and own a smartphone. Patients are either being enrolled with their own personal devices or they are provided an iPhone and/or Apple Watch for the duration of the study. Phase 3 started in October 2017 and we aim to recruit 140 participants. This article will provide an in-depth understanding of the feasibility associated with implementing a digital health intervention in an acute care setting and the potential of Corrie as a self-management tool for acute myocardial infarction recovery.

Randomized Trial of a Lifestyle Intervention for Urban Low-Income African Americans with Type 2 Diabetes.

African Americans suffer more than non-Hispanic whites from type 2 diabetes, but diabetes self-management education (DSME) has been less effective at improving glycemic control for African Americans. Our objective was to determine whether a novel, culturally tailored DSME intervention would result in sustained improvements in glycemic control in low-income African-American patients of public hospital clinics. This randomized controlled trial (n= 211) compared changes in hemoglobin A1c (A1c) at 6, 12, and 18months between two arms: (1) Lifestyle Improvement through Food and Exercise (LIFE), a culturally tailored, 28-session community-based intervention, focused on diet and physical activity, and (2) a standard of care comparison group receiving two group DSME classes. Cluster-adjusted ANCOVA modeling was used to assess A1c changes from baseline to 6, 12, and 18months, respectively, between arms. At 6months, A1c decreased significantly more in the intervention group than the control group (- 0.76 vs - 0.21%, p= 0.03). However, by 12 and 18months, the difference was no longer significant (12months - 0.63 intervention vs - 0.45 control, p= 0.52). There was a decrease in A1c over 18months in both the intervention (β= - 0.026, p= 0.003) and the comparison arm (β= - 0.018, p= 0.048) but no difference in trend (p= 0.472) between arms. The intervention group had greater improvements in nutrition knowledge (11.1 vs 6.0 point change, p= 0.002) and diet quality (4.0 vs - 0.5 point change, p= 0.018) while the comparison group had more participants with improved medication adherence (24% vs 10%, p< 0.05) at 12months. The LIFE intervention resulted in improved nutrition knowledge and diet quality and the comparison intervention resulted in improved medication adherence. LIFE participants showed greater A1c reduction than standard of care at 6months but the difference between groups was no longer significant at 12 and 18months. NCT01901952.

Intra-operative gallbladder scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study

IntroductionLaparoscopic cholecystectomy, the gold-standard approach for cholecystectomy, has surprisingly variable outcomes and conversion rates. Only recently has operative grading been reported to define disease severity and few have been validated. This multicentre, multinational study assessed an operative scoring system to assess its ability to predict the need for conversion from laparoscopic to open cholecystectomy.MethodsA prospective, web-based, ethically approved study was established by WSES with a 10-point gallbladder operative scoring system; enrolling patients undergoing elective or emergency laparoscopic cholecystectomy between January 2016 and December 2017. Gallbladder surgery was considered easy if the G10 score < 2, moderate (2 ≦ 4), difficult (5 ≦ 7) and extreme (8 ≦ 10). Demographics about the patients, surgeons and operative procedures, use of cholangiography and conversion rates were recorded.ResultsFive hundred four patients, mean age 53.5 (range 18–89), were enrolled by 55 surgeons in 16 countries. Surgery was performed by consultants in 70% and was elective in (56%) with a mean operative time of 78.7 min (range 15-400). The mean G10 score was 3.21, with 22% deemed to have difficult or extreme surgical gallbladders, and 71/504 patients were converted. The G10 score was 2.98 in those completed laparoscopically and 4.65 in the 71/504 (14%) converted. (p < 0.0001; AUC 0.772 (CI 0.719–0.825). The optimal cut-off point of 0.067 (score of 3) was identified in G10 vs conversion to open cholecystectomy. Conversion occurred in 33% of patients with G10 scores of ≥ 5. The four variables statistically predictive of conversion were GB appearance—completely buried GB, impacted stone, bile or pus outside GB and fistula.ConclusionThe G10 operative scores provide simple grading of operative cholecystectomy and are predictive of the need to convert to open cholecystectomy. Broader adaptation and validation may provide a benchmark to understand and improve care and afford more standardisation in global comparisons of care for cholecystectomy.

A Randomized Trial to Train Vulnerable Primary Care Patients to Use a Patient Portal.

Patient portals are becoming ubiquitous. Previous research has documented substantial barriers, especially among vulnerable patient subgroups such as those with lower socioeconomic status or limited health literacy (LHL). We tested the effectiveness of delivering online, video-based portal training to patients in a safety net setting. We created an online video curriculum about accessing the San Francisco Health Network portal, and then randomized 93 English-speaking patients with 1+ chronic diseases to receive 1) an in-person tutorial with a research assistant, or 2) a link to view the videos on their own. We also examined a third, nonrandomized usual care comparison group. The primary outcome was portal log-in (yes/no) 3 to 6 months post-training, assessed via the electronic health record. Secondary outcomes were self-reported attitudes and skills collected via baseline and follow-up surveys. Mean age was 54 years, 51% had LHL, 60% were nonwhite, 52% were female, 45% reported fair/poor health, and 76% reported daily Internet use. At followup, 21% logged into the portal, with no differences by arm (P = .41), but this was higher than the overall clinic rate of 9% (P < .01) during the same time period. We found significant prepost improvements in self-rated portal skills (P = .03) and eHealth literacy (P < .01). Those with LHL were less likely to log in post-training (P < .01). Both modalities of online training were comparable, and neither mode enabled a majority of vulnerable patients to use portals, especially those with LHL. This suggests that portal training will need to be more intensive or portals need improved usability to meaningfully increase use among diverse patients.

Comparison of Bone Marrow Concentrate, Non-Operative Care and Fusion for Discogenic Back Pain

Comparison of Bone Marrow Concentrate, Non-Operative Care and Fusion for Discogenic Back Pain

Comparison of Clinical Care and In-Hospital Outcomes of Asian American and White Patients With Acute Ischemic Stroke

Although overall stroke incidence and mortality in the United States is improving, little is known about the characteristics and clinical outcomes of acute ischemic stroke in Asian American individuals. To compare the characteristics, care, and outcomes of Asian American and white patients with acute ischemic stroke. Retrospective analysis of Asian American and white patients admitted with a primary diagnosis of acute ischemic stroke to hospitals participating in the Get With The Guidelines-Stroke (GWTG-Stroke) program between April 1, 2004, and July 31, 2016. The GWTG-Stroke database is a prospectively collected stroke quality improvement registry sponsored by the American Heart Association/American Stroke Association. Multivariable logistic regression models assessed the association of Asian American race/ethnicity, clinical outcomes, and quality measures. The study population of 1 772 299 patients (mean [SD] age, 72.4 [14.2] years; 51.3% female) consisted of 64 337 Asian American patients (3.6%) and 1 707 962 white patients (96.4%) admitted to 2171 GWTG-Stroke hospitals with acute ischemic stroke. After adjustment for patient and hospital variables, Asian American patients were seen with greater stroke severity compared with white patients (National Institutes of Health Stroke Scale [NIHSS] score ≥16) (odds ratio [OR], 1.35; 95% CI, 1.30-1.40; P < .001), manifested higher in-hospital mortality (OR, 1.14; 95% CI, 1.09-1.19; P < .001), had longer length of stay (OR, 1.17; 95% CI, 1.14-1.20; P < .001), and were less likely to ambulate independently at discharge (OR, 0.84; 95% CI, 0.79-0.90; P < .001). Although Asian American patients had fewer intravenous tissue plasminogen activator (IV tPA) administrations than white patients (OR, 0.95; 95% CI, 0.91-0.98; P = .003), they had more symptomatic hemorrhage after tPA (OR, 1.36; 95% CI, 1.20-1.55; P < .001) and overall post-tPA complications (OR, 1.31; 95% CI, 1.18-1.46; P < .001). Asian American patients had better quality measure adherence overall than white patients, including rehabilitation (OR, 1.27; 95% CI, 1.18-1.36; P < .001), door to tPA within 60 minutes (OR, 1.14; 95% CI, 1.06-1.22; P < .001), and intensive statin therapy (OR, 1.14; 95% CI, 1.10-1.18; P < .001). After adjustment for stroke severity, Asian American patients had lower in-hospital mortality than white patients (OR, 0.95; 95% CI, 0.91-0.99; P = .008). Asian American patients manifested more severe ischemic strokes, were less likely to receive IV tPA, and had worse functional outcomes than white patients. These findings warrant additional research toward improving clinical outcomes for Asian American patients with acute ischemic stroke.

Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders.

Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely. To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with:1. Anorexia nervosa and atypical anorexia nervosa;2. Bulimia nervosa and other eating disorders. We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches. We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM-5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder. We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM-5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta-analysis. We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study.We had planned four comparisons, and had data for meta-analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) -0.22, 95% CI -0.49 to 0.05; 2 trials, 232 participants; low-quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low-quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment.We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons.No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual.There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa.There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders. There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders.More research is needed for all comparisons of inpatient care versus alternate care.

Maternal mortality and 'near miss' morbidity at a tertiary hospital in Timor-Leste.

Assessment of severe maternal morbidity is increasingly being undertaken to understand the aetiology and factors which lead to adverse maternal outcomes. Their use in conjunction with maternal deaths may allow a comprehensive assessment of care provided, highlight areas for improvement within the health system and allow benchmarking of care against other institutions. Timor-Leste has one of the highest rates of maternal mortality in the Asia-Pacific region; however, there has been limited research into the level of severe obstetric morbidity in the country. To determine the aetiology and rates of severe obstetric morbidity and mortality at Hospital Nacional Guido Valadares, Timor-Leste. Cases of maternal 'near misses' and deaths were prospectively identified over a period of 12months using the World Health Organization maternal near-miss criteria. Cases of maternal death and near miss were combined (severe maternal outcomes) for descriptive analysis. During the audit period, 69 severe maternal outcomes were identified: 30 maternal deaths and 39 'near misses'. The maternal mortality ratio and the maternal near-miss ratio were 662/100000 live births and 8/1000 live births, respectively. The main identified obstetric aetiologies were haemorrhage and pre-eclampsia, while 22% of severe maternal outcomes did not have a clearly identified cause. The high institutional maternal mortality ratio requires urgent attention and identification of areas for improvement. Auditing and benchmarking using the WHO near-miss criteria provide a mechanism for standardised comparison of obstetric care but require further refinement to the local context.

Validation of a New Clinical Tool for Post-Intensive Care Syndrome.

Post-intensive care syndrome is defined as the long-term cognitive, physical, and psychological impairments due to critical illness. To validate the self-report version of the Healthy Aging Brain Care Monitor as a clinical tool for detecting post-intensive care syndrome. A total of 142 patients who survived a stay in an intensive care unit completed the Healthy Aging Brain Care Monitor Self-report and standardized assessments of cognition, psychological symptoms, and physical functioning. Cronbach α was used to measure the internal consistency of the scale items. Validity between the Healthy Aging Brain Care Monitor and comparison tests was measured by using Spearman correlation coefficients. Patients with post-intensive care syndrome were compared with a sample of primary care patients (known groups validity) by using the Mann-Whitney test. General linear models were used to adjust for age, sex, and education level. The total scale and all subscales had good to excellent internal consistency (Cronbach α, 0.83-0.92). Scores on the psychological subscale strongly correlated with standardized measures of psychological symptoms (Spearman correlation coefficient, 0.68-0.74). Results on the cognitive subscale correlated with the delayed memory measure (-0.51). Scores on the physical subscale correlated with the Physical Self-Maintenance Scale (-0.26). Patients with post-intensive care syndrome had significantly worse scores on subscales and total scores on the Healthy Aging Brain Care Monitor than did primary care patients. The self-report version of the Healthy Aging Brain Care Monitor is a valid clinical tool for assessing symptoms of post-intensive care syndrome.

An advanced practice registered nurse (APRN)-led initiative to improve post-splenectomy education and vaccine follow-up in adult trauma patients

The spleen is a commonly injured immune organ in the abdomen. Traumatic injury to the spleen often causes life-threatening bleeding, which necessitates emergent removal. After splenectomy, patients are vulnerable to a rare but lethal overwhelming infection that is largely preventable through vaccination. Despite this well-documented, lifelong mortality risk; many patients are undereducated about their condition and fail to receive preventative vaccines. This quality improvement project aims to improve post-splenectomy care through evidence-based changes in vaccine practice and refinement of provider education in a level I trauma center intensive care unit. Patients were contacted post-discharge to confirm they received follow-up vaccines and were monitored for readmission. In 36 months, 12,086 trauma patients were observed in a before and after comparison of post-splenectomy care. Forty-seven patients underwent splenectomy following trauma. Of those who survived to discharge, all (100%) received vaccines in the hospital. Patient education improved from 10% to 100% with standard materials and advanced practice registered nurse (APRN) involvement. In the after group, 12% of patients confirmed they received follow-up vaccines, while 88% were unable to be contacted. No readmissions for septicemia were observed in the study period. The APRN is in an ideal role to lead practice change in trauma and critical care populations. Consistent, high-quality provider education can be achieved using an evidence-based model on a busy academic trauma service. Despite improving education strategies, post-ICU follow-up is poor in trauma patients and the inability to contact patients post-discharge prevents gathering accurate outcome data.

Lessons Learned: It Takes a Village to Understand Inter-Sectoral Care Using Administrative Data across Jurisdictions.

Cancer care is complex and exists within the broader healthcare system. The CanIMPACT team sought to enhance primary cancer care capacity and improve integration between primary and cancer specialist care, focusing on breast cancer. In Canada, all medically-necessary healthcare is publicly funded but overseen at the provincial/territorial level. The CanIMPACT Administrative Health Data Group’s (AHDG) role was to describe inter-sectoral care across five Canadian provinces: British Columbia, Alberta, Manitoba, Ontario and Nova Scotia.This paper describes the process used and challenges faced in creating four parallel administrative health datasets. We present the content of those datasets and population characteristics. We provide guidance for future research based on ‘lessons learned’.The AHDG conducted population-based comparisons of care for breast cancer patients diagnosed from 2007-2011. We created parallel provincial datasets using knowledge from data inventories, our previous work, and ongoing bi-weekly conference calls. Common dataset creation plans (DCPs) ensured data comparability and documentation of data differences. In general, the process had to be flexible and iterative as our understanding of the data and needs of the broader team evolved.Inter-sectoral data inconsistencies that we had to address occurred due to differences in: 1) healthcare systems, 2) data sources, 3) data elements and 4) variable definitions. Our parallel provincial datasets describe the breast cancer diagnostic, treatment and survivorship phases and address ten research objectives. Breast cancer patient demographics reflect inter-provincial general population differences. Across provinces, disease characteristics are similar but underlying health status and use of healthcare services differ.Describing healthcare across Canadian jurisdictions assesses whether our provincial healthcare systems are delivering similar high quality, timely, accessible care to all of our citizens. We have provided a description of our experience in trying to achieve this goal and, for future use, we include a list of ‘lessons learned’ and a list of recommended steps for conducting this kind of work.Key FindingsThe conduct of inter-sectoral research using linked administrative health data requires a committed team that is adequately resourced and has a set of clear, feasible objectives at the start.Guiding principles include: maximization of sectoral participation by including single-jurisdiction expertise and making the most inclusive data decisions; use of living documents that track all data decisions and careful consideration about data quality and availability differences.Inter-sectoral research requires a good understanding of the local healthcare system and other contextual issues for appropriate interpretation of observed differences.

The Cost Analysis of Pressure Ulcer Treatment; The Treatment Cost Comparison of Conventional and Modern Wound Care

The Cost Analysis of Pressure Ulcer Treatment; The Treatment Cost Comparison of Conventional and Modern Wound Care

Preclinical Pharmacology in the Rhesus Monkey of CW 1759-50, a New Ultra-short Acting Nondepolarizing Neuromuscular Blocking Agent, Degraded and Antagonized by L-Cysteine.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Structure-activity studies were performed to identify a new neuromuscular blocking agent retaining the ultra-short acting characteristics of gantacurium, including degradation and reversal by L-cysteine, but lacking its histaminoid properties in man. CW 1759-50 has emerged from this program. Adduction of CW 1759-50 with L-cysteine was studied by high-performance liquid chromatography and mass spectrometry. Institutional Animal Care and Use Committee-approved comparisons of CW 1759-50 to gantacurium were performed in rhesus monkeys. ED95 for neuromuscular blockade was established. Spontaneous recovery was compared to reversal by L-cysteine in paired studies of boluses or infusions. In addition, changes in mean arterial pressure and heart rate after very large doses of 15 to 60 × ED95 were compared. The half-time of adduction of L-cysteine to CW 1759-50 in vitro was 2.3 min. The ED95 of CW 1759-50 was 0.069 ± 0.02 mg/kg; ED95 of gantacurium was 0.081 ± 0.05 mg/kg (P = 0.006). Duration of action (recovery to 95% twitch height after 98 to 99% blockade) was as follows: CW 1759-50, 8.2 ± 1.5 min; and gantacurium, 7.4 ± 1.9 min; (n = 8 and 9, P = 0.355). Administration of L-cysteine (30 mg/kg) shortened recovery (i.e., induced reversal) from CW 1759-50 after boluses or infusions (P always less than 0.0001). Recovery intervals (5 to 95% twitch) ranged from 6.1 to 6.7 min (and did not differ significantly) after boluses of 0.10 to 0.50 mg/kg, as well as control infusions (P = 0.426 by analysis of variance). Dose ratios comparing changes of 30% in mean arterial pressure or heart rate to ED95 for neuromuscular blockade (ED 30% Δ [mean arterial pressure or heart rate]/ED95) were higher for CW 1759-50 than for gantacurium. CW 1759-50, similar to gantacurium, is an ultra-short acting neuromuscular blocking agent, antagonized by L-cysteine, in the monkey. The circulatory effects, however, are much reduced in comparison with gantacurium, suggesting a trial in humans.

Quality improvement in melanoma care: Multidisciplinary quality program development and comparison of care before and after implementation

IntroductionAdherence to guideline-based care for melanoma remains suboptimal. This study describes the development of a quality monitoring program and compares the quality of care before and after its implementation. MethodsThirty quality metrics were adopted. An abstraction tool, manual and electronic database were developed. Metrics were analyzed from 1/1/2008-8/31/2013 (Group A) and compared to melanoma care from 9/1/2013-12/31/2017 (Group B). ResultsA total of 311 patients were treated from 2008 to 2017. Demographic data were similar between the groups.21.7% of patients in Group A had clinical stage (TNM) documented before surgery compared to 100% in Group B. 86.9% of patients in Group A had surgical margins documented in the operative report compared to 100% of Group B. Appropriate surgical margins were obtained in 85.7% of Group A compared to 99.5% in Group B. Pathology reporting of margin status, satellitosis, regression and mitotic rates improved from ∼60% Group A to >92% in Group B. Multidisciplinary process and structural metrics were unchanged. ConclusionsA comprehensive melanoma quality program has produced significantly improved guideline-based multidisciplinary care.