Great Need For Improvement Research Articles

The development of a posttraumatic stress disorder (PTSD) consultation program to support system-wide implementation of high-quality PTSD care for veterans.

Among veterans, there is a 7% lifetime prevalence of posttraumatic stress disorder (PTSD; Goldstein et al., 2016), with this diagnosis being linked to poor health and quality of life (Goldstein et al., 2016; Schnurr et al., 2009). Veterans with PTSD may present for treatment in a variety of health care settings, meaning that providers across all of these settings need information about how to care for veterans with PTSD. Despite a number of ongoing efforts to ensure that veterans have access to effective, recovery-oriented treatments for PTSD within Veterans Affairs (VA), there is a need for further improvement and likely an even greater need for improvement in non-VA settings. A variety of consultation and technical assistance models exist, though research has lagged in this area. This article reports the rationale, development, and initial outcomes of the PTSD Consultation Program, a centralized consultation program started in 2011, which is available to all providers offering care to veterans with PTSD on an "on-request" basis. From 2011 to 2022, there have been 17,417 consultation requests, with about three quarters coming from VA providers, most often related to resources or treatment questions. The program has also flexibly responded to current events and crises. Survey feedback indicates high satisfaction. Data indicate that this type of on-request consultation may be an effective method to utilize the expertise of a few providers to help support a broader range of providers in implementing high-quality PTSD-or other types of specialty-care. Future research can link these data to more distal outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Assessment highlights need for improvement in standards of development of core outcome sets for rare genetic diseases

ObjectivesA rare disease is classified as such if it affects less than one person in 2,000. The Core Outcome Set STandards for Development (COS-STAD) is a set of standards that represent the minimum recommendations to be considered in the process of core outcome set (COS) development. The aim of this study was to provide a baseline assessment of COS development standards for rare genetic diseases. Study Design and SettingCore Outcome Measures in Effectiveness Trials (COMET) database contains nearly 400 published COS studies according to the latest systematic review. Studies focusing on COS development for rare genetic diseases were eligible for inclusion and were assessed by two independent evaluators. ResultsNine COS studies were included in the analysis. Eight different rare genetic diseases were investigated. None of the studies met all the standards for development. The number of standards met ranged from 6 to 10, and the median was 7. ConclusionThis study is the first study to assess COS-STAD for rare genetic diseases, and it highlights a great need for improvement. First in terms of numbers of rare diseases considered for COS developments, second in methodology, particularly regarding the consensus process, and third in reporting of the COS development studies.

Impact of a performance monitoring intervention on the timeliness of Hepatitis B birth dose vaccination in the Gambia: a controlled interrupted time series analysis

IntroductionThe Hepatitis B virus that can cause liver cancer is highly prevalent in the Gambia, with one in ten babies at risk of infection from their mothers. Timely hepatitis B birth dose administration to protect babies is very low in The Gambia. Our study assessed whether 1) a timeliness monitoring intervention resulted in hepatitis B birth dose timeliness improvements overall, and 2) the intervention impacted differentially among health facilities with different pre-intervention performances.MethodsWe used a controlled interrupted time series design including 16 intervention health facilities and 13 matched controls monitored from February 2019 to December 2020. The intervention comprised a monthly hepatitis B timeliness performance indicator sent to health workers via SMS and subsequent performance plotting on a chart. Analysis was done on the total sample and stratified by pre-intervention performance trend.ResultsOverall, birth dose timeliness improved in the intervention compared to control health facilities. This intervention impact was, however, dependent on pre-intervention health facility performance, with large impact among poorly performing facilities, and with uncertain moderate and weak impacts among moderately and strongly performing facilities, respectively.ConclusionThe implementation of a novel hepatitis B vaccination timeliness monitoring system in health facilities led to overall improvements in both immediate timeliness rate and trend, and was especially helpful in poorly performing health facilities. These findings highlight the overall effectiveness of the intervention in a low-income setting, and also its usefulness to aid facilities in greatest need of improvement.

Evaluation of the allocation efficiency of medical and health resources in China's rural three-tier healthcare system

ObjectivesEvaluating the efficiency of health resource allocations is critical to improving China's rural three-level health service network. Study designThis was a prospective panel data study. MethodsBased on panel data of the medical and health resources of 31 provinces within rural China, collected from 2003 to 2020, this study uses a three-stage Data Envelopment Analysis–Malmquist index to analyze the evolution of efficiency and productivity. ResultsThe efficiency and productivity of county and county-level medical and health institutions rank highest, followed by township hospitals, whereas village clinics are shown to be in great need of improvement. A decline in technical advancement appears as a crucial factor exacerbating loss of factor productivity. ConclusionsPolicy makers should further optimize the efficiency of medical resource allocation and promote the coordinated development of rural health in China.

Barriers and Facilitators of Pharmacoeconomic Studies: A Review of Evidence from the Middle Eastern Countries.

The world is facing a continuous increase in medical costs. Due to the surge in disease prevalence, medical science is becoming more sensitive to the economic impact of medications and drug therapies. This brings about the importance of pharmacoeconomics, which is concerned with the effective use of health resources to optimize the efficiency and costs of medications of treatment for the best outcomes. This review was conducted to find out the potential barriers and facilitators to implementing pharmacoeconomic studies in the Middle Eastern region having both high- and low-income countries. The varying economies in the region depict diverse healthcare systems where implementation of pharmacoeconomics faces a large number of challenges and is also aided by numerous facilitators that contribute to the growth of its implementation. In this context, we have reviewed the status of pharmacoeconomics in Middle Eastern countries in research databases (Google Scholar, MEDLINE, Science Direct and Scopus) using keywords (“pharmacoeconomics”, “barriers”, “facilitators”, “Middle East”). The study reported that Yemen, Syria, Palestine, Iran, Iraq, Jordan and Lebanon are the lowest-income countries in the Middle East and the implementation of pharmacoeconomics is the poorest in these states. The UAE, Saudi Arabia and Israel are high-income rich states where economic aspects were comparatively better but still a large number of barriers hinder the way to its effective implementation. These include the absence of national governing bodies, the lack of data on the effectiveness of medications, the absence of sufficient pharmacoeconomic experts and the lack of awareness of the importance of pharmacoeconomics. The main facilitators were the availability of pharmacoeconomic guidelines, the encouragement of pharmacoeconomic experts and the promotion of group discussions and collaborations between researchers and policymakers. Cost-benefit analysis is still evolving in Middle Eastern countries, and there is a great need for improvement so that states can effectively benefit from cost analysis tools and utilize their health resources. In this regard, governments should develop national governing bodies to evaluate, implement pharmacoeconomics at the local and state levels and bring about innovation in the field through further research and development incorporating all sectors of pharmacy and pharmaceutics. The data presented in this research can further be extended in future studies to cover the various domains of pharmacoeconomics including cost-minimization analysis, cost-effectiveness analysis and cost-benefit analysis and their applications within the healthcare sectors of Middle Eastern countries.

Technology Focus: Artificial Lift (March 2022)

What is the one thing you can do that will provide the greatest benefit to your artificial lift operations? For me, the answer to that question is simple: focus on surveillance. Surveillance is the foundation of any artificial lift optimization program. Effective surveillance practices allow you to keep track of how your system is performing against predefined targets, understand the current state of your artificial lift system, and identify which wells are at risk of failure. It also helps you identify ways to prevent failures through better selection, design, and application of artificial lift technology. At the heart of any effective surveillance program is a set of thoughtfully selected key performance indicators (KPIs). Establishing surveillance KPIs helps you set goals and track your progress against them so that you can zero in on the areas in greatest need of improvement. Typical KPIs include production volumes, operational expenditures, downtime, capital expenditures, failure frequency, and intervention frequency. A variety of tools and techniques are used daily to monitor and control the performance of artificial lift systems. As technology has evolved, so have these surveillance practices. Historically, artificial lift surveillance was performed using manual techniques, such as measuring and evaluating produced volumes, collecting acoustic fluid levels, evaluating two-pen charts and amp charts, collecting and analyzing dynamometer cards, collecting pressure and temperature surveys, performing teardowns and root-cause failure analysis, and using well and network models to understand system performance better. As automation technology developed, these techniques were enhanced through real-time data collection, the use of permanent downhole gauges, and real-time control using wellsite intelligence. With the introduction of automation, exception-based management techniques were introduced to leverage the time and energy of personnel to the greatest benefit. This allowed operators to focus their efforts on dealing with “bad actors” and finding “low-hanging fruit” rather than spending their time looking at every single well each day. Today, artificial lift surveillance practices continue to evolve through data-science and data-analytics techniques. Data analytics allow operators to put an ever-growing volume of data to work. Such techniques, generally classified as descriptive analytics, diagnostic analytics, predictive analytics, and prescriptive analytics, often combine statistical and physics-based principles to find opportunities faster than traditional practices can. Descriptive analytics allow operators to answer questions about what has happened, diagnostic analytics help operators answer questions about why the events happened, predictive analytics help operators answer questions about what will happen, and prescriptive analytics help operators answer questions about what should be done. This month’s JPT features examples of three such systems. Paper SPE 207290 provides an example of how automated well models are being used to improve the performance of progressing cavity pumps in a large Middle Eastern asset. Paper SPE 200825 shows how one operator is using artificial neural networks to predict failures in sucker rod pumping applications. Finally, paper IPTC 20254 shows how genetic algorithms can be used to accelerate the surveillance and optimization of a large population of gas lift wells. As an added bonus, one of our recommended papers for further reading, paper SPE 207550, illustrates how data analytics techniques are being used to predict failures in electric submersible pumping applications. Recommended additional reading at OnePetro: www.onepetro.org. SPE 208136 - Gas-Lift-Valves Replacement in Norway Field Using Riserless Light Well Intervention Vessel by Antonio Fiameni, Eni, et al. SPE 207550 - Real-Time Implementation of ESP Predictive Analytics—Toward Value Realization From Data Science by Antonio Andrade Marin, Petroleum Development Oman, et al. URTEC 208406 - Statistical Process Control for Early Detection of Progressive Cavity Pump Failures in Vertical Unconventional Gas Wells by Suren Indrajith Rathnayake, The University of Queensland, et al.

Neonatal Morbidity Patterns and Admission Outcomes: A Cross Sectional Study at a Tertiary Care Hospital in Pakistan

Objective: To determine the neonatal mortality and ascertain the disease patterns at neonatal ward in a tertiary care hospital
 Material and Methods: 
 Design: Hospital based cross sectional study.
 Participants: Two thousand, two hundred and seventy five neonates were registered using retrospective data from 1st January 2020 to 31st Dec 2020. We recorded gender, birth weight, cause of admission, and admission outcome. Data was analyzed using Microsoft excel data spread sheet.
 Results: There were 2275 patients registered from CPDR (complete patient data record register) from 1st January 2020 to 31st Dec 2020. The mean birth weight was 2.35 kg, with lowest birth weight of 0.9kg and highest birth weight of 4.8kg (SD 0.8 and SE 0.01, CI 0.025). Out of 2175 admitted neonates 506 (23.2%) died, 1250 (57.4%) were discharged after desired improvement, most common presenting complaint and cause of admission was HIE grade 1 , followed by Sepsis, 418 (18.5%), 380(16.9%), respectively.
 Conclusions: Hypoxic Ischemic Encephalopathy grade I is the most common morbidity pattern in our study, the mortality rate was observed very high, indicators of birth weight were also poor. There is a great need for improvement of antenatal care for mothers to enhance different measures of newborn welfare and wellbeing.

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up.

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

1002 Catheter Directed Thrombolysis; Are Poor Quality Referrals Impacting Patient Selection for Treatment?

Abstract Introduction NICE guidelines relating to catheter directed thrombolysis for iliofemoral DVT were renewed in March 2020. These state that patients should be considered if they have: symptoms lasting <14 days, good functional status, a life expectancy of 1 year or more and a low bleeding risk. Anecdotally, we felt the quality of DVT referrals to our tertiary Vascular Centre, were not meeting these guidelines. Method Vascular registrar on call handovers between October 2019 and October 2020 were reviewed, identifying 85 referrals for patients with iliofemoral DVT. Referrals were evaluated for the inclusion of information pertaining to the four aforementioned criteria. A search of electronic patient records identified those patients who subsequently received thrombolysis. Results Of the 85 patients, 10.6%(n = 9) received thrombolysis. Over 90% (n = 77) of referrals included none or only one of the four criteria. The most frequently included criterion was “days since symptom onset” (n = 41), but this was still fewer than half of referrals (48%). Interestingly, eight patients were noted to have concurrent malignancy with none receiving thrombolysis, although malignancy itself is not a contraindication. Neither functional status nor information relating to life expectancy was included in any of their referrals. Conclusions Good quality referrals are essential in aiding clinical decision-making surrounding treatment options for iliofemoral DVT. Our audit revealed the majority of referrals lacked the information NICE guidelines have outlined, revealing a great need for improvement. Future work in this area will look at implementing changes to bring referrals more closely in line with current guidelines.

CROSS SECTIONAL STUDY ON THE PREVALENCE OF INTESTINAL PARASITIC INFECTIONS AMONG DISPLACED PERSONS IN YEMEN

Background: Intestinal parasitic infections (IPIs) are considered major health concerns in developing countries especially among economically disadvantaged communities. Currently, there is a lack of information on the prevalence of IPIs among internally displaced persons in Yemen.
 Objectives: To determine the prevalence of IPIs among internally displaced person in Saber camp, Lahaj governorate, Yemen during May- November 2019.
 Methods: A cross-sectional study was conducted among internally displaced person from the Saber camp. samples of fresh stool were collected from the participants and examined by wet mount and formal-ether fecal concentration technique. Data were processed using the Statistical Package of Social Science (SPSS), version 25.0. The significant level set was p-value <0.05.
 Results: The study involved a sample of 350 participants. Overall, the study found that 156 (44.6%) of the participants were infected with at least one intestinal parasite. The most predominant parasite determined in this study was Entamoeba histolytica/dispar (24.6%) followed by Giardia lamblia (19.7%), Hymenolepis nana 7.1%, Enterobius vermicularis 0.90%, and Strongyloides.stercoralis 0.30%. The prevalence rate of parasitic infection in males was 55 (45.8%), whereas females were 101 (43.9 %). The association between intestinal parasitic infections (IPIs) and gender was found statistically insignificant (χ² = 0.118, P = 0.732, df = 1). The finding of the study showed that the prevalence rate was significantly different based on the age of respondents (χ² = 12.10 P = 0.033, df = 5) with the highest prevalence in the age group 1-9 years was 45.5%, where the lowest was 5.8 % in groups of respondents age between 40 to49 years.
 Conclusion: This study reveals an alarmingly high prevalence of IPIs (44.6 %) on IPIs infection among internally displaced person in Saber camp in Lahaj governorate, Yemen. Hence, there is a great need for improvement of sanitation and proper health education is required to reduce intestinal parasitic infection.

Epidemiologic Health Survey of a Rural Peasant Association in Southwestern Ethiopia


 
 
 
 In many developing countries, health care is either severely inadequate or ineffective. This is especially true in Ethiopia where the rates of infant mortality, child mortality, and maternal mortality are approximately 10-100 times higher than those found in developed countries. However, reliable and comprehensive data on the incidence and prevalence of endemic diseases in many regions of the country are scarce. In the present study, we performed a cross-sectional census survey of a rural peasant association in the Jimma region in southwestern Ethiopia to (i) gather demographic and socioeconomic characteristics of the community and (ii) assess the primary health problems facing the children and women of childbearing age. Our data demonstrate that there was a significant lack of proper sanitation and personal hygiene: 90% of households shared living space with domestic animals, less than 10% of households were equipped with a latrine, and nearly 40% of all water was obtained from unprotected springs and rivers. Of the 166 women of childbearing age (15-49 years), only 13.8% had any knowledge of methods of contraception, and almost 90% had experienced a teenage pregnancy. Less than 2% of all deliveries were aided by trained traditional birth attendants or health professionals. The two-week period prevalence of acute childhood diarrhea was 26.3% and less than 10% of all diarrheal cases were treated with oral rehydration solution. Regarding the nutritional status of children under five years of age, 56.3% were suffering from moderate to severe protein-energy malnutrition based on weight for age, and 57% were moderately to severely stunted based on height for age measurements. Finally, over 90% of randomly chosen individuals were found to be positive for an intestinal parasitic infection. The results demonstrate that there is a great need for improvement in several basic health areas, including the environmental sanitary conditions of the community, as well as the fundamental health status of women and children. Our findings suggest that specific intervention programs must be initiated in order to address the basic health problems facing this rural community.
 
 
 

Primary Care Use Among Commercially Insured Adolescents: Evidence From the 2018 Healthcare Effectiveness Data and Information Set

Improving the utilization of preventive care among adolescents is important for achieving individual-level and population-level health goals. The Healthcare Effectiveness Data and Information Set reports data submitted by managed care health plans, capturing a large number of individuals in the U.S. Using Healthcare Effectiveness Data and Information Set from 2018, mean performance levels were calculated for 5 preventive care measures among adolescents. Differences in performance between states that use Healthcare Effectiveness Data and Information Set or Health Plan Accreditation and those that use neither were estimated. Analysis was conducted in January-July 2020. The sample included data from 39 states, with 32 that use Healthcare Effectiveness Data and Information Set or Health Plan Accreditation and 7 that do not. Adolescent vaccination coverage was 28% for the complete human papillomavirus series, 81% for meningococcal, and 88% for tetanus, diphtheria, and acellular pertussis. Access to a primary care practitioner (a 2-year measure) was 91%, and well-care visits (a 1-year measure) were 50%. When compared with states that do not use Healthcare Effectiveness Data and Information Set or Health Plan Accreditation, the mean performance of states that used either Healthcare Effectiveness Data and Information Set or Health Plan Accreditation was statistically significantly higher for 4 of the 5 assessed measures. Healthcare Effectiveness Data and Information Set measures can help public health officials to monitor progress toward health goals, such as Healthy People 2020, and identify poorly performing health plans and types of preventive services in greatest need of improvement. States using Healthcare Effectiveness Data and Information Set or Health Plan Accreditation were associated with better performance in some adolescent measures, which suggests that health plan accountability may have a role in achieving health outcomes and could be an important area for future research.

Risk factors for hospital readmission in older adults within 30\u2009days of discharge \u2013 a comparative retrospective study

BackgroundThe area of hospital readmission in older adults within 30 days of discharge is extensively researched but few studies look at the whole process. In this study we investigated risk factors related, not only to patient characteristics prior to and events during initial hospitalisation, but also to the processes of discharge, transition of care and follow-up. We aimed to identify patients at most risk of being readmitted as well as processes in greatest need of improvement, the goal being to find tools to help reduce early readmissions in this population.MethodsThis comparative retrospective study included 720 patients in total. Medical records were reviewed and variables concerning patient characteristics prior to and events during initial hospital stay, as well as those related to the processes of discharge, transition of care and follow-up, were collected in a standardised manner. Either a Student’s t-test, χ2-test or Fishers’ exact test was used for comparisons between groups. A multiple logistic regression analysis was conducted to identify variables associated with readmission.ResultsThe final model showed increased odds of readmission in patients with a higher Charlson Co-morbidity Index (OR 1.12, p-value 0.002), excessive polypharmacy (OR 1.66, p-value 0.007) and living in the community with home care (OR 1.61, p-value 0.025). The odds of being readmitted within 30 days increased if the length of stay was 5 days or longer (OR 1.72, p-value 0.005) as well as if being discharged on a Friday (OR 1.88, p-value 0.003) or from a surgical unit (OR 2.09, p-value 0.001).ConclusionPatients of poor health, using 10 medications or more regularly and living in the community with home care, are at greater risk of being readmitted to hospital within 30 days of discharge. Readmissions occur more often after being discharged on a Friday or from a surgical unit. Our findings indicate patients at most risk of being readmitted as well as discharging routines in most need of improvement thus laying the ground for further studies as well as targeted actions to take in order to reduce hospital readmissions within 30 days in this population.

Real-World Gaps in Chart Documentation and Patient-Centered Care Inform Team-Based Action Plans for Relapsed/Refractory DLBCL: Results from a Quality Improvement Study

Background Using shared decision-making (SDM) to define therapeutic goals and shape individualized treatment plans for relapsed/refractory diffuse large B-cell lymphoma (R/R DLBCL) can profoundly improve patient-reported outcomes. However, unique barriers within oncology systems can impede patient-centered care coordination and delivery. In this quality improvement (QI) initiative, we assessed barriers to patient-centered R/R DLBCL care in 2 community oncology systems and conducted team-based audit-feedback (AF) sessions within each system to facilitate improved care coordination. Methods Between 12/2019 and 1/2020, 33 hematology/oncology healthcare professionals (HCPs) completed team-based surveys designed to assess barriers to quality R/R DLBCL care in 2 community oncology systems (Table 1). In addition, we retrospectively audited electronic medical records (EMRs) of 75 patients with R/R DLBCL to compare documented practice patterns with self-reported survey results. To address identified gaps, 31 HCPs practicing within the 2 systems participated in AF sessions; together, clinical teams developed action plans guided by survey insights and EMR findings. Additional surveys completed before and after the AF sessions measured changes in participants' beliefs and confidence in care delivery. A planned prospective follow-up EMR audit of 75 patients will assess changes in documentation and practice behavior. Results Team Surveys and EMR Audit: Using a 5-point Likert scale (0 = extremely unlikely; 5 = extremely likely), HCPs indicated a high likelihood of using prognostic scores (mean score, 3.8) and cell of origin (mean score, 3.9) to inform DLBCL treatment decisions. However, despite documentation of individual prognostic factors, only 30% of EMRs included the calculated International Prognostic Index (IPI) risk score and only 8% included cell of origin. No EMRs included an age-adjusted IPI, stage-modified IPI, or NCCN-IPI score (Figure 1). Despite only 6% of HCPs identifying engaging patients in SDM as a major practice challenge, SDM resources were consistently underutilized (Figure 2). Only 30% of HCPs estimated using SDM in more than half of their patients; 23% of HCPs reported using SDM with none of their patients with R/R DLBCL. Moreover, while 63% of HCPs reported routinely asking the patient what role he/she wishes to play (active, passive, collaborative), fewer HCPs integrated other SDM tools: using visual aids to communicate treatment benefits/risks (59%), referring patients to online education resources (53%), including the patient's spouse/family members in decisions (47%), and discussing financial toxicity (38%). Small-Group AF Sessions: When asked to identify a single aspect of R/R DLBCL care in greatest need for improvement in their systems, HCPs most commonly selected care coordination (34%) and adverse event recognition/management (20%), followed by individualizing treatment (16%) and prognostic scoring (14%). As part of their action plans, HCPs prioritized 3 practice behaviors to address with their clinical teams: individualizing treatment decisions based on patient- and disease-related factors (40%), improving communication during care transitions (40%), and providing adequate patient education about treatment options and potential side effects (20%). As a result of participating in the AF sessions, HCPs reported a meaningful shift in beliefs about collaborative care: 84% of HCPs agreed or strongly agreed that collaboration across the extended oncology care team is essential for achieving DLBCL treatment goals, an increase from 64% prior to the AF sessions. Further, HCPs reported increased confidence in their ability to perform each of 6 aspects of evidence-based, collaborative, patient-centered care (Figure 3). Conclusions Key system-based barriers to providing individualized R/R DLBCL care include adequate documentation of prognostic factors, care coordination, and effective SDM. After participating in this QI initiative, HCPs demonstrated improved commitment to team-based collaboration and increased confidence in delivering patient-centered care. Remaining practice gaps and challenges can inform future QI programs. Study Sponsor Statement The study reported in this abstract was funded by an independent educational grant from Genentech. The grantor had no role in the study design, execution, analysis, or reporting. Disclosures No relevant conflicts of interest to declare.

"Challenges and facilitators-navigating in the landscape of spinal cord injury neuropathic pain"-a qualitative study on the use of prescribed drugs.

A qualitative study with an emergent design using semi-structured interviews in focus groups. To explore the expectations, experiences and desires among individuals who are prescribed drugs for spinal cord injury (SCI) neuropathic pain (NP). SCI rehabilitation centre. Eighteen informants with SCI and NP were enrolled. The informants originated from large and small cities in southern Sweden. Data were collected in focus groups consisting of 4-5 individuals in four separate sessions. An emergent design was employed using an interview guide containing open questions. The interviews were transcribed verbatim and data were analyzed according to qualitative content analysis. A model of three themes emerged: "Balancing between pain and side-effects" described the difficult choices the informants had to make between drugs and their unwanted side-effects and pain, "Desiring competence and structure in pain management" described the informants wishes regarding pain management and "From hope to personal solutions" described the process from hope of total pain relief from drugs to the development of personal strategies. There is a great need for improvement of SCI-related neuropathic pain management since recommended drugs are insufficiently effective and accompanied by severe side-effects that impact quality of life but also due to structural limitations and physicians' lack of competence in pain management.

Important Factors Affecting User Experience Design and Satisfaction of a Mobile Health App-A Case Study of Daily Yoga App.

In recent years, mobile health (mHealth) has gained popularity. Yoga apps help users to exercise at home and improve their health. It is worth discussing how to give yogis a better experience and higher satisfaction to improve their willingness to keep using yoga apps. In this study, the Daily Yoga app was selected as the research object to explore important factors related to its user experience design and user satisfaction. Through a literature review and Delphi method composed of eight experts, this study put forward the important criteria framework of user experience design for the Daily Yoga app and then, used the DEMATEL (Decision Making and Trial Evaluation Laboratory)-based ANP (Analytic Network Process) method to determine the factors’ importance order and the causal relationships among them. Finally, combined with the results of an importance–performance analysis of 16 real users, we discuss the improvement measures. The research results show that the yoga class is the most critical factor in the user experience design of the Daily Yoga app, the target plan is a factor that is in great need of improvement, and having an attractive interface can improve user experience. The evaluation model of the study can act as a reference for improving user experience with the Daily Yoga app, and can also be widely used in the process of user experience design, questionnaire production, and evaluation optimization of mHealth app and related applications.

Facebook Hospital Reviews: Automated Service Quality Detection and Relationships with Patient Satisfaction

ABSTRACTAs patient satisfaction is heavily linked to their choice of provider and medical outcomes, hospital administrations routinely consider a bevy of factors to improve patient satisfaction. These considerations are complex, so targeting the most important areas for improvement is challenging. However, consumers’ online reviews of their hospital experience provide a vital lens into the factors associated with their satisfaction. In this study, we use a large dataset of Facebook reviews to construct a taxonomy of potential service attributes that consumers discuss online. We find partial overlap between this taxonomy and prior works and more traditional survey measures; the specific mix of service attributes found in these reviews is unique. Next, we utilize regression modeling to determine which service attributes are most closely associated with star ratings, which we use to measure overall satisfaction. This study demonstrates that mentions of waiting times, treatment effectiveness, communication, diagnostic quality, environmental sanitation, and cost considerations tend to be most associated with patients’ overall ratings. Finally, we construct text analyses to rapidly detect consumers’ mentions of these service attributes in an automated manner. We derive a set of “smoke terms,” or terms especially prevalent in posts that mention specific service attributes. We find that these are generally non‐emotive terms, indicating limited utility of traditional sentiment analysis. Managerially, this information helps to prioritize the areas in greatest need of improvement. Additionally, generating smoke terms for each service attribute aids health care policy makers and providers in rapidly monitoring concerns and adjusting policies or resources to improve service.

A novel bispecific nanobody with PD-L1/TIGIT dual immune checkpoint blockade

Cancer immunotherapy have changed the paradigm of cancer treatment, but there remains a great need for improvement given that less patients with tumors respond to the treatment of PD-1/PD-L1 blockade. TIGIT (also called T cell immunoreceptor with Ig and ITIM domains), a novel immune checkpoint molecule, has been shown a promising target for drug development of immunotherapy. Here we report generation and characterization of a multivalent bispecific antibody (BsAb) that co-targets PD-L1 and TIGIT. The BsAb consists of tetravalent anti-PD-L1 Fc-fusion nanobody (Nb) and tetravalent anti-TIGIT Nb. The parental anti-PD-L1 Nb showed high specificity and affinity to primate PD-L1, the enhanced T cell activity in vitro and anti-tumor activity in vivo. Similarly, the parental anti-TIGIT Nb showed the high specificity and affinity to primate TIGIT and the enhanced T cell activity. Furthermore, we demonstrated that the BsAb retained high blocking activity towards PD-1/PD-L1 or TIGIT/CD155 interaction. The BsAb synergistically enhanced T cell activities in vitro compared to two parental Nbs. Taken together, we obtained a multivalent BsAb blocking biological function of PD-L1 and TIGIT and it is worthy to further study the anti-tumor activities of this BsAb in vivo.

Determinants of Tax Compliance of Micro and Small Business Enterprise (MSE) Category “C” Taxpayers, the Case of Gurage Zone, Ethiopia

This study sought to identify the determinant of tax compliance in Ethiopia, specifically focusing on Micro and Small business enterprises operating in the Gurage zone. The researcher outlined a detailed literature review and identified the variables for this research to be tax rate, tax knowledge, tax compliance cost; the attitude of Micro and small enterprises and tax system. The research employed both descriptive and explanatory research design. A sample size of 325 was used from a population of 1726 micro and small business enterprises category “C” taxpayers in the Gurage zone. Data was collected using questionnaires and the structured interview. The collected data was consequently analyzed using Statistical Package for Social Scientist software (SPSS V.22) and the findings of the research presented using tables, various chart types and graphs. The results showed that tax rate, tax knowledge, tax compliance cost, the attitude of SME's and tax system significant determine tax compliance of taxpayers. Tax rate, Tax system and compliance cost predominantly affect tax compliance. Concerning the cost of tax compliance, the study revealed that Micro and Small businesses incur different costs such as salary of accountants, fees to tax consultants, cost of stationeries, etc. that contributed for their non-compliance and estimation of Micro and Small Enterprises tax is another problem-related tax system. However, the taxpayers do feel and strongly agree that the taxation system in Ethiopia is in great need of improvement. The study then recommended that the current tax law should be amended to incorporate provisions that grant special tax incentives to MSEs to improve voluntary tax compliance by MSE taxpayers. The study also recommended that the ERCA should disseminate information on the tax rate and tax system more frequently to improve the levels of tax know-how for voluntary tax compliance.

Reflection rounds to facilitate resilience in hematology/medical oncology fellows.

11019 Background: Given the prevalence of burnout among medical oncologists (40-60% in the literature), education on burnout risk factors, recovery, and prevention are needed urgently in training curricula for medical oncology fellows. Care of patients with cancer is increasingly complex, and often can seem overwhelming to new trainees. Debriefing as a resiliency skill to develop self-reflection and identify coping strategies may provide a durable way to navigate these complexities. Optimization of fellowship Reflection Rounds (RR) was selected as a fellow-led quality improvement (QI) project for the current academic year. Methods: A QI team including the APD and representatives from all levels of fellowship training was assembled. Feedback regarding previously unstructured, monthly, hour long faculty-facilitated RR for first year fellows was reviewed. Topics with associated readings were selected and paired with fellow-nominated faculty based on the most common recurring themes. The QI team administered the Stanford Professional Fulfillment Index (PFI) to all fellows at the midway point of the academic year. RR were re-structured to include a chaplain with trainee communication expertise and a chief fellow to participate the sessions to assess changes in trainee engagement. Repeat assessment of the Stanford PFI is planned for the end of the academic year. Results: Topics identified for discussion included handling bias, futile care, patient communication, end of life care, and work-life balance. 26 fellows completed the Stanford PFI including nine 1st year fellows, 13 2nd year fellows, and 6 3rd year fellows. Survey results revealed emotional and/or physical fatigue as areas of greatest need for improvement in fellow well-being with 27% of fellows reporting “moderate” emotional or physical exhaustion. Conclusions: RR provides a safe and effective forum to develop peer debriefing and self-refection as resiliency skills within hematology/medical oncology fellowship training. Optimization of RR will continue as fellows become more involved in planning and implementation of curricular improvements to promote resiliency and enhance wellness.