Current Care System Research Articles

Satisfaction with the quality of outpatient care of medical students as an element of the assessment of the current system of medical care

Introduction. This article discusses the problems of the quality of outpatient care for medical students. Most of the students prefer not to seek medical help from specialists even in difficult situations, and in most cases they self-medicate. This is caused by an insufficient degree of quality service by the outpatient polyclinic service of the attached contingent. The existing state system of medical care is imperfect: there is no unified approach to the organization of student polyclinics; medical organizations do not take into account the age and social specifics of students; low continuity in the rehabilitation and treatment of patients; there is insufficient preventive work among students.Aim: To determine the level of satisfaction with the quality of medical services provided to medical students.Material and Methods. The sociological method included a survey of medical students (1026 respondents) according to a specially designed questionnaire that contained questions about the scope, nature, quality of work and satisfaction with the conditions of the polyclinic institution. The logistic method consisted in the analysis of personnel, resource provision, as well as the activities of the medical institution.Results. Most of the medical students encounter organizational obstacles (appointment, waiting lists at the registry, waiting lists at the day hospital, waiting lists at the reception, etc.). 38.0% of respondents noted that when health problems appear, it is easier for them to go to the medical office of the college than to the district doctor. Moreover, 64.3% of respondents do not have information about the district doctor. Satisfaction depends on a number of factors such as: waiting time for a doctor’s appointment at the office (p < 0.001), availability when making an appointment with a doctor at a polyclinic (p < 0.001), preference when contacting a doctor when health problems appear (p < 0.001), the presence of organizational difficulties to get an appointment or treatment in a polyclinic (p < 0.001), the location of the registry and specialist offices, the terminal for making an appointment (p < 0.001), as well as the conditions of stay in a medical facility (p < 0.001).Conclusion. The necessity of introducing feedback into the practice of working with a contingent of medical students, using available screening technologies to actively identify the most significant factors and risk groups of the most common pathology, taking measures to reduce the impact of controlled factors, as well as annual preventive examinations and medical examinations has been identified.

Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US

Professional societies and the Centers for Medicare & Medicaid Services suggest volume thresholds to ensure quality in transcatheter aortic valve implantation (TAVI). To model the association of volume thresholds vs spoke-and-hub implementation of outcome thresholds with TAVI outcomes and geographic access. This cohort study included patients who enrolled in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. Site volume and outcomes were determined from a baseline cohort of adults undergoing TAVI between July 1, 2017, and June 30, 2020. Within each hospital referral region, TAVI sites were categorized by volume (<50 or ≥50 TAVIs per year) and separately by risk-adjusted outcome on the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy 30-day TAVI composite during the baseline period (July 2017 to June 2020). Outcomes of patients undergoing TAVIs from July 1, 2020, to March 31, 2022, were then modeled as though the patients had been treated at (1) the nearest higher volume (≥50 TAVIs per year) or (2) the best outcome site within the hospital referral region. The primary outcome was the absolute difference in events between the adjusted observed and modeled 30-day composite of death, stroke, major bleeding, stage III acute kidney injury, and paravalvular leak. Data are presented as the number of events reduced under the above scenarios with 95% bayesian credible intervals (CrIs) and median (IQR) driving distance. The overall cohort included 166 248 patients with a mean (SD) age of 79.5 (8.6) years; 74 699 (47.3%) were female and 6657 (4.2%) were Black; 158 025 (95%) were treated in higher-volume sites (≥50 TAVIs) and 75 088 (45%) were treated in best-outcome sites. Modeling a volume threshold, there was no significant reduction in estimated adverse events (-34; 95% CrI, -75 to 8), while the median (IQR) driving time from the existing site to the alternate site was 22 (15-66) minutes. Transitioning care to the best outcome site in a hospital referral region resulted in an estimated 1261 fewer adverse outcomes (95% CrI, 1013-1500), while the median (IQR) driving time from the original site to the best site was 23 (15-41) minutes. Directionally similar findings were observed for Black individuals, Hispanic individuals, and individuals from rural areas. In this study, compared with the current system of care, a modeled outcome-based spoke-and-hub paradigm of TAVI care improved national outcomes to a greater extent than a simulated volume threshold, at the cost of increased driving time. To improve quality while maintaining geographic access, efforts should focus on reducing site variation in outcomes.

Consensus-based recommendations for strengthening emergency care at primary health care level: a Delphi study

ABSTRACT Background Emergency care at a primary health care (PHC) level must be strengthened to reduce overall mortality and morbidity in any country. Developing recommendations for improvement in this area should take into consideration the context and nuances of the current emergency care system and primary health care context. Contribution to policy from the experts in the cross-cutting fields of PHC and emergency care is lacking. Objectives This study aims to evaluate the strengths and weaknesses of emergency care in primary health settings and develop consensus-based recommendations for the strengthening of emergency care at this level. Methods Using a modified Delphi technique, data were collected from various data sources to evaluate the strengths and weaknesses of emergency care at PHC level, from which recommendation statements were developed. These recommendations were proposed to a panel of experts using a Delphi survey to build consensus on 14 recommendations to strengthen emergency care at PHC level. Results Ten experts were recruited to participate (n = 10) with a response rate of 90% in round II and 80% in round III of Delphi. Recommendations broadly addressed the areas of education and training in emergency care, the role and placement of various actors, leadership in emergency care and the development of a national plan for emergency care. Consensus was reached in round II for 97.61% of the statements and after modification based on open-ended comments, 98.21% consensus was reached in round III. Conclusion Strengthening emergency care at primary and subsequent levels of health care requires a coordinated effort and mandate from authority in order to effect real change.

Observational Study of Elderly Suicidal Deaths

Suicide is a self-planed and deliberate termination of one’s own life. Painful experiences suffered during their lifelead to varying degrees of depersonalization and alienation. In the course of defending themselves from onslaughtof negative stimuli, elderly people establish a desire for hastened death. An Observational study of suicides amongelderly age group ≥60 years was conducted in the Department of Forensic Medicine and Toxicology, OsmaniaMedical College and General Hospital, Hyderabad during the period of 2016 to 2020.Police inquests, hospitalrecords, toxicological reports and suicide letters were collected and studied.The total elderly suicidal deathsduring the period of 5 years were 257, more common among 60-64 years aged people. Educated, middle class,joint family and different categories of professional background with physical ailments were common factors inthe study. The methods used for suicide ranged from poisoning, hanging, burns to fall from height. The resultswere analysed and compared with previous research studies and this study matched with results of several otherstudies. This is possibly due to beginning of dependency and stressful life following their retirements. Suicideis the 3rdleading unnatural cause of death among elderly which is not an impulsive act.Intervention in the agedsuicide will be a complex task and should involve changes at different levels of the current aged care system.

INTEGRATED CARE POLICY AND PRACTICE IN THE US: THE SCENARIO OF AGING IN CHINATOWN

Abstract Background Older Chinese adults, the fastest-growing population among older immigrants, experience multiple barriers to access quality physical and behavioral health care, including low English proficiency, low health literacy, and segregation between health care and social care sectors (Tsoh et al., 2016). While integrated care attempts to address these issues, there is still a lack of culturally sensitive integrated care practices to address the needs of older Chinese immigrants. Methods This article reviews the definition and history of integrated care policies in the U.S., and compares four integrated care models on the service user and community levels, including the Chronic Care Model (CCM), Program of All-Inclusive Care for the Elderly (PACE), Patient Navigation Model, and Delivery System Reform Incentive Payment (DSRIP) Program. Results Taking the community-dwelling older Chinese immigrants as the context, this article discusses factors that are essential to this group of older adults and proposes a framework to integrate social determinants of health in the development of integrated care practice with the infusion of cultural values and norms. Conclusion Integrated care for older immigrants asks for a complicated mass reconstruction of current care systems. We propose an innovative framework that fully takes advantage of CBO’s capacity in providing culturally appropriate services is proactive and preventive in nature by addressing social determinants of health directly, recognizes the role of family and community in older immigrants’ life and aging process, and provide equal attention to the older adults’ needs in health, mental health, and elderly care.

Imperfect Patients: Disparities in Treatment of Stroke Patients with Premorbid Disability.

Despite the high proportion of stroke patients with a pre-existing impairment, patients with disabilities are often excluded from stroke treatment trials. Trials are designed for "perfect patients": patients who are functionally independent and thus generally younger with fewer comorbidities; ironically, such patients are less likely to experience stroke than those with premorbid disability. Exclusionary practices in trials may translate into disparities in stroke care in practice. Through a review of literature, our purpose is to illuminate how people with disabilities are treated across the care continuum following a stroke. We completed a qualitative systematized review of articles pertaining to the care of patients with premorbid disability and stroke and their outcomes. Using a critical disability studies' theoretical lens, we analyzed inequity across the stroke care continuum. Among 24 included studies, we found evidence that people with disabilities did not receive equitable access to treatment ranging from being admitted to stroke units to receiving post-stroke rehabilitation. However, observational studies suggest that stroke therapies may be beneficial in selected patients with disabilities when measures of success are framed more achievable (e.g. return to pre-stroke status). This leaves us concerned about how people with pre-existing impairments might be structurally disabled within current systems of stroke care. We use our critical disability studies' theoretical lens to argue that an intersectional approach to stroke treatment is much needed if we are to remedy structural inequities embedded throughout the care continuum.

Mild Traumatic Brain Injury: What We Can Learn from a Qualitative Study of Patient Perceptions Following Emergency Department Discharge

Aims: This study investigated the experiences of patients with mild traumatic brain injury (mTBI) to identify barriers and suggest clinically relevant areas for improvement in the current system of care.&#x0D; Methods: 16 patients with a clinical diagnosis of mTBI were recruited from the Cork University Hospital Emergency Department (ED) for participation in this study. Semi-structured phone interviews were conducted at approximately 2.5-3 months post-discharge. Reflexive thematic analysis with an inductive and realist approach was used to code and inductively analyse the data. The most frequently occurring themes and their relationship to subthemes are reported.&#x0D; Results: A total of 16 mTBI adult patients were interviewed (mean age: 50.5 (18-85)). Major themes identified in the experience of mTBI patients were: lack of clarity in diagnosis and treatment, poor access to information, and ongoing symptoms. Notably, 87.5% of participants reported being uncertain about their diagnosis of mTBI and 93.8% of participants did not seek further information regarding their head injury. Nearly half (43.8%) of the participants reported prolonged recovery with two participants (12.5%) reporting ongoing symptoms. Headache, photophobia, and difficulty with thinking and memory were the predominant symptoms reported.&#x0D; Conclusion: Several overarching themes were identified in the qualitative self-reported experiences of mTBI patients following ED discharge. Participants reported persistent symptoms, lack of clarity, and a lack of access to information regarding their mTBI diagnosis and treatment. Suggested recommendations for future practice include adding psychoeducational resources and increasing awareness and training among staff to provide timely patient education.

Prenatal Nutrition Care in Alberta: The Perspectives of Pregnant Women and Registered Dietitians.

Introduction: Optimizing women's diets in pregnancy improves maternal and child health outcomes; however, the best format for supporting women's nutrition goals in pregnancy is not clear, and access to dietetic services is not standard in prenatal care in Alberta. This study explored women's perceptions about access to Registered Dietitians (RDs) throughout pregnancy and RDs experiences providing prenatal nutrition counselling.Methods: Two studies were conducted. Study A: Pregnant women completed a short survey while attending a prenatal appointment in a large prenatal clinic. The survey assessed women's perspectives about accessing dietetic services during pregnancy. Survey data were analyzed using descriptive statistics. Study B: RDs participated in either a semi-structured phone interview or a focus group and described their experiences working with pregnant women. Data were analyzed using thematic analysis.Results: One hundred pregnant women completed the survey. Ninety percent indicated that they had not seen a RD at this time in pregnancy, and 48% reported that they would like to access a RD in pregnancy, if available. Dietitians discussed the diversity of women's concerns and the challenges to providing prenatal nutrition support.Conclusions: Women have nutrition-related questions during pregnancy. Dietitians experience challenges providing services in the current care systems.

Poor Compliance of Diabetic Patients with AI-Enabled E-Health Self-Care Management in Saudi Arabia

Still in its nascent stage, the Kingdom of Saudi Arabia’s self-care system lacks most features of a state-of-the-art e-health care system. With the Industrial Revolution 4.0 and the expanding use of artificial intelligence (AI), e-health initiatives in Saudi Arabia are increasing, which is compelling academics, clinicians, and policymakers to develop a better understanding of e-health trends, their efficacy, and their high impact areas. An increase in the number of diabetic patients in the Kingdom demands improvements to the current e-health care system, where the capability to manage diabetic patients is still in its infancy. In this survey, a total of 210 valid responses were obtained for analysis. SPSS version 27.0 was used for the quantitative analysis. The main technique used to address the aims of the data analysis was Spearman’s correlation analysis. This study indicated that the compliance rate with prescribed medication, blood glucose monitoring, and insulin injections from hospitals is increasing, with the highest rates found for Jeddah City. However, diet control and physical activity compliance levels were found to be poorly combined, predominantly due to the lower number of registered patients in the e-health care system. This non-compliance trends with selected variables (education and income) and highlights the dire need for improvement to the current health system by the inclusion of the latest technology, including big data, cloud computing, and the Internet of Things (IoT). Hence, this study suggests the implementation of government-regulated e-health care systems on mobile-based policies. The study revealed the experience of patients using e-health systems, which could be used to improve their efficacy and durability. More research needs to be conducted to address the deficiencies in the current e-health care system regarding diabetes care, and how it can be integrated into the healthcare system in general.

EP10.01-009 The Impact of the COVID-19 Pandemic on Palliative Care for Cancer: A Preliminary Cross-Country Survey of Clinical Oncologists

IntroductionPalliative care is a crucial intervention to improve the quality of life for patients with cancer, although the impacts of the COVID-19 pandemic on palliative care remain unclear. This preliminary survey across China aims to investigate the influence of COVID-19 on palliative care, from the perspective of oncologists.MethodsElectronic questionnaire surveys were distributed to clinicians in China. Participants working in cancer-related departments are eligible. Data was collected including demographic characteristics, subjective perception, and personal suggestions.ResultsA total of 37 oncologists participated in the survey, 78% of whom were male. The median age was 40 (22-56). A large proportion of them have doctor degrees (68%) currently working in urban areas (81%). One-third participants are from the department of radiation oncology (33%) and 24% from medical oncology. They usually practice palliative care in professional medical centres or hospitals (70%), yet 57% had only non-accredited training experience. Most agree that COVID-19 has a significant negative impact on their clinical work (76%) and palliative care practice (65%). 73% of them believe the current palliative care system is underdeveloped in China, and 78% think other factors besides COVID-19 relate to this inadequacy. Participants further tabled suggestions (Figure 1), such as more online guidance on palliative care for patients (35%), strengthening remote multidisciplinary cooperation (29%), promoting home-based palliative care (18%), and involving more information on COVID-19 in palliative care guidelines (6%).ConclusionsKeywordsPalliative care, COVID-19, Cancer IntroductionPalliative care is a crucial intervention to improve the quality of life for patients with cancer, although the impacts of the COVID-19 pandemic on palliative care remain unclear. This preliminary survey across China aims to investigate the influence of COVID-19 on palliative care, from the perspective of oncologists. Palliative care is a crucial intervention to improve the quality of life for patients with cancer, although the impacts of the COVID-19 pandemic on palliative care remain unclear. This preliminary survey across China aims to investigate the influence of COVID-19 on palliative care, from the perspective of oncologists. MethodsElectronic questionnaire surveys were distributed to clinicians in China. Participants working in cancer-related departments are eligible. Data was collected including demographic characteristics, subjective perception, and personal suggestions. Electronic questionnaire surveys were distributed to clinicians in China. Participants working in cancer-related departments are eligible. Data was collected including demographic characteristics, subjective perception, and personal suggestions. ResultsA total of 37 oncologists participated in the survey, 78% of whom were male. The median age was 40 (22-56). A large proportion of them have doctor degrees (68%) currently working in urban areas (81%). One-third participants are from the department of radiation oncology (33%) and 24% from medical oncology. They usually practice palliative care in professional medical centres or hospitals (70%), yet 57% had only non-accredited training experience. Most agree that COVID-19 has a significant negative impact on their clinical work (76%) and palliative care practice (65%). 73% of them believe the current palliative care system is underdeveloped in China, and 78% think other factors besides COVID-19 relate to this inadequacy. Participants further tabled suggestions (Figure 1), such as more online guidance on palliative care for patients (35%), strengthening remote multidisciplinary cooperation (29%), promoting home-based palliative care (18%), and involving more information on COVID-19 in palliative care guidelines (6%). A total of 37 oncologists participated in the survey, 78% of whom were male. The median age was 40 (22-56). A large proportion of them have doctor degrees (68%) currently working in urban areas (81%). One-third participants are from the department of radiation oncology (33%) and 24% from medical oncology. They usually practice palliative care in professional medical centres or hospitals (70%), yet 57% had only non-accredited training experience. Most agree that COVID-19 has a significant negative impact on their clinical work (76%) and palliative care practice (65%). 73% of them believe the current palliative care system is underdeveloped in China, and 78% think other factors besides COVID-19 relate to this inadequacy. Participants further tabled suggestions (Figure 1), such as more online guidance on palliative care for patients (35%), strengthening remote multidisciplinary cooperation (29%), promoting home-based palliative care (18%), and involving more information on COVID-19 in palliative care guidelines (6%). Conclusions KeywordsPalliative care, COVID-19, Cancer Palliative care, COVID-19, Cancer

Older people's experiences of community engagement in aged care: A qualitative study

BackgroundEngagement and social connection are key elements of a meaningful life however the current aged care system does not universally foster community connectedness. Limited research has explored community engagement from the perspective of older people in aged care. AimTo explore older people's perceptions of community engagement in aged care. MethodsA qualitative exploratory descriptive approach involving individual interviews and focus groups SettingA large not-for-profit aged care provider in Victoria and Tasmania, Australia. ParticipantsTwenty-eight older adults living in residential aged care (n = 23) and independent living units (n = 5). FindingsFour themes were identified: (i) a new home; (ii) opportunities to engage in aged care; (iii) connecting with the wider community, and; (iv) social connection to community. DiscussionParticipants perceived community as being characterised by the notion of home, that is, the place where they lived. Being socially connected to a community was important and benefits included being with people to avoid being alone, reconnecting with the wider community and having positive social connections. Opportunities for engagement were either created for, or by them. In residential aged care, staff facilitated engagement opportunities using a one-size-fits-all approach. This approach was deemed to be unsuitable. People from independent living units, although not completely removed from the wider community, desired to maintain their independence and be part of the wider community. ConclusionsUnderstanding older people's perceptions of community engagement in aged care can support development of appropriate, applicable and meaningful strategies to promote engagement and socialisation within aged care and the wider community.

We are not doing enough for children with neuro-disabilities

I recently made a submission to the Abuse in Care: Royal Commission of Inquiry on behalf of a young whānau-member survivor who is autistic and lives with Foetal Alcohol Spectrum Disorder (FASD), Attention Deficit Hyperactivity Disorder (ADHD) and mental health issues. I made that submission also because I am a social worker and a staunch advocate for those who live with neuro- disabilities; many of them have experienced early removal from birth families, as well as lifelong rejection and misunderstanding by systems of education, health, care and justice. In my submission, I discussed how today’s current care and justice systems cause as much harm to children and whānau as historic ones. In my recent Reimagining Social Work blog (Gibbs, 2022), I highlighted the harm to children caused specifically by current, residence-based interventions in youth justice, but in this piece, I also want to highlight how multiple aspects of both current care and protection, and youth justice provision harm our children with neuro-disabilities. In a future, research-based article, I will highlight specific findings on best practices for working in the justice space for youth living with FASD (in preparation).

Associations of tobacco cigarette use and dependence with substance use disorder treatment completion by sex/gender and race/ethnicity

IntroductionIndividuals with substance use disorders (SUD) are approximately five times more likely to smoke cigarettes than the general population. Individuals who smoke cigarettes have greater odds of SUD relapse compared to individuals who do not smoke cigarettes, but we know little about how cigarette use is related to SUD treatment completion overall by sex/gender or race/ethnicity. MethodsThis study examined 2855 adults (71.98 % male; >70 % racial/ethnic minority) in outpatient and residential SUD treatment at a New York–based treatment agency over a six-month period in 2018. ResultsOverall, approximately three-fourths of SUD treatment-seeking participants smoked cigarettes, with high rates across sex/gender and racial/ethnic groups. Nicotine dependence did not differ by sex/gender, and White Non-Hispanic adults had the highest levels of nicotine dependence across racial/ethnic groups. Those who smoked cigarettes were significantly less likely to complete treatment compared to those who did not smoke cigarettes (OR = 0.69; 95 % CI: 0.58, 0.82). The study found no overall differences in SUD treatment completion and length of stay by sex/gender or race/ethnicity. ConclusionsGiven the high prevalence of cigarette smoking and lower odds of completing SUD treatment, the current system of care for SUD treatment may be enhanced by addressing cigarette smoking from onset of treatment.

The experience of structural burden for culturally and linguistically diverse family carers of people living with dementia in Australia.

Evidence suggests that family carers of culturally and linguistically diverse (CALD) people living with dementia experience higher stress and unmet need than the general Australian population. These disparities are often framed as the result of CALD communities failing to seek formal support. Challenging this, we draw on the concept of 'structural burden' to explore how the complexity of health and aged systems contribute to the burden that CALD carers experience. We conducted semi-structured interviews with 104 family carers for CALD people with dementia in Australia,followed by thematic analysis of transcripts. Additional to structural burdens encountered by the general older population, CALD carers faced challenges understanding Australia's Anglo-centric aged care system, locating culturally appropriate care and were required to translate the languages and operations of health and aged care systems into terms their family members understood. This burden was mitigated by the presence of ethno-specific organisations and other navigation support. Australia's aged care system has moved towards centralised governance and consumer-directed care provision. This system involves a confusing array of different programmes and levels, bureaucratic applications and long waiting times. Carers' encounters with these systems demonstrates how some CALD people are being left behind by the current aged care system. While ethno-specific services can reduce this burden, not all CALD groups are represented. Consequently, improving access to dementia care among CALD populations requires entry point and navigation support that is culturally appropriate and linguistically accessible.

Creating Coherence-Based Nurse Planning in the Perinatology Care System.

The combination of increasing demand and a shortage of nurses puts pressure on hospital care systems to use their current volume of resources more efficiently and effectively. This study focused on gaining insight into how nurses can be assigned to units in a perinatology care system to balance patient demand with the available nurses. Discrete event simulation was used to evaluate the what-if analysis of nurse flexibility strategies and care system configurations from a case study of the Perinatology Care System at Radboud University Medical Center in Nijmegen, the Netherlands. Decisions to exercise nurse flexibility strategies to solve supply–demand mismatches were made by considering the entire patient care trajectory perspective, as they necessitate a coherence perspective (i.e., taking the interdependency between departments into account). The study results showed that in the current care system configuration, where care is delivered in six independent units, implementing a nurse flexibility strategy based on skill requirements was the best solution, averaging two fewer under-/overstaffed nurses per shift in the care system. However, exercising flexibility below or above a certain limit did not substantially improve the performance of the system. To meet the actual demand in the studied setting (70 beds), the ideal range of flexibility was between 7% and 20% of scheduled nurses per shift. When the care system was configured differently (i.e., into two large departments or pooling units into one large department), supply–demand mismatches were also minimized without having to implement any of the three nurse flexibility strategies mentioned in this study. These results provide insights into the possible solutions that can be implemented to deal with nurse shortages, given that these shortages could potentially worsen in the coming years.

The Effectiveness of a Mobile Health Care App and Human Coaching Program in Primary Care Clinics: Pilot Multicenter Real-World Study.

BackgroundAs the global burden of chronic conditions increases, their effective management is a concern. Although the need for chronic disease management using mobile self-management health care apps is increasing, there are still many barriers to their practical application in the primary care field.ObjectiveThis study evaluated the effectiveness of primary care services combining a mobile self-management health care app with human coaching for patients with chronic diseases in the current primary care system.MethodsA total of 110 patients (mean age 53.2, SD 9.2 years; 64 of 110, 58.2% female) with hypertension, diabetes, dyslipidemia, or metabolic syndrome who visited one of 17 participating primary care clinics from September to November 2020 were included in this study. All participants recorded data regarding changes in body weight, sleep conditions, quality of life, depression, anxiety, stress, BMI, waist circumference, blood sugar levels, blood pressure, and blood lipids levels. The app user group (n=65) used a mobile self-management health care app with human coaching for 12 weeks, and the control group (n=45) underwent conventional self-managed health care.ResultsPatients in the app user group reported significantly more weight loss than those in the control group—the body weight of the app user group decreased by 1.43 kg (95% CI –2.07 to –0.79) and that of the control group decreased by 0.13 kg (95% CI –0.67 to 0.41; P=.002). The weight loss was markedly greater after using the app for 9 weeks than that when used for 4 weeks or 5-8 weeks (P=.002). Patients in the app user group reported better sleep quality (P=.04) and duration (P=.004) than those in the control group.ConclusionsThe combination of primary care clinics and a mobile self-management health care app with human coaching results in better management of chronic conditions. This study shows that the primary care services combining a mobile self-management health care app with human coaching are effective in the current primary care system. An implication of this study is the possibility that a mobile self-management health care app with human coaching is a treatment option in the current primary care system.

Telerobotic neurovascular interventions with magnetic manipulation.

Advances in robotic technology have been adopted in various subspecialties of both open and minimally invasive surgery, offering benefits such as enhanced surgical precision and accuracy with reduced fatigue of the surgeon. Despite the advantages, robotic applications to endovascular neurosurgery have remained largely unexplored because of technical challenges such as the miniaturization of robotic devices that can reach the complex and tortuous vasculature of the brain. Although some commercial systems enable robotic manipulation of conventional guidewires for coronary and peripheral vascular interventions, they remain unsuited for neurovascular applications because of the considerably smaller and more tortuous anatomy of cerebral arteries. Here, we present a teleoperated robotic neurointerventional platform based on magnetic manipulation. Our system consists of a magnetically controlled guidewire, a robot arm with an actuating magnet to steer the guidewire, a set of motorized linear drives to advance or retract the guidewire and a microcatheter, and a remote-control console to operate the system under real-time fluoroscopy. We demonstrate our system's capability to navigate narrow and winding pathways both in vitro with realistic neurovascular phantoms representing the human anatomy and in vivo in the porcine brachial artery with accentuated tortuosity for preclinical evaluation. We further demonstrate telerobotically assisted therapeutic procedures including coil embolization and clot retrieval thrombectomy for treating cerebral aneurysms and ischemic stroke, respectively. Our system could enable safer and quicker access to hard-to-reach lesions while minimizing the radiation exposure to physicians and open the possibility of remote procedural services to address challenges in current stroke systems of care.

Transitional and Long-Term Rehabilitation Care System After Stroke in Korea.

Stroke is one of the leading causes of mortality and disability in Korea. Patients who experience stroke require adequate management throughout the acute to subacute and chronic stages. Many patients with long-term functional issues require rehabilitative management even in the chronic stage. A comprehensive rehabilitation and care model for patients who experience stroke is necessary to effectively manage their needs during rehabilitation and allocate medical resources throughout the stages, thus ensuring reduced unmet needs and improved post-stroke quality of life. In Korea, the government and medical specialists are working on re-organizing the rehabilitation care model, including standardized triage and discharge planning after acute stroke treatment, and establishing systematic transitional and long-term rehabilitation care plans. This review briefly introduces the general rehabilitation triage after acute stroke and describes the current transitional and continuous care systems available for these patients in Korea. We also present the issues faced in transitional and long-term care plans of the current system and the efforts invested in resolving them and promoting long-term care in stroke cases.

Interhospital Readmissions and Early Post-Discharge Outcomes of Transcatheter Mitral Valve Edge-to-Edge Repair

IntroductionFragmented postoperative care following elective procedures has been associated with poor outcomes. However, the association between interhospital readmission (IHR) and clinical outcomes after transcatheter edge-to-edge repair (TEER) is unknown. MethodsAdults who underwent TEER between 2014 and 2018 were identified in the National Readmission Database (NRD). We classified patients who were re-hospitalized within 90-days after TEER as: patients admitted to the index hospital (same hospital readmission; SHR) and those admitted to a different hospital (interhospital readmission; IHR). We compared 90-day outcomes, cause of readmission, length of stay (LOS), and costs between the two groups. Moreover, we tested whether IHR was an independent predictor of 180-day morality using logistic regression. ResultsOf the 12,716 patients who underwent TEER, 2444 were hospitalized within 90-days; among those, 1179 (48.2%) were admitted to a different hospital (IHR). Cardiovascular causes of readmission were more common in the SHR group (63.5% vs 56.7%, P < 0.001). After PSM, major adverse events were higher in the SHR group during both the index admission and during rehospitalization. Also, during the readmission, LOS and cost of care were both higher in the SHR group, while non-home discharge rates were higher in the IHR group. In the logistic regression model, IHR was not independently associated with 180-day mortality. ConclusionAdmission to a different hospital post TEER was not associated with higher adverse event rate. The current system of care wherein patients requiring TEER are referred to tertiary centers of excellence appears appropriate.

Abstract TMP61: Telerobotic Neurovascular Interventions With Magnetic Manipulation

Background: Advances in robotic technology have been adopted in various subspecialties of both open and minimally invasive surgery, offering benefits such as enhanced surgical precision and accuracy with reduced efforts and fatigue. Despite the advantages, robotic applications to endovascular neurosurgery have remained largely unexplored due to technical challenges such as the miniaturization of robotic devices that can navigate the complex and tortuous cerebral vasculature. Although some commercial robotic systems enable precise manipulation of conventional guidewires for coronary and peripheral vascular interventions, they remain unsuited for neurovascular applications due to the considerably smaller and more tortuous anatomy of cerebral arteries. Methods: We present a teleoperated robotic system designed for neurovascular interventions based on magnetic steering and navigation. Our system consists of a magnetically controlled guidewire, a robot arm with a permanent magnet attached to its end-effector for steering control of the guidewire, a set of motorized linear drives to advance or retract the guidewire and a microcatheter, and a remote-control console to operate the system under feedback from real-time fluoroscopic imaging and visualization. Results: With a life-sized neurovascular phantom, we demonstrate the navigational capability to reach several branches of circle of Willis and distal cerebral vasculature with the magnetic guidewire under teleoperation of the system. We further demonstrate telerobotically-assisted therapeutic procedures including coil embolization and clot retrieval thrombectomy for intracranial aneurysms and ischemic stroke, respectively. Conclusion: Our telerobotic neurointerventional platform could enable safer and quicker access to hard-to-reach lesions, significantly reduce operative time and perioperative risk by reducing intravascular manipulation, minimize the radiation exposure to interventionalists, and open the possibility of remote procedural services to address challenges in current stroke systems of care. Note: Animal testing will be performed in Q3 2021 and the results will be presented at ISC.