Large Academic Health Care Research Articles

Motivators and Barriers to Seeking Metabolic and Bariatric Surgery Among Adolescents: A Qualitative Study.

The prevalence of severe obesity among adolescents has increased the use of metabolic and bariatric surgery (MBS) as a therapeutic option. Understanding factors influencing adolescent MBS choice and the support needed to undergo MBS is crucial for improving health outcomes. This study examines the motivations and support needs of a diverse sample of adolescents seeking MBS via the patient voice. Adolescents (n=14) at a weight loss surgery clinic in a large academic healthcare system participated in qualitative interviews. Of the participants, 10 were female, 6 were non-Hispanic Black, 3 were non-Hispanic White, and 5 were Hispanic. Interviews were recorded, transcribed, and thematically analyzed. Three themes emerged: Intrinsic motivators, extrinsic motivators, and barriers. Intrinsic motivators include personal physical and mental health goals. Extrinsic motivators involved family and medical team support, which provided encouragement, validation, and perceived confidence for lifestyle changes. Additionally, observing family members who previously completed MBS was a significant extrinsic motivator. Concerns included fear of dying/complications from MBS, and possible weight regain post-MBS. Adolescent MBS programs should enhance intrinsic motivation for behavior changes. Findings highlight opportunities for bolstering support pre- and post-MBS and addressing MBS-related anxieties related to long-term weight management.

Using the EPIS Framework to Implement a Physical Activity Promotion Intervention at a Large Academic Healthcare System.

This study aimed to describe the implementation of a workplace health promotion to address low levels of physical activity (PA). Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, we implemented and evaluated a 10-week workplace step-count challenge to promote PA. All health system employees invited to participate. Data were collected on the exploration, preparation, and implementation phases. During exploration, we recognized inadequate PA among employees. Meetings with key personnel were held to determine details of the health promotion and obtain support. We pursued a step-count PA intervention, capitalizing on employee ownership of smartphones with accelerometers. Vendors to host the intervention were evaluated. All employees were invited to participate. Participants received weekly messages about improving PA and notifications of weekly challenges. Exit interviews provided feedback and suggestions. A workplace health promotion focused on employee PA is feasible using EPIS.

Population-Based Study of the Epidemiology of Stiff Person Syndrome in a Large Colorado-Based Health System.

Stiff person syndrome spectrum disorder (SPSD) is a rare autoimmune disorder characterized by progressive muscle stiffness and painful spasms with an estimated prevalence of 1-2 cases per million people. Population-based epidemiologic studies are lacking because of both poor patient capture and the lack of standardized diagnostic criteria. Objectives of this study were to describe the incidence and prevalence of SPSD within the University of Colorado Health (UCH) system and apply previously proposed published criteria for SPSD within this population. We queried Health Data Compass, an electronic health data repository for a large academic health care system, from 2012 through 2022 for all patients older than 18 years with International Classification of Diseases, 10th Revision (ICD-10) codes pertaining to stiff person syndrome. Records were reviewed for diagnostic confirmation. We calculated yearly and period prevalence and incidence rates based on observable person-time exposure of our cohort. We applied previously published Mayo Clinic and Johns Hopkins criteria for SPSD and compared period prevalence based on each criterion and evaluated for agreement. Two hundred and seventy-three patients met the initial inclusion criteria using ICD-10 codes; 59 were confirmed to have SPSD. The mean age was 49.7 years (SD = 12.9), 59.3% were female, 59.3% were considered antibody positive. The total database population over the interval was 2,801,674 persons. The estimated prevalence of SPSD based on our UCH cohort was 2.11 (95% CI 1.57-2.64) per 100,000 persons. The average yearly incidence was 0.35 per 100,000 person-years (95% CI 0.27-0.46). Applying different clinical diagnostic criteria, the estimated prevalence ranged from 1.36 (95% CI 0.93-1.79) to 1.82 (95% CI 1.32-2.32) per 100,000 persons. We describe a prevalence of SPSD of 2.11 per 100,000 persons in our UCH cohort. Prevalence estimates differed depending on which clinical diagnostic criteria were applied and whether possible SPSD cases were included. Using the most stringent criteria for diagnosis, we report a prevalence of 1.36 per 100,000 persons. While our study uniquely captures many US demographic groups, limitations remain because this is a retrospective review of a single system. Additional studies are needed to determine whether these results are representative of a national or global population.

Graph theoretic visualization of patient and health worker messaging in the EHR.

The electronic health record (EHR) has greatly expanded healthcare communication between patients and health workers. However, the volume and complexity of EHR messages have increased health workers' cognitive load, impeding effective care delivery and contributing to burnout. To understand these potential detriments resulting from EHR communication, we analyzed EHR messages sent between patients and health workers at Emory Healthcare, a large academic healthcare system in Atlanta, Georgia. We quantified the burden of messages interacted with by each health worker type and visualized the communication patterns using graph theory. Our analysis included 76,694 conversations comprising 144,369 messages sent between 47,460 patients and 3,749 health workers across 85 healthcare specialties. On average, nurses/certified nursing assistants/medical assistants (nurses/CNA/MA) interacted with the most messages (350), followed by non-physician practitioners (NPP) (241), physicians (166), and support staff (155), with the average conversation involving 10.51 interactions before resolution. Network analysis of the communication flow revealed that each health worker was connected to approximately two other health workers (average degree = 2.10). In message sending, support staff led in closeness centrality (0.44), followed by nurses/CNA/MA (0.41), highlighting their key role in fast information spread. For message reception, nurses/CNA/MA (0.51) and support staff (0.41) also had the highest values, underscoring their vital role in the communication network on the receiving end as well. Our analysis demonstrates the feasibility of applying graph theory to understand communication dynamics between patients and health workers and highlights the burden of EHR-based messaging.

A Model for Implementing Psychotherapy for Individuals with Cognitive Impairments

AbstractIndividuals with Mild Cognitive Impairment (MCI) and dementia are at greater risk for mental health conditions including depression and anxiety than those without cognitive impairments.1,2 Non‐pharmacological interventions are considered first‐line to address these problems, but access to psychotherapy services for these groups remains limited. Adapted evidence‐based therapy approaches, including Cognitive Behavioral Therapy (CBT)3‐5 and Acceptance and Commitment Therapy (ACT)6 are effective for treating comorbid mental health conditions in populations with cognitive impairments. We report on the implementation of psychotherapy services for patients with MCI and Mild Dementia within the Memory Assessment Clinic of a large academic healthcare system in Midwest U.S. Pre‐implementation process included identifying a clinic champion to support adoption and observing current clinic flow by the practitioner (a licensed Clinical Health Psychologist with expertise treating patients with neurological issues) to determine logistics. Referrals were initially solely provided by the clinic champion, then opened to the entire clinic with pre‐determined eligibility guidelines: recent MCI or Mild Dementia diagnosis, comorbid anxiety or depressive symptoms, and lack of rapid forgetting in during medical examination. Therapy patients were seen on a short‐term basis (6‐8, 45‐minute sessions) to maximize access for as many patients as possible, using CBT or ACT‐based therapy modalities. Therapy content was tailored and person‐centered but included (in chronological order): evaluation of cognitive capacities to leverage during therapy, identification of treatment goals, identification of problematic cognitions/behaviors, introduction of new treatment content/coping skills (one topic/session), assign homework assignments using learned skills, evaluation of homework effectiveness and roadblocks. The initial session was in‐person to facilitate comprehensive evaluation and build rapport, and family caregivers were included as indicated. Follow‐up sessions were provided in‐person or via telehealth. Barriers to implementation included incorrect use of referral process, lack of provider knowledge of new services, and limited provider availability. Facilitators included developing a wait list for referred patients and regular education to providers with written details of the service (e.g., referral process and eligibility; waitlist duration). Similar strategies have been used in other health systems and suggest the feasibility of incorporating psychological treatment for cognitively impaired patients as part of a multi‐component treatment model.

Exploring the Knowledge, Attitudes, and Perceptions of Hospital Staff and Patients on Environmental Sustainability in the Operating Room: Quality Improvement Survey Study.

In Canada, the health care system has been estimated to generate 33 million metric tons of greenhouse gas emissions annually. Health care systems, specifically operating rooms (ORs), are significant contributors to greenhouse gas emissions, using 3 to 6 times more energy than the hospital's average unit. This quality improvement study aimed to investigate the knowledge, attitudes, and perceptions of staff members and patients on sustainability in the OR, as well as identify opportunities for initiatives and barriers to implementation. A total of 2 surveys were developed, consisting of 27 questions for staff members and 22 questions for patients and caregivers. Topics included demographics, knowledge and attitudes regarding environmental sustainability, opportunities for initiatives, and perceived barriers. Multiple-choice, Likert-scale, and open-ended questions were used. A total of 174 staff members and 37 patients participated. The majority (152/174, 88%) of staff members had received no and minimal training on sustainability, while 93% (162/174) cited practicing sustainability at work as moderately to extremely important. Among patients and caregivers, 54% (20/37) often or always noticed when a hospital is being eco-friendly. Both staff members and patients agreed that improving sustainability would boost satisfaction (125/174, 71.8% and 22/37, 59.4%, respectively) and hospital reputation (22/37, 59.4% and 25/37, 69.5%, respectively). The staff members' highest-rated environmental initiatives included transitioning to reusables, education, and improved energy consumption, while patients prioritized increased nature, improved food sourcing, and education. Perceived barriers to these initiatives included cost, lack of education, and lack of incentives. Staff members and patients and caregivers in a large academic health care center acknowledge the significance of environmental sustainability in the OR. While they do not perceive a direct impact on patient care, they anticipate positive effects on satisfaction and hospital reputation. Aligning initiatives with staff members and patient and caregiver preferences can help drive meaningful change within the OR and beyond.

Healthcare Utilization Among Youth with Chronic Illness Receiving Care at a Large Urban Academic Healthcare System.

We sought to understand healthcare utilization and barriers to care among youth with chronic illness who interact frequently with the healthcare system. This was a retrospective analysis of healthcare utilization for youth ≤25 years of age with chronic illness during one calendar year (1 January 2021-31 December 2021) in a single urban academic healthcare system. Inclusion criteria were (1) having at least one healthcare encounter in the calendar year of 2021 and (2) having at least six healthcare encounters over the preceding 3-year period or having a qualifying chronic illness. Demographic and clinical characteristics were collected along with self-reported and derived social determinants of health. Univariable and multivariable regression models were created to identify predictors of missed clinic visits, telehealth use, and activated patient portal accounts. The cohort (N = 14,245) was demographically, clinically, and socioeconomically diverse. The youth had frequent clinic visits (median 9, IQR 4-18), multiple subspecialty care referrals (median 4, 1-8), were prescribed multiple medications (median 6, 3-10), and a high proportion received emergency department (18%) or inpatient treatment (15%). Race and public insurance were significant predictors of missed clinic visits and telehealth use. Primary language was a significant predictor of patient portal activation. Youth with chronic illness who are high users of the healthcare system face a high burden of clinic, emergency room, and hospital visits, referrals, and medications. Systematic efforts to lower the healthcare burden and improve care access should address existing racial and socioeconomic disparities affecting this patient population, who are likely to need frequent healthcare over their lifetime.

Development and application of a non-technical skills coaching intervention framework for surgeons: A pilot quality improvement initiative.

Non-technical skills (NTS) challenges experienced by surgeons may degrade performance, ultimately impacting the safety and quality of care delivered to patients. The objectives of this work were to develop a framework for NTS coaching for surgeons and implement a coaching program utilizing the developed NTS coaching framework. Leveraging adult learning and self-determination theories, a specialty-agnostic NTS coaching framework was developed for individual coaching sessions with robotic surgeons. The framework was used to deliver NTS coaching sessions to robotic surgeons. Surgeon's robotic procedures were recorded, and expert raters assessed their NTS using the Non-Technical Skills for Surgeons tool. Measures of surgeon satisfaction, learning outcomes, and performance improvement were determined. Cohen's d statistic was used to estimate the effect size of the coaching intervention. To pilot the program, ten robotic-assisted surgeries (five pre-coaching and five post-coaching) were observed from five practicing robotic surgeons who were recruited from a large academic healthcare system. Expert raters' assessment of surgeons' NTS revealed several exemplar and non-exemplar behaviors. Surgeons were satisfied with the coaching, rating its quality very highly on all NTS dimensions. On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), surgeons had a stronger agreement that the coaching could improve their situation awareness (4.0±.5) and leadership (4.8±.2) skills compared to their decision making and communication (3.8±.7). From the post-coaching observations, coaching had medium-to-large effect on situation awareness (d = .65) and leadership (d = .41), small effect on communication and teamwork (d = .14), and no effect on decision-making. Overall, the coaching intervention had a medium effect on total NTS (d = .33). We presented a quality improvement initiative to enhance the NTS of surgeons by implementing a coaching program that leverages our developed NTS framework. Recognizing the importance of NTS in surgeries, our initiative shows a commitment to continuous improvement of patient safety and quality of care.

Retrospective analysis of HPV infection: Cotesting and HPV genotyping in cervical cancer screening within a large academic health care system.

In 2019, the American Society for Colposcopy and Cervical Pathology introduced fundamental shifts toward "risk-based" guidelines, with human papillomavirus (HPV) genotyping as a principal test for investigating squamous intraepithelial lesions. This study aims to provide practice-based evidence and supplement the updated guidelines by investigating HPV demographic distribution and uncovering the pathological features of high-grade squamous intraepithelial lesions (HSILs) caused by high-risk HPV (hrHPV) subtypes. Patients who underwent Papanicolaou screening and HPV testing in two hospital systems over the course of 4 years were recruited. The cytology results were categorized on the basis of the 2014 Bethesda classification. DNA sequences of 14 types of hrHPV were detected by Aptima test. The histological features of HSILs caused by different subtypes were compared between biopsies and excisions. A total of 63,709 cases were included. The HPV prevalence was 14.70%, predominantly in the 30 to 39-year-old age group, with slightly higher rates observed in African Americans. There was no significant racial distribution difference between HPV 16/18/45 and other types. HPV 16/18/45 infection was directly correlated with the severity of abnormal cytology, although the other subtypes were the major causes of cytological abnormalities. The trend for HPV prevalence was consistent across calendar years, and was associated with 8.77% negative for intraepithelial lesion or malignancy, 30.46% atypical squamous cell of undetermined significance, 64.62% low-grade squamous intraepithelial lesion, 66.75% atypical squamous cell-cannot exclude a high-grade squamous intraepithelial lesion, and 91.80% HSIL. Furthermore, 29.09% of HSILs associated with other subtypes were not detectable on subsequent resections. Given the HPV demographic distribution and the histological features of HSILs caused by different subtypes, cotesting with reflex HPV genotyping in specific populations, or expanding the subtypes in the primary HPV screening test, should be considered.

GLP-1 Receptor Agonists Confer No Increased Rates of IBD Exacerbation Among Patients With IBD.

In patients with inflammatory bowel disease (IBD), multimorbidity with obesity and type 2 diabetes is common and increasing. Glucagon-like peptide 1 (GLP-1) receptor agonists are increasingly being prescribed for patients with IBD, yet their impact on patients with IBD is largely unknown. We aimed to assess the impact of GLP-1 receptor agonists on the course of IBD. We identified all IBD patients prescribed GLP-1 receptor agonists at a large academic healthcare network between 2009 and 2023. We analyzed demographics and IBD characteristics in the year pre- and post-GLP-1 receptor agonist prescription and matched them to non-IBD controls. Our primary outcome was IBD exacerbation in the year following GLP-1 receptor agonist initiation, measured as a composite of IBD-related hospitalization, corticosteroid prescription, medication escalation or changes, or IBD-related surgery. Secondary outcomes included change in metabolic risk factors. Overall, 224 patients met inclusion criteria. At GLP-1 receptor agonist initiation, the median age was 54 years, 63% were female, 77% were White, and median BMI was 33.2kg/m2. Compared to the 12-month period prior to GLP-1 receptor agonist initiation, in the 12 months post-GLP-1 receptor agonist initiation, there was no change in rates of IBD exacerbation, IBD-related hospitalization, steroids prescription, medication escalation or changes, or IBD-related surgery. There was a significant decrease in BMI in the year following GLP-1 receptor agonist initiation (median BMI 33.5 vs 31.6kg/m2, P < .01), with rates of decrease comparable to non-IBD matched controls. In patients with IBD, GLP-1 receptor agonists are effective for weight loss and associated with few episodes of disease exacerbation.

Evaluating Receipt of Optimal Medical Therapy Among Structurally Disadvantaged Groups Undergoing Amputation

Optimal medical therapy (OMT) for peripheral artery disease (PAD) is associated with decreased major amputation and mortality. OMT has several components, includingantiplatelet and high-intensity statin therapy, blood pressure control, etc. While there are disparities in receipt of OMT among PAD patients, it is unknown if patients from disadvantaged neighborhoods, measured by the area deprivation index (ADI), are less likely to be on OMT. We performed a retrospective review of patients that underwent major lower extremity amputation between 2015 and 2019 at 2 large academic healthcare systems. Primary exposure was high ADI, defined as ADI ≥60th percentile, and secondary exposure was non-Hispanic Black (NHB) race. For each analysis, the primary outcome of interest was receipt of OMT, defined here as at least one antiplatelet agent and a high-intensity statin. The exposure outcome relationship was assessed using multivariable logistic regression. Among 354 patients with median age of 66 (interquartile range [IQR] 58-74), 267 (75.4%) were male, 219 (61.9%) identified as NHB and 116 (32.8%) as non-Hispanic White (NHW). Overall, 91 (25.7%) patients were on OMT at time of amputation despite 57.3% of the cohort being established with a vascular surgeon. Compared to those with low ADI, the category high ADI had a higher proportion of NHB patients (48.1% vs 70.3%, P=0.001) and patients were more often hospitalized at the University-affiliated facilities (47.4% vs 63.0%, P=0.004). High ADI was not associated with receipt of OMT prior to major amputation (adjusted odds ratio [aOR] 0.72, 95% confidence interval [CI] 0.42-1.24). In secondary analysis, NHB race was notassociated with receipt of OMT. Stratification by facility type (Veterans Affairs and University-affiliated facilities) also showed no association between high ADI or race and receipt of OMT. Neighborhood economic well-being is not associated with receipt of OMT prior to major amputation. While the absence of socioeconomic disparities is notable, the proportion of patients on OMT is suboptimal. Care processes should be critically evaluated and quality measures potentially created to improve the rate of receipt of OMT among patients at risk for amputation.

Extracting Critical Information from Unstructured Clinicians' Notes Data to Identify Dementia Severity Using a Rule-Based Approach: Feasibility Study.

The severity of Alzheimer disease and related dementias (ADRD) is rarely documented in structured data fields in electronic health records (EHRs). Although this information is important for clinical monitoring and decision-making, it is often undocumented or "hidden" in unstructured text fields and not readily available for clinicians to act upon. We aimed to assess the feasibility and potential bias in using keywords and rule-based matching for obtaining information about the severity of ADRD from EHR data. We used EHR data from a large academic health care system that included patients with a primary discharge diagnosis of ADRD based on ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Statistical Classification of Diseases, Tenth Revision) codes between 2014 and 2019. We first assessed the presence of ADRD severity information and then the severity of ADRD in the EHR. Clinicians' notes were used to determine the severity of ADRD based on two criteria: (1) scores from the Mini Mental State Examination and Montreal Cognitive Assessment and (2) explicit terms for ADRD severity (eg, "mild dementia" and "advanced Alzheimer disease"). We compiled a list of common ADRD symptoms, cognitive test names, and disease severity terms, refining it iteratively based on previous literature and clinical expertise. Subsequently, we used rule-based matching in Python using standard open-source data analysis libraries to identify the context in which specific words or phrases were mentioned. We estimated the prevalence of documented ADRD severity and assessed the performance of our rule-based algorithm. We included 9115 eligible patients with over 65,000 notes from the providers. Overall, 22.93% (2090/9115) of patients were documented with mild ADRD, 20.87% (1902/9115) were documented with moderate or severe ADRD, and 56.20% (5123/9115) did not have any documentation of the severity of their ADRD. For the task of determining the presence of any ADRD severity information, our algorithm achieved an accuracy of >95%, specificity of >95%, sensitivity of >90%, and an F1-score of >83%. For the specific task of identifying the actual severity of ADRD, the algorithm performed well with an accuracy of >91%, specificity of >80%, sensitivity of >88%, and F1-score of >92%. Comparing patients with mild ADRD to those with more advanced ADRD, the latter group tended to contain older, more likely female, and Black patients, and having received their diagnoses in primary care or in-hospital settings. Relative to patients with undocumented ADRD severity, those with documented ADRD severity had a similar distribution in terms of sex, race, and rural or urban residence. Our study demonstrates the feasibility of using a rule-based matching algorithm to identify ADRD severity from unstructured EHR report data. However, it is essential to acknowledge potential biases arising from differences in documentation practices across various health care systems.

(255) “WHAT PUSHED IT FOR ME WAS THE OVERTURNING OF ROE V. WADE”: ASSESSING THE PATIENT-REPORTED INFLUENCE OF SOCIOPOLITICAL ISSUES ON POST-DOBBS VASECTOMY DECISIONS

Abstract Introduction Following the June 2022 US Supreme Court decision on Dobbs v Jackson Women’s Health Organization overturning the federal constitutional right to abortion recognized since Roe, high levels of vasectomy interest and confusion regarding male reproductive healthcare options have persisted despite no direct impact to male contraception. To the best of our knowledge, the patient-reported influence of sociopolitical issues on male patients’ vasectomy decisions has not been studied. Objective Our objective was to characterize the impact of sociopolitical issues, including the Dobbs reversal of the right to abortion recognized since 1973, on male patients’ vasectomy decisions and timing. Methods Patients of a men's reproductive health outpatient clinic within a large academic healthcare system in Southwestern Pennslyvania who had initiated a vasectomy consult from July 2022 – February 2024 were eligible to participate in a survey questionnaire. Patients were called retrospectively or approach prospectively in-person. Demographics, factors influencing vasectomy, and general economic and political interest data were collected via modified Likert and short free-text answers. Chi-square, logistic regression, Mann–Whitney U, and Kruskal-Wallis tests were performed as indicated. Results 311 patients completed the survey. Mean age of patients was 37 years of age (range: 21, 61); 11.7% (n = 30) were under 30 at time of appointment. Median number of biological children was two (IQR: 1, 3); 19.6% (n = 50) had no biological children. Patients spent on average 2.9 years (range: 0, 33) considering a vasectomy prior to deciding. Regarding factors influencing vasectomy, 31.3% (n = 80) of participants indicated sociopolitical issues as very influential in deciding to undergo a vasectomy, with 17 participants writing in the “reversal of Roe v Wade” or “abortion legislature” in response to a free-text question asking what prompted their vasectomy decision. Men with no children were seven times more likely than men with to cite sociopolitical issues as influencing their vasectomy (sociopolitical: OR = 7.3, p &amp;lt; 0.001). When asked how Roe would influence access to male reproductive healthcare options in their home state, 21.9% (n = 56) answered Roe would limit or prevent access to the listed options (ie, hormone replacement therapy, IVF, vasectomy, or sperm cryopreservation). Conclusions While recent sociopolitical and legislative issues may not directly impact male patients’ reproductive healthcare, our results demonstrate the influence broader events have on male patients’ contraceptive decisions and reproductive healthcare understanding. Furthermore, clinicians may need to proactively address uncertainty and confusion around the impact of reproductive healthcare legislature on male patients’ reproductive healthcare options. Disclosure No.

Effect of a behavioral nudge on adoption of an electronic health record-agnostic pulmonary embolism risk prediction tool: a pilot cluster nonrandomized controlled trial.

Our objective was to determine the feasibility and preliminary efficacy of a behavioral nudge on adoption of a clinical decision support (CDS) tool. We conducted a pilot cluster nonrandomized controlled trial in 2 Emergency Departments (EDs) at a large academic healthcare system in the New York metropolitan area. We tested 2 versions of a CDS tool for pulmonary embolism (PE) risk assessment developed on a web-based electronic health record-agnostic platform. One version included behavioral nudges incorporated into the user interface. A total of 1527 patient encounters were included in the trial. The CDS tool adoption rate was 31.67%. Adoption was significantly higher for the tool that included behavioral nudges (39.11% vs 20.66%; P < .001). We demonstrated feasibility and preliminary efficacy of a PE risk prediction CDS tool developed using insights from behavioral science. The tool is well-positioned to be tested in a large randomized clinical trial. Clinicaltrials.gov (NCT05203185).

Relationship between Hand Hygiene and MDRO Acquisition after Implementation of an Electronic Hand Hygiene Monitoring System

Background: Hand hygiene (HH) is fundamental to preventing the transmission of pathogens between patients. Unfortunately, adherence to HH is suboptimal and monitoring adherence is challenging. Electronic HH monitoring systems (EHHMS) are emerging potential solutions to increase the number of HH observations and eliminate the potential for observation bias. This aim of this study is to assess the impact of improved HH adherence after the introduction of an EHHMS on the rates of healthcare facility-onset multidrug-resistant organisms and Clostridioides difficile (HO-MDRO). Methods: We performed a retrospective, quasi-experimental study to evaluate the impact of HH on HO-MDROs across 4 acute care facilities (59 hospital units, 14 of which were ICUs) from January 2021 - September 2022 after implementing an EHHMS in a large academic healthcare system. Clinical cultures from all sources were included; routine surveillance cultures were not collected during this period. HO determination was made using National Healthcare Safety Network (NHSN) definitions. The association between monthly unit-level HH adherence (%) and HO-MDRO rate per 1000 patient-days was assessed using mixed-effects Poisson regression using rate ratios (RR), which accounts for unobserved heterogeneity between units while controlling for number of tests ordered per month per hospital unit. HH adherence was stratified in quartiles (Q1: 24-43%, Q2: 43-51%, Q3: 52-61%, Q4: 61-84%). Results: During the study period, there were 23 million HH opportunities and 1875 MDROs in 772,930 patient-days. HH adherence increased from 41% January 2021 to 57% September 2022. ESBL, MSSA, and CDIFF accounted for most MDROs (Figure 1). The mean monthly HH adherence rate was 52% per unit, with a median of 1.66 (IQR: 0-3.5) MDROs/1000 patient-days. Mixed-effects Poisson regression suggested no significant overall relationship between HH adherence and MDRO rate (Figure 2). A close to null association was observed when comparing quartile two to quartile one (RR: 0.97, 95% CI: 0.82, 1.15), quartile three to quartile one (RR: 0.96, 95% CI: 0.79, 1.17), and quartile four to quartile one (RR: 1.05, 95% CI: 0.86, 1.28). Results were similar across hospitals (Figure 3). Conclusions: Although implementing an EHHMS led to an improvement in HH adherence, we were not able to demonstrate a resultant decrease in HO-MDROs. Potential explanations include the relatively rare outcomes of interest, unrecognized confounders, and the complex interaction between HH and HO-MDROs, since poor HH adherence on a unit may lead to increased attention from infection prevention and therefore increased focus on other MDRO prevention measures.

Invasive Fungal Infections of the Head and Neck: A Tertiary Hospital Experience.

From the existing millions of fungal species, only a few cause disease. In this study, we investigated invasive fungal infections in the head and neck (H&N) over a 19-year period (2005 to 2024) at a large academic healthcare system. Among the 413 documented fungal H&N infections, 336 were noninvasive, and 77 were invasive. The highest incidence of invasive infections occurred in the sinonasal cavities, with a 15-fold difference compared to other sites. Most infections affected adults over 40 years old. The most common organisms were Mucorales (51%), hyaline molds (29%), and Candida (11%). Risk factors included malignancy, transplant, diabetes, and illicit drug use. Mortality was high in patients with malignancy and/or transplant. Infections affecting the mandible were usually a complication of osteoradionecrosis and were associated with the coinfection of Candida and Actinomyces. At other sites, infections were rare and were usually the result of penetrating injuries or immunosuppression. Treatment typically involved a combination of antifungals and surgical procedures.

Applying ordered network analysis to video-recorded physician–nurse interactions to examine communication patterns associated with shared understanding in inpatient oncology care settings

ObjectivesThe main aim of this study was to demonstrate how ordered network analysis of video-recorded interactions combined with verbal response mode (VRM) coding (eg, edification, disclosure, reflection and interpretation) can...

A Pilot Trial of CRESCENT in a Large Academic Healthcare System: A CaReEcoSystem Primary Care Embedded DemeNtia Treatment

ObjectiveThe prevalence of Alzheimer's Disease (AD) and related dementias is escalating, with substantial societal and economic impact. Existing dementia care is often inadequate due to underdiagnosis, delayed diagnosis, and insufficient resources, especially for caregivers. Behavioral symptoms of dementia further complicate care, contributing to negative outcomes. Collaborative care programs show promise, yet resource-intensive models can be challenging to scale. This study aimed to assess the feasibility of CRESCENT (CaReEcoSystem primary Care Embedded dementia Treatment), an adaptation of the CareEcosystem intervention, providing dementia care training to nurse care managers in a primary care setting. DesignEmbedded pilot cluster randomized controlled study. ParticipantsThe thirty nurse care managers enrolled in the trial had 393 patients with an ICD-10 diagnosis code consistent with dementia on their panels, 206 patients corresponding to the 15 intervention nurses and 187 patients corresponding to the 15 control nurses. MeasurementsPrimary outcome: Feasibility of capturing ED utilization using Medicare claims data and of implementing the intervention in a care management program. Secondary outcomes: ED use and change in caregiver distress (via survey) between baseline and 6-month follow-up using the Neuropsychiatric Inventory Questionnaire (NPI-Q) Distress scale. ResultsWe demonstrated the feasibility of collecting ED visit data through Medicare claims and of implementing the intervention in a busy care management program. In the 6-month follow-up, there were no changes in ED visits postintervention. A nonsignificant 2.7-point greater reduction in caregiver distress among caregivers of PWD in the intervention cohort was observed. ConclusionA dementia care coordination program can be integrated into a care management program. Future trials will explore the effectiveness of CRESCENT in a fully powered clinical trial, aiming to address the rising dementia epidemic and improve dementia-informed care in healthcare systems.

Duloxetine and cognitive behavioral therapy with phone-based support for the treatment of chronic musculoskeletal pain: study protocol of the PRECICE randomized control trial

BackgroundChronic musculoskeletal pain (CMP) is the most common, disabling, and costly of all pain conditions. While evidence exists for the efficacy of both duloxetine and web-based cognitive behavioral therapy (CBT) as monotherapy, there is a clear need to consider study of treatment components that may complement each other. In addition, given the reported association between patient’s adherence and treatment outcomes, strategies are needed to enhance participant’s motivation to adopt and maintain continued use of newly learned pain coping skills from CBT.MethodsTwo hundred eighty participants will be recruited from the primary care clinics of a large academic health care system in North Carolina. Participants with CMP will be randomized to one of three treatment arms: (1) combination treatment (duloxetine + web-based self-guided CBT) with phone-based motivational interviewing (MI), (2) combination treatment without phone-based MI, and (3) duloxetine monotherapy. Participants will be in the study for 24 weeks and will be assessed at baseline, week 13, and week 25. The primary outcome is the Brief Pain Inventory (BPI)-Global Pain Severity score, which combines BPI pain severity and BPI pain interference. Secondary measures include between-group comparisons in mean BPI pain severity and BPI pain interference scores. Data collection and outcome assessment will be blinded to treatment group assignment.DiscussionThis randomized controlled trial (RCT) will determine if combination treatment with duloxetine and web-based CBT is superior to duloxetine monotherapy for the management of CMP. Furthermore, this RCT will determine the effectiveness of phone-based motivational interviewing in promoting the continued practice of pain coping skills, thereby enhancing treatment outcomes.Trial registrationNCT04395001 ClinicalTrials.gov. Registered on May 15, 2020.

Difficult-to-treat (DTR) Pseudomonas aeruginosa harboring Verona-Integron metallo-β-lactamase (blaVIM): infection management and molecular analysis.

Pseudomonas aeruginosa harboring Verona Integron-encoded metallo-β-lactamase enzymes (VIM-CRPA) have been associated with infection outbreaks in several parts of the world. In the US, however, VIM-CRPA remain rare. Starting in December 2018, we identified a cluster of cases in our institution. Herein, we present our epidemiological investigation and strategies to control/manage these challenging infections. This study was conducted in a large academic healthcare system in Miami, FL, between December 2018 and January 2022. Patients were prospectively identified via rapid molecular diagnostics when cultures revealed carbapenem-resistant P. aeruginosa. Alerts were received in real time by the antimicrobial stewardship program and infection prevention teams. Upon alert recognition, a series of interventions were performed as a coordinated effort. A retrospective chart review was conducted to collect patient demographics, antimicrobial therapy, and clinical outcomes. Thirty-nine VIM-CRPA isolates led to infection in 21 patients. The majority were male (76.2%); the median age was 52 years. The majority were mechanically ventilated (n = 15/21; 71.4%); 47.6% (n = 10/21) received renal replacement therapy at the time of index culture. Respiratory (n = 20/39; 51.3%) or bloodstream (n = 13/39; 33.3%) were the most common sources. Most infections (n = 23/37; 62.2%) were treated with an aztreonam-avibactam regimen. Six patients (28.6%) expired within 30 days of index VIM-CRPA infection. Fourteen isolates were selected for whole genome sequencing. Most of them belonged to ST111 (12/14), and they all carried blaVIM-2 chromosomally. This report describes the clinical experience treating serious VIM-CRPA infections with either aztreonam-ceftazidime/avibactam or cefiderocol in combination with other agents. The importance of implementing infection prevention strategies to curb VIM-CRPA outbreaks is also demonstrated.