Gaps In Patient Care Research Articles

Training Nigerian pharmacy interns for leadership and clinical pharmacy advancement using the ADDIE method of instructional design

Background: Leadership skills are required to promote and advance clinical pharmacy practice in Nigeria. The Nigerian pharmacy curriculum does not include any modules or training in leadership. Objective: A twelve-month online training on leadership and clinical pharmacy improvement was designed and delivered to intern pharmacists in Nigeria using the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) method of instructional design. The goal was to train interns to demonstrate leadership skills by identifying gaps in patient care or medication use processes at their practice sites and developing projects to solve them. Method: The Kirkpatrick's four-level method of training evaluation was used to assess the training. Result: About 42% of participants completed the training with the required capstone project. Conclusion: This paper describes the implementation and evaluation of a yearlong training designed to provide pharmacy interns in Nigeria with the necessary leadership skills to advance the field of clinical pharmacy.

Do clinicians address impairments in muscle strength and physical performance for older adults with cancer?

IntroductionLow physical function is associated with adverse outcomes in older adults with cancer, but evidence on real-world, clinical management of low physical function in oncology is lacking. We explored whether impairments in muscle strength and/or physical performance triggered downstream management by clinicians, the types of recommended strategies, and the reasons for not providing a referral/strategy for addressing such impairments in older cancer survivors prior to treatment. Materials and MethodsWe conducted a retrospective, cross-sectional study of older adults who completed a comprehensive geriatric assessment (CGA) prior to cancer treatment in a tertiary cancer centre. Muscle strength and physical performance were assessed through grip strength and the Short Physical Performance Battery (SPPB), respectively. Patients who exhibited an impairment in grip strength and/or SPPB were classified as having abnormal objective physical function. Downstream management strategies and clinicians' reasons for not providing referrals were retrieved from clinical notes and an institutional database. ResultsIn total, 515 older adults (mean age: 80.7 years) were included. Low grip strength and/or SPPB combined was observed in 66.4% (n = 342) of participants, of whom 54.1% (n = 185) received an acceptable intervention. However, 41.2% (n = 141) were not provided with a referral/strategy by clinicians to address such impairments following CGA. No reasons were provided in clinical notes for not addressing impairments in physical function for 100 participants (70.9%). DiscussionMany older adults with cancer have impaired physical function prior to treatment. However, we found that such impairments are not systematically addressed by clinicians, and documentation was often suboptimal, identifying gaps in patient care that need to be addressed.

Why are patients with acute traumatic brain injury not routinely assessed or treated for vestibular dysfunction in the UK? A qualitative study

ObjectivesVestibular dysfunction is common in patients with acute traumatic brain injury (aTBI). Persisting vestibular symptoms (ie, dizziness and imbalance) are linked to poor physical, psychological and socioeconomic outcomes. However, routine...

Facilitation of Forgiveness: Impact on Health and Well-being.

Although the practice of forgiveness is encouraged, the healing properties of this virtue by health care professionals are often overlooked. Forgiveness is the voluntary, conscious decision to abandon negative feelings toward another who has caused hurt and replacing those feelings with unconditional love and compassion. It is not about forgetting the hurt or ignoring the pain; it is an actual transformation of the heart. The Enright Forgiveness Process Model and the Pyramid Model of Forgiveness are 2 models that facilitate the forgiveness process. By utilizing either of these pathways, the forgiver ultimately experiences peace of mind and a "release from emotional prison" that leads to holistic healing. As a result, the forgiver experiences lower levels of depression, anxiety, and aggression, which improves quality of life. In addition, physiological benefits such as decreased stress levels, lower blood pressure, and a lower heart rate have also been reported. Throughout the course of their careers, nurses encounter patients and families in acute or end-of-life care situations who want to forgive or be forgiven. As holistic health care providers, nurses should be able to facilitate and close this gap in patient care. This article attempts to raise awareness to the importance of forgiveness in health and well-being among nurses and other health care professionals.

Psychiatric genetic counseling: A survey of Australian genetic counselors' practice and attitudes.

Genetic counseling plays a critical role in supporting individuals and their families' adaption to psychiatric conditions, addressing the multifactorial nature of these conditions in a personally meaningful and empowering way. Yet data related to the practice and attitudes of Australian genetic counselors about psychiatric genetic counseling (PGC) is limited. This survey investigated the practice of Australian genetic counselors, and their attitudes toward PGC. Genetic counselors (N=393) were invited to participate in an anonymous online survey between March and May 2022. Forty-four genetic counselors (response rate=11%) from Australia and New Zealand responded. No respondents practice in psychiatric genetics as their speciality area; most respondents do not see any patients where the primary indication is a personal and/or family history of psychiatric disorders (91%). Greater than half of respondents (56%) believed there was sufficient evidence to support PGC, and 64% enquire about personal and/or family history of psychiatric disorders, but only 25% provide genetic counseling on this topic. Most respondents do not feel confident providing risk assessments for psychiatric disorders (72%), while the majority expressed interest in attending specialist training (95%), and in incorporating PGC into future practice (77%). Australian genetic counselors would benefit from psychiatric genetic education and training, and establishment of specialized PGC services would address this gap in patient care, while providing opportunities for genetic counselors to gain skills and experience in PGC.

Management of iron-deficiency anemia following acute gastrointestinal hemorrhage: A narrative analysis and review.

Many patients experiencing acute gastrointestinal bleeding (GIB) require iron supplementation to treat subsequent iron deficiency (ID) or iron-deficiency anemia (IDA). Guidelines regarding management of these patients are lacking. We aimed to identify areas of unmet need in patients with ID/IDA following acute GIB in terms of patient management and physician guidance. We formed an international working group of gastroenterologists to conduct a narrative review based on PubMed and EMBASE database searches (from January 2000 to February 2021), integrated with observations from our own clinical experience. Published data on this subject are limited and disparate, and those relating to post-discharge outcomes, such as persistent anemia and re-hospitalization, are particularly lacking. Often, there is no post-discharge follow-up of these patients by a gastroenterologist. Acute GIB-related ID/IDA, however, is a prevalent condition both at the time of hospital admission and at hospital discharge and is likely underdiagnosed and undertreated. Despite limited data, there appears to be notable variation in the prescribing of intravenous (IV)/oral iron regimens. There is also some evidence suggesting that, compared with oral iron, IV iron may restore iron levels faster following acute GIB, have a better tolerability profile, and be more beneficial in terms of quality of life. Gaps in patient care exist in the management of acute GIB-related ID/IDA, yet further data from large population-based studies are needed to confirm this. We advocate the formulation of evidence-based guidance on the use of iron therapies in these patients, aiding a more standardized best-practice approach to patient care.

Empowering Patient Self-Management: A Community Paramedicine Model of Care in Ontario

Community Paramedicine Remote Patient Monitoring (CPRPM) was launched in Ontario in April 2015 to address high health system usage in vulnerable patients living with chronic disease. CPRPM expands on the home visit model of community paramedicine (CP) to bridge gaps in patient care and address inefficiencies in resource utilization. At patient and systems levels, CPRPM aims to promote patient self-management of chronic diseases. Several reports driving the development of the Ontario Seniors Strategy, which include key recommendations for expanding CP programs, provided the impetus for government to deliver on their electoral platform promise to increase health care spending. The Local Health System Integration Act, 2006 gave Local Health Integration Networks the authority to make home and community care services accessible to Ontario residents, including the supplies and equipment required by patients and their caregivers to support their care at home. Outcome measures of CPRPM point to positive benefits for encouraging patient self-management of chronic diseases and reducing health system strain, with a return on investment of 542%. The variety of options for patient interaction and ability to lessen health system burden makes CPRPM a desirable model of care.

Quality Improvement in Itself Changes Your Thinking: Lessons From Disseminating Quality Improvement Methods Through a Multisite International Collaborative Palliative Care Project in India.

Seven major palliative care (PC) centers in India were mentored through the Palliative Care-Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India. A quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches. We interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture. Engaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.

32655 Assessment of literacy inclusivity of dermatologic patient education material at UMass dermatology and beyond

Inequalities in society are emphasized, consciously or not, by the current health care system. They can be based off race, income, and education level. The needs of marginalized communities should be examined, and systems corrected accordingly, to provide more equality in care. Patient education materials are an opportunity to bridge the gap in patient care. However, these materials are often not inclusive to the public. With 82.7% of people reporting to use the internet as a medical resource and the NIH recommending a literacy level between 3rd and 7th grade, it is critical to examine these websites.

Alcoholism and American healthcare: The case for a patient safety approach

Alcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioral health condition. The aims of this paper are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population. The authors performed a narrative review of the literature on the current state of AUD treatment and patient safety, finding extensive evidence that patients with AUD usually go undiagnosed, unreferred and untreated. When they do receive AUD treatment, little evidence was found to indicate that a patient safety approach is incorporated into their care. Behavioral medicine is virgin territory for the patient safety movement. Medical care and behavioral medicine in the United States currently constitute two separate and unequal systems generally lacking in pathways of communication or care coordination for AUD patients. Significant barriers include institutional culture, individual and systemic bias against those with AUD, and health care infrastructure, especially the separation of medical and behavioral treatment. It is the authors’ conclusion that care of patients with AUD is unsafe. We advocate for the patient safety approach common in American hospitals to be extended to AUD treatment. Experienced patient safety leaders are in the strongest position to initiate collaboration between the mainstream medical and substance abuse treatment communities to reduce harm for this patient population.

Stroke care and collaborative academic research in Latin America.

A narrative overview of regional academic research collaborations to address the increasing burden and gaps in care for patients at risk of, and who suffer from, stroke in Latin America (LA). A summary of experiences and knowledge of the local situation is presented. No systematic literature review was performed. The rapidly increasing burden of stroke poses immense challenges in LA, where prevention and manage-ment strategies are highly uneven and inadequate. Clinical research is increasing through various academic consortia and networks formed to overcome structural, funding and skill barriers. However, strengthening the ability to generate, analyze and interpret randomized evidence is central to further develop effective therapies and healthcare systems in LA. Regional networks foster the conduct of multicenter studies -particularly randomized controlled trials-, even in resource-poor regions. They also contribute to the external validity of international studies and strengthen systems of care, clinical skills, critical thinking, and international knowledge exchange.

Closing Gaps in Care of Patients with Embolic Stroke of Unknown Source: A Multi-disciplinary approach (P18-10.003)

Closing Gaps in Care of Patients with Embolic Stroke of Unknown Source: A Multi-disciplinary approach (P18-10.003)

Telehealth in Trans and Gender Diverse Communities: the Impact of COVID-19.

Purpose of ReviewThis paper synthesizes current knowledge regarding telehealth and the impact of the SARS-COV2 pandemic on transgender and gender diverse (TGD) patients. We discuss the benefits and challenges of telehealth for patients, providers, and trainees.Recent FindingsMental health of TGD populations has been disproportionately challenged in the context of SARS-COV2, and telehealth interventions focused on gender affirmation and mental health are desired and acceptable by TGD populations.SummaryTelehealth in the era of SARS-COV-2 has a mixed impact on TGD patients and families, increasing access, decreasing travel time, and allowing for comfort and safety during care while also leaving gaps in care for patients without web/phone access and/or without a confidential place to participate in appointments, or to manage health concerns that require in-person evaluation. Providers have benefitted from the ability to reach TGD patients that are far from practice sites and to provide remote consultation for procedures and other interventions. Trainees have challenges as a result of telehealth practice which can impair the ability to learn in-person care, but have benefitted from remote training opportunities, including surgical training. Alterations in compensation structures have allowed sustainable telehealth practice to be an option for providers and health systems. As telehealth evolves, quality improvement and research efforts aimed at resolving known challenges and expanding beneficial uses of telehealth should consistently include and consider not only the beneficiaries of telehealth but also those who may struggle with access.

Advanced Practice Provider Perceptions of Barriers and Opportunities for Conducting Telehealth Encounters in the PALTC Setting

Prior to the Public Health Emergency of 2020/2021, telemedicine services were limited to specific geographic areas in the U.S. that were designated as Healthcare Resource Shortage Areas (HRSA). On January 31, 2020, HHS declared a public health emergency across the U.S. On March 13, 2020, HHS authorized waivers and modifications under Section 1135 of the Social Security Act. Reimbursement for telehealth services were included in the waivers to ensure that there would be no gaps in patient care. To prevent spread of the virus from center to center, clinicians were encouraged not to provide in-person care in more than one facility and/or not to provide in-person care if they had been exposed, were in quarantine or ill themselves.

Abstract WMP36: Closing Gaps In Care Of Patients With Embolic Stroke Of Unknown Source: A Multi-disciplinary Approach

Introduction: Embolic Stroke of Undetermined Source (ESUS) describes non-lacunar ischemic strokes, with no definite etiology after minimal standard work-up. Approximately 17% of ischemic strokes are ESUS, and patients are generally younger with mild strokes and higher Quality-Adjusted Life Years at stake, given annual 5% recurrence. Additional cardiac evaluation is often required for ESUS evaluation. A Multi-Disciplinary Clinic (MDC) employing vascular neurology and cardiology may improve diagnosis and outcomes, facilitate shared decision-making, and provide an enhanced clinical experience for patients with ESUS. We describe our experience. Methods: The UTHealth ESUS clinic was established in April 2019, as a monthly half-day clinic. Patients with ESUS (and without known PFO) are referred following ischemic stroke hospitalization or after evaluation in the stroke clinic. Patients are seen by a vascular neurologist and a cardiologist (EP specialist) in a single visit to ensure standardized, appropriate secondary stroke prevention. The specialists review cardiac imaging and monitoring data and discuss the need for additional work-up. While some patients present to the clinic with an event monitor or implantable loop recorder (ILR) in place, others are referred for long-term monitoring following the encounter. Patients are also screened for clinical trials, and stroke fellows rotate through the clinic to gain experiences managing this patient population. Results: A total of 36 patients have been evaluated at the ESUS clinic. Median age was 63 (52-71) and 15 (41%) patients were women. Patients were seen a median of 30 days from discharge/referral. Long-term cardiac monitoring was performed in (95%) of patients, including with either a 30-day event monitor (n=15) or ILR (n=20). Two patients were found to have atrial fibrillation, and a different potential cause (PFO, large vessel disease) was detected in 3 others. Five patients were consented for the ARCADIA clinical trial. Conclusion: A Multidisciplinary ESUS Clinic offers a patient-centered approach which may facilitate care coordination for stroke prevention and clinical trial enrollment, while providing learning opportunities for trainees.

Pharmacists expanded role in providing care for opioid use disorder during COVID-19: A qualitative study exploring pharmacists’ experiences

IntroductionDuring the COVID-19 pandemic, patients with opioid use disorder (OUD) struggled with access to prescribers and opioid agonist therapy (OAT). Recognizing this gap in care, Health Canada issued a short-term subsection 56(1) class exemption from the Controlled Drugs and Substances Act authorizing pharmacists to independently manage controlled substances. The purpose of this study was to explore the expanded role of Canadian pharmacists in providing care to patients with OUD during the pandemic. MethodsWe conducted qualitative key informant telephone interviews in the fall of 2020 with Canadian pharmacists who used the exemption. We included community or primary healthcare team-based pharmacists who managed opioid medication under the exemption. We recorded, transcribed verbatim, and de-identified all transcripts. Data was analyzed using a thematic approach involving line-by-line coding and constant comparison. ResultsWe interviewed nineteen pharmacists with representation from all provinces and urban and rural practice settings. Three major themes emerged that captured the pharmacists’ perspectives when providing care for patients with OUD during the pandemic: (i) continuity of care; (ii) harm reduction; and (iii) access to care. Pharmacists used the exemption to extend prescriptions, transfer prescriptions, receive verbal orders, and deliver OAT. ConclusionsThroughout the pandemic, pharmacists were able to provide continuity of care to patients with OUD who would have otherwise been unable to access care. The exemption permitted pharmacists to assess patients and provide OAT through this expanded role. Other countries should look to the Canadian experience and leverage the expertise of the pharmacist to expand their scope so that they can help fill the gap in care for patients with OUD.

Racial Disparities in Elective Total Joint Arthroplasty for Osteoarthritis.

Total joint arthroplasty (TJA) is an effective elective surgical procedure for knee and hip osteoarthritis (OA), yet racial disparities in the use of and outcomes from TJA have been recognized. Racial minority individuals are less willing to undergo TJA, demonstrate worse surgical and functional outcomes, and are more likely to undergo surgery at a low‐procedure‐volume center. In this systematic review, we summarize evidence to date on racial disparities in TJA and discuss potential factors that may underlie this gap in care for patients with OA.

Quality of Care for Patients With Systemic Lupus Erythematosus: Data From the American College of Rheumatology RISE Registry.

Although multiple national quality measures focus on the management and safety of rheumatoid arthritis, few measures address the care of patients with systemic lupus erythematosus (SLE). Our objective was to apply a group of quality measures relevant to the care of patients with SLE, and we used the American College of Rheumatology's Rheumatology Informatics System for Effectiveness (RISE) registry to assess nationwide variations in care. The data derived from RISE and included patients who had ≥2 visits with SLE codes ≥30 days apart in 2017-2018. We calculated performance on 5 quality measures: renal disease screening, blood pressure assessment and management, hydroxychloroquine (HCQ) prescribing, safe dosing for HCQ, and prolonged glucocorticoid use at doses of >7.5 mg/day. We reported performance on these measures at the practice level. We used logistic regression to assess independent predictors of performance after adjusting for sociodemographic and utilization factors. We included 27,567 unique patients from 186 practices; 91.7% were female and 48% White, with a mean age of 53.5 ± 15.2 years. Few patients had adequate screening for the development of renal manifestations (39.5%). Although blood pressure assessment was common (94.4%), a meaningful fraction of patients had untreated hypertension (17.7%). Many received HCQ (71.5%), but only 62% at doses of ≤5.0 mg/kg/day. Some received at least moderate-dose steroids for ≥90 days (18.5%). We observed significant practice variation on every measure. We found potential gaps in care for patients with SLE across the US. Although some performance variation may be explained by differences in disease severity, dramatic differences suggest that developing quality measures to address important health care processes in SLE may improve care.

Adapting the Environmental Scan for Gerontology Graduate Students’ Career Exploration

Environmental scanning is a process that provides organizations with information about their internal and external strengths, challenges, and opportunities. Although traditionally used in business and strategic planning, environmental scanning is now being utilized in health care to evaluate currently available programs and services, identify gaps in patient care or research, and make educational, organizational, and policy recommendations. The current study explores adapting the environmental scan for students enrolled in a gerontology graduate program as a tool to facilitate career exploration. Students learned about environmental scanning and were instructed to perform an environmental scan on an important issue, program, or service relevant to their overall career goals. Because students completed their environmental scan while enrolled in an Alzheimer’s Disease Management course, they were encouraged to factor in the increasing prevalence of Alzheimer’s disease into their project. Students’ environmental scan projects spanned several timely topics, including an evaluation of the services currently offered in assisted living facilities from the perspective of a geriatric social worker, a review of memory training interventions and a proposal for a new research study, and preliminary plans for opening an assisted living facility catering to older adults in the LGBTQ community that outlined financial considerations, staff training goals, and patient care plans. Completing the environmental scan project gave students an opportunity to investigate the current state of the career field they are planning to enter, and provided them with a product that they can build upon as they complete the graduate program and begin their careers.

Abstract 11504: Socioeconomic Factors Including Neighborhood SES Leading to Gaps in Care for Patients with Significant Congenital Heart Disease

Introduction: Lifelong continuity of care is crucial for patients with significant congenital heart disease (CHD). Unfortunately, gaps in care (GIC) are common and may be attributed to vulnerable developmental periods, changes in insurance status, lack of symptoms or knowledge regarding follow-up, and inability to access specialty care. There is limited understanding of socioeconomic and demographic factors that contribute to GIC in CHD. Hypothesis: Socioeconomic factors including U.S. neighborhood socioeconomic score(SES) are associated with GIC in patients with significant CHD. Methods and Results: A total of 8674 patients followed at Boston Children's Hospital (BCH) with moderate to severe CHD(as defined by AHA/ACC 2008 guidelines) were seen in clinic between January 2013 and December 2015. Socioeconomic characteristics including language, race, ethnicity, and U.S. neighborhood socioeconomic score (SES) were analyzed. GIC of > 3.25-years were identified in 33% (2829) of patients. GIC were associated with being an adolescent or young adult (13-23 years) (P<0.001), non-English speaking (P<0.002), non-white (P<0.001), Hispanic ethnicity (P = 0.02), and a low SES (P <0.001). Conclusions: A third of patients with significant CHD experienced a substantial GIC (>3.25 years). Adolescent young adult age and socioeconomic factors, including race, ethnicity, language, and a low SES were associated with GIC in patients with significant CHD. Interventions to identify and support these vulnerable populations could improve patient continuity of care and overall outcomes. Further studies are needed to understand the reasons for such GIC in vulnerable populations.