Improvements In Functional Quality Research Articles

Total Anomalous Pulmonary Venous Connection in Adults: Should We Offer Surgery?

Background: We aim to determine the surgical outcomes of adult patients with total anomalous pulmonary venous connection (TAPVC) and examine the regression of pulmonary artery (PA) pressures after the procedure. Methods: We reviewed the hospital records from 2003 to 2022 and identified 49 adult patients with TAPVC. We assessed their surgical outcomes and the trend of PA pressures after the procedure. Continuous data are presented as mean ± SD or median (interquartile range) and categorical variables are presented as percentages. Results: The median age of the patients was 23 years (range 18-42) and 31 (63.3%) were male. Thirty-six patients (73.5%) had supracardiac TAPVC. The mean systolic PA pressure was 65.8 ± 16.4 mm Hg and it decreased by 47.9% (34%, 61.8%) after surgery. Moderate or more tricuspid regurgitation was seen in 27 (55.1%) patients before surgery; however, it was present in only 3 (6.1%) patients during early follow-up. There was no intraoperative or 30-day mortality, and the median hospital length of stay was six days. Long-term follow-up data were available for 29 patients with the average duration of follow-up being 5.6 years (range 6 months to 15 years) and the mean systolic PA pressures of this cohort was 29.8±7.9 mm Hg. Forty-six (93.1%) patients were asymptomatic; four women had uneventful pregnancies and delivered healthy children. Conclusion: Surgical repair of the naturally selected group of adult TAPVC patients can be performed safely with good results. Regression in flow-related pulmonary hypertension and an improvement in functional quality of life are seen in nearly all patients.

Synergistic effects of Vitamin D and magnesium in non-specific low back ache (nLBA) – A prospective comparative study

Low back ache constitute a group of symptoms with no clear etiopathogenesis and pose a major difficulty for a health care professional to diagnose and treat the disease per se. Low back ache has become permanent disability for certain individuals and interferes with normal functioning of day-to-day life activities. This study was undertaken to establish the correlation and functional outcome between combination of Vitamin D & magnesium supplementation and Vitamin D supplementation for patients with non-specific low back ache. An observational comparative study was performed with 117 patients of non-specific low back ache from June 2019 to May 2020. Out of 117 patients, a total of 60 patients (Group A) were treated with a combination of Vitamin D supplementation along with magnesium tablets for 3 consecutive months and remaining 57 patients (Group B) were treated with Vitamin D supplementation for 3 consecutive months. Both the groups were followed up for 6 months for pain relief assessed by VAS score and functional improvement in quality of life assessed by Oswestry Low Back Pain Disability Questionnaire. A significant difference was noted in the Group A compared to Group B which demonstrates an additive effect on the combination used in them. When analysing the change in parameters compared to the pre-interventions state both the groups showed significant improvements. However, upon analysis of the correlation between the parameters with regard to the change among the groups, we noted that Group A showed significant correlation with respect to the Calcium and Vit-D level improvement out of the intervention upon the observed results. Treatment of non-specific low back ache with vitamin-D and magnesium shows synergistic effects with significant improvement in the functional outcomes and the pre-intervention metabolic parameters.

Practice Characteristics Associated with Better Implementation of Patient Self-Management Support.

Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation. Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation. In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all P < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, P = .0081), rural location (P = .0109), and higher percent Medicaid (P < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery. Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.

Team dynamics within quality improvement teams: a scoping review.

This scoping review examines what is known about the processes of quality improvement (QI) teams, particularly related to how teams impact outcomes. The aim is to provide research-informed guidance for QI leaders and to inform future research questions. Databases searched included: MedLINE, EMBASE, CINAHL, Web of Science and SCOPUS. Eligible publications were written in English, published between 1999 and 2016. Articles were included in the review if they examined processes of the QI team, were related to healthcare QI and were primary research studies. Studies were excluded if they had insufficient detail regarding QI team processes. Descriptive detail extracted included: authors, geographical region and health sector. The Integrated (Health Care) Team Effectiveness Model was used to synthesize findings of studies along domains of team effectiveness: task design, team process, psychosocial traits and organizational context. Over two stages of searching, 4813 citations were reviewed. Of those, 48 full-text articles are included in the synthesis. This review demonstrates that QI teams are not immune from dysfunction. Further, a dysfunctional QI team is not likely to influence practice. However, a functional QI team alone is unlikely to create change. A positive QI team dynamic may be a necessary but insufficient condition for implementing QI strategies. Areas for further research include: interactions between QI teams and clinical microsystems, understanding the role of interprofessional representation on QI teams and exploring interactions between QI team task, composition and process.

Chronic pelvic pain in an interdisciplinary setting: 1-year prospective cohort

Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities associated with changes in chronic pelvic pain severity over time. We sought to describe trends and factors associated with chronic pelvic pain severity over a 1-year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects. This was a prospective 1-year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age >50 years. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was chronic pelvic pain severity at 1 year on an 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0-3, moderate 4-6, severe 7-10). Secondary outcomes included functional quality of life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year. Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10-4/10, P < .001). There was also an improvement in functional quality of life (42-29% on the pain subscale of the Endometriosis Health Profile-30, P < .001), and a reduction in subjects requiring a physician visit (73-36%, P < .001) or emergency visit (24-11%, P < .001) in the last 3 months. On multivariable ordinal regression for the primary outcome, chronic pelvic pain severity at 1 year was independently associated with a higher score on the Pain Catastrophizing Scale at baseline (odds ratio, 1.10; 95% confidence interval, 1.00-1.21, P= .04), controlling for baseline pain, treatment effects (surgery), age, and referral status. Improvements in chronic pelvic pain severity, quality of life, and health care utilization were observed in a 1-year cohort in an interdisciplinary setting. Higher pain catastrophizing at baseline was associated with greater chronic pelvic pain severity at 1 year. Consideration should be given to stratifying pelvic pain patients by catastrophizing level (rumination, magnification, helplessness) in research studies and in clinical practice.

Converting a clinical indicator on patient missed treatments into a functional quality improvement metric.

101 Background: Extended time to complete a course of radiation can be detrimental to a patient’s overall local tumor control and survival. The American College of Radiology (ACR) Radiation Oncology Practice Guideline requires review of any unplanned interruptions during treatment. However, factors that impact missed treatments are neither required to be reviewed nor well characterized within the literature. We sought to understand the variables contributing to missed treatments by generating a functional metric for quality improvement. Methods: The departmental electronic medical record (EMR) was modified to create sub-sets of classifications for missed treatments. These categories were divided into intended and unintended breaks, with intended classification of physician prescribed break and eight subcategories of unintended breaks: patient preference, physician mandated, patient feels ill, transportation/social services, cancelled, no-show, weather, and machine downtime. Missed treatments were documented real-time by the treating radiation therapists using one of these eight categories. A custom report was generated to extract and separate missed treatments by category. Results: Over three years of ACR tracking, our department missed treatment rate ranged from 5-10%, out of 64,000 patient treatments. The new subcategory metric has been in place for the past six months. Overall compliance with documentation by therapists was 100%. The new metric yielded a six month total rate of missed treatments of 8% with detailed analysis showing the main reasons as: patient preferences (14%), inclement weather (14%), and machine down time (9%). Transportation was only a minor issue for the patient population. Conclusions: This stratification of a simple clinical indicator has identified the major factors influencing the total time to complete a course of treatment. Based on this analysis, our departmental quality committee is focusing on engaging and educating patients about the negative impact of missed treatments on their overall cancer care. Future research will attempt to identify patient characteristics that may predict individuals more likely to miss treatments.

Genetic diversity in morphological characters and phenolic acids content resulting from an interspecific cross between eggplant, Solanum melongena, and its wild ancestor (S. incanum)

AbstractSolanum incanum, the wild ancestor of eggplant, Solanum melongena, has been considered as a source of variation for high content of phenolic acid conjugates in breeding programmes aimed at improving the functional quality of eggplant. We have evaluated the morphological and phenolic acids content in an interspecific family including S. incanum (P1), S. melongena (P2), their interspecific hybrid (F1), progeny from the selfing of the F1 (F2) and the backcross of the F1 to P2 (BC1P2). Many morphological differences were found between parents, while the F1 was intermediate for most traits. However, F1 plants were taller and pricklier and presented higher fruit flesh browning than any of the parents. F2 and BC1P2 were morphologically highly variable and the results obtained suggest that a rapid recovery of the characteristic combination of S. melongena traits can be achieved in a few backcross generations. Segregation for prickliness was found to be compatible with simple genetic control, prickliness being dominant over non‐prickliness. A total of 16 phenolic acid conjugates were studied, of which chlorogenic acid (5‐O‐(E)‐caffeoylquinic acid) was the most common compound in all samples, averaging 77.8% of all hydroxycinnamic acid derivatives. Contents of total phenolic acid conjugates were much higher in S. incanum than in S. melongena fruit flesh, and no major differences were found in the profile of phenolic acids among parents. The interspecific hybrid (F1) was intermediate between the two parents in phenolic acids content. Non‐segregating generations presented considerable variation in phenolic acids content, but the range of variation was wider in segregating F2 and BC1P2 generations. Additive genetic effects were the most important in explaining the results obtained for the phenolic acids content. A number of BC1P2 plants presented a good combination of phenolic acids content and fruit weight or flesh browning. Overall, the results demonstrate that improvement of functional quality in S. melongena can be obtained using S. incanum as a donor of alleles for high phenolic acids content.

A Paradigm Shift Toward Systemwide Quality Improvement Education

Widespread changes in the health care landscape require a paradigm shift from an educational model where quality improvement (QI) expertise is centralized to a model where foundational and functional QI knowledge is widespread through all levels of a health care organization. To support a new educational structure prioritizing QI education as a stand-alone priority, a 6-month educational course was introduced for operational leaders (requiring completion of a real-life improvement project) and a second, introductory QI education set of 5 stand-alone classes was introduced for managers and frontline staff; the latter is provided at centralized sites, on-site, and via webinars. Additional QI courses have been introduced for board members. Sixty operational leaders attended the first 2 offerings of the 6-month course and completed 50 associated QI projects, as of July 2012; nearly 1500 participants have attended the "Just-in-Time" classes, representing 13 University of Pittsburgh Medical Center hospitals and affiliated facilities. Eighty-three percent of recent participants rated the 6-month course a 4 or 5 in terms of efficacy. Two-thirds of participants from both 6-month series reported that they continued to work on their project once the class was over. The number of course attendees and their feedback regarding efficacy of this educational approach, as well as the volume of associated completed projects, indicate success in providing greater numbers of staff at all levels of the organization with QI education and tools. This educational format shows promise for further refinement and replicability.

Modified Charles Procedure Using Negative Pressure Dressings for Primary Lymphedema

The Charles procedure is an aggressive operation usually only indicated for severe lymphedema as it often yields an unpredictable outcome. We modified this procedure in order to achieve predictable results. The modification entailed the use of a negative-pressure dressing after the initial debulking surgery and then the delay of skin grafting by 5 to 7 days. Patients were graded by means of a lower limb functional scale to assess their functional status pre- and postoperatively. Eight patients with severe primary lymphedema underwent a modified Charles procedure. All patients underwent this procedure without any major complications with an average resection of 8.5 kg of lymphedematous tissue. Minor complications included operative blood loss and additional regrafting (3 patients). The average follow-up was 27.3 months. The results show a dramatic functional improvement in quality of life and a high overall satisfaction rate of patients undergoing this procedure. Our modification makes this a relatively simple procedure with a predictable outcome.

Impact of Prosthesis–Patient Size on Functional Recovery After Aortic Valve Replacement

Prosthesis-patient size mismatch results when an implanted prosthetic aortic valve is of insufficient size for a patient's body surface area. The relation between prosthesis-patient size and functional capacity and adverse postoperative outcome is inconsistent. Our objectives were to examine the impact of valve replacement, continuous prosthesis-patient size, and other factors on functional recovery after aortic valve replacement (AVR) with the Duke Activity Status Index (DASI). From June 15, 1995, through May 14, 1998, 1108 patients underwent AVR after completing a DASI survey. Of these, 1014 completed a postoperative DASI survey at an average of 8.3 months postoperatively. Logistic ordinal regression was used to examine the influence of demographic variables, comorbidities, baseline DASI scores, indexed valve orifice area, standardized orifice size, and postoperative morbid events on postoperative DASI. There was overall improvement in postoperative functional recovery reflected by median preoperative and postoperative DASI scores of 29 and 46, P<0.001, respectively. Neither indexed orifice area, P=0.94, nor standardized orifice size, P=0.96, was associated with functional recovery. Female sex, increasing age, elevated serum creatinine, increased central venous pressure, and red blood cell transfusion were factors associated with poor postoperative functional recovery. A majority of patients report improvement in functional quality of life early after AVR. Similar functional recovery was demonstrated for patients along the full spectrum of valve sizes indexed to body size, even for values considered to represent severe mismatch for patient size. Factors other than prosthesis-patient size influence functional quality of life early after AVR.

H + H 2 quantum dynamics using potential energy surfaces from density functional theory

Density functional theory (DFT) potential energy surfaces are determined for the collinear H + H 2 reaction, using the standard B3LYP, B97-1, and B97-2 hybrid exchange-correlation energy functionals. The surfaces are used to calculate state-to-state reaction probabilities. B3LYP is wholly inadequate, whereas B97-1 and B97-2 yield a realistic description of the reaction dynamics, reproducing the widths and spacings of the resonances. Further improvements in functional quality are required, particularly with regard to the height and width of the DFT barrier.