Large Public Health Care Research Articles

Use of a radiopharmaceutical multidose dispenser for positron emission tomography: Risk assessment and mitigation measures for infection prevention.

Positron emission tomography (PET) imaging necessitates the use of multidose vials for radiopharmaceutical delivery to patients. Conventional practices involve manual extraction of radiopharmaceuticals from a multidose vial prior to each PET procedure, which exposes the technologist to increasing levels of radiation and poses a potential infection risk to patients with frequent handling and access of the vial. New technologies for automated dosing and infusion delivery are available, however these incorporate both a multidose vial and a multi-patient infusion set. There is an absence of guidance for infection prevention (IP) units regarding the safety and acceptability of these devices. This paper describes the process of risk assessment and the mitigation measures for training, workflows, and documentation which led to the safe introduction of an automated PET infusion device in a large tertiary public healthcare facility.

Evaluation of Hematuria in a Large Public Health Care System.

Background:Hematuria is the most common presenting symptom in bladder cancer, but many patients are not adequately evaluated.Objectives:To evaluate the type and frequency of hematuria evaluation in a large public health care system.Patients and Methods:Electronic medical records of adult patients with urinalysis positive for hematuria (≥3 RBCs/HPF) from January 2015 to April 2018 in an outpatient setting were reviewed. Logistic regression was performed to determine factors associated with urology referral and complete evaluation.Results:11,422 patients met the inclusion criteria; the majority were females (72%) and white race (60%). There were an additional 3,221 patient’s with initial diagnosis of UTI. Median age was 49.0 years. Testing included repeat urinalysis (50%), imaging (26%), urology referral (11.4%), cystoscopy (4.4%) and complete evaluation defined as cystoscopy and US/CT/MRI (4%). In the multivariable analysis, factors independently associated with higher referral to urology were age >35, male gender, hypertension, RBCs ≥20. African American race was associated with less referral to urology. Smoking was a significant variable on univariable analysis only. 37 patients (0.25%) were diagnosed with urological malignancies, with bladder cancer in 33, 12 of whom are missed by excluding UTI patients.Conclusions:In the outpatient setting of a public health care system, the vast majority of patients with hematuria are not referred and evaluated properly across all age categories and regardless of smoking status. This might result in missed cancer diagnoses and requires quality improvement measures.

Semistructured interviews regarding patients’ perceptions of Choosing Wisely and shared decision-making: an Australian study

ObjectivesThis study aimed to examine how patients perceive shared decision-making regarding CT scan referral and use of the five Choosing Wisely questions with their general practitioner (GP).DesignThis is a qualitative...

A basic anesthesia training program for nurses in Chad: first steps for a south-south academic cooperation program.

Safe perioperative care remains a large public healthcare problem in low- and middle-income countries. Anesthesia care provided by trained professionals is one of the essential determinants to address this situation. This article reports the design and implementation of a focused anesthesia educational program for nurses in Chad. This program consisted of four full-time courses of one month each, taught in a local hospital. The program included supervised practice in the operating room and post-anesthesia recovery room, skills lab simulation training, high fidelity crisis simulation, theoretical classes, integration sessions, evaluations, and structured feedback sessions. Seven male nurses, aged 28-40 yr, were accepted and successfully completed the program. The median [interquartile range] students' global satisfaction with the program was high (86 [85-93]%). Cognitive and skills assessment improved significantly after the program. Students subsequently worked in city and district hospitals performing essential and emergency surgical interventions. This is a novel south-south academic cooperation program for nurses in Chad. The program evaluation indicated a high level of satisfaction, effective cognitive and skills learning, and changes in clinical behaviour. Addressing the lack of adequate provision of anesthesia care is a task still to be faced, and this program depicts a bridge alternative until formal educational programs are implemented in the country.

Diagnostic accuracy of the Xpert CT/NG and OSOM Trichomonas Rapid assays for point-of-care STI testing among young women in South Africa: a cross-sectional study

ObjectivesSyndromic management of sexually transmitted infections (STIs) omits asymptomatic infections, particularly among women. Accurate point-of-care assays may improve STI care in low- and middle-income countries (LMICs). We aimed to evaluate...

Treatment Documentation in Practice-Based Evidence Research for Patients Receiving Physical Therapy Because of Lymphedema

ObjectivesTo describe development and testing of a physical therapy treatment code documentation taxonomy. DesignClinician survey within a practice-based evidence study framework for patients with lymphedema. SettingOutpatient physical therapy clinics within a large public health care service using a central electronic medical record. ParticipantsCertified lymphedema therapists (CLTs) (N=43). InterventionTreatment coding of 10 treatment vignettes representing real-life clinical scenarios. The CLTs were asked to accurately select 35 activity-intervention combination codes. Main Outcome MeasuresThe CLT score represented percentage of treatment codes accurately selected by each therapist. The code score represented percentage of CLTs who accurately selected each treatment code. ResultsThe mean CLT score was 91%, with 72% of CLTs meeting the 90% criterion. Personal feedback was provided to each CLT. The mean code score was also 91%; with 71% of treatment codes meeting the 90% criterion. We identified 9 low-score codes needing additional education or found to be redundant. These codes were either clarified or removed. ConclusionsThe proposed treatment code documentation system for lymphedema therapy was found to be clear and accurately used by most CLTs. Specific needs for improvement were identified. Follow-up testing is warranted to ensure ongoing accurate implementation of the treatment documentation system.

934. Incidence of Skin and Soft-tissue Infection in People Living With HIV in a Large Urban Public Health Care System in Houston, Texas, 2009–2014

BackgroundSkin and soft-tissue infections (SSTIs) disproportionately impact patients with HIV. Recent declines have been noted in the incidence of SSTIs in the non-HIV population. We set out to study the epidemiology and microbiology of SSTIs in a population of 8,597 patients followed for HIV primary care in a large urban county system from January 1, 2009 to December 31, 2014.MethodsSSTIs were identified from the electronic medical record (EMR) by the use of ICD-9 billing codes. Charts were reviewed to confirm the diagnosis of acute SSTI and abstract culture and susceptibility data. We calculated yearly SSTI incidence using Poisson regression with clustering by patient.Results2202 SSTIs were identified. Of 503 (22.8%) cultured SSTIs, 332 (66.0%) included S. aureus as a pathogen, of which 287/332 (86.4%) featured S. aureus as the sole pathogen. Of S. aureus isolates with susceptibilities, 231/331 (69.8%) were methicillin-resistant, and the proportion did not vary by year (P = NS).The observed incidence of SSTI was 78.0 per 1,000 person-years (95% CI 72.9–83.4) and declined from 96.0 infections per 1,000 person-years in 2009 to 56.5 infections per 1,000 person years in 2014 (P < 0.001). Other significant predictors of SSTI incidence in both univariate as well as multivariate analysis included CD4 count, viral load, and being a Spanish-speaking Hispanic.ConclusionAlthough SSTI rates in a large urban HIV-infected outpatient cohort declined approximately 40% between 2009 and 2014, SSTIs remain a significant problem.Figure 1.SSTI incidence per 1000 person-years, 2009–2014Table 1:Univariate and Multivariate Poisson Regression ResultsFactorUnivariate IRR (95% CI)Multivariate IRR (95% CI)Male gender1.06 (0.92–1.22)–MSM1.09 (0.95–1.25)–Race/ethnicityWhite/Asian/otherRefRefNon-Hispanic African-American0.92 (0.76–1.11)0.86 (0.71–1.04)English-speaking Hispanic0.88 (0.69–1.12)0.88 (0.69–1.12)Spanish-speaking Hispanic0.46¥ (0.36–0.60)0.48¥ (0.37–0.62)CD4 count (cells/µL)100+RefRef50–1001.56* (1.19–2.04)1.23 (0.93–1.62)<502.28¥ (1.80–2.90)1.49* (1.16–1.92)Viral load (copies/mL)<1,000RefRef1,000+2.17¥ (1.91–2.46)1.90¥ (1.66–2.19)Year2009RefRef20100.89 (0.75–1.06)0.92 (0.78–1.10)20110.90 (0.75–1.07)0.96 (0.80–1.15)20120.91 (0.76–1.09)0.99 (0.83–1.19)20130.71¥ (0.58–0.85)0.77* (0.64–0.93)20140.59¥ (0.49–0.71)0.65¥ (0.54–0.79)*P < 0.01. ¥ P < 0.001.Disclosures C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support

Developing allied health leaders to enhance person-centred healthcare

PurposeThe purpose of this paper is to present findings from a mixed methods study investigating leadership development of allied health practitioners within a large public healthcare organization in Australia.Design/methodology/approachThe South Eastern Sydney Local Health District Allied Health Leadership Development Program was undertaken with an allied health cohort (n=16) between May 2014 and March 2015 and comprised all-day workshops, action learning sets and individual coaching. Using experiential learning, the program tested whether practice development methods and action learning approaches developed the leadership skills of participants compared with a control group (n=17). Descriptive statistics were collected to evaluate participant and program outcomes. Leadership, workplace culture and engagement measures were analyzed as part of the study.FindingsThe Allied Health Leadership Development Program received high ratings by participants. They reported enhanced skills in leading self and others through mechanisms such as critical reflection and facilitation, and greater confidence managing change and with engaging staff, colleagues and patients in decision making, affecting the quality and safety of healthcare. Statistically significant differences were found with transformational leadership elements, leadership outcomes, and measures of workplace culture and engagement after program completion for intervention group participants, compared with the control group.Research limitations/implicationsResults provide new empirical evidence about the effectiveness of using practice development for allied health leadership development.Practical implicationsThis low-cost leadership program can be replicated by other organizations.Originality/valueOutcomes from an Allied Health Leadership Development Program have not been previously reported in the literature.

Frequency of Intraocular Lens Dislocation and Pseudophacodonesis, 20 Years After Cataract Surgery – A Prospective Study

To examine the incidence and trends of late intraocular lens (IOL) dislocation/decentration and the frequency of pseudophakodonesis. Prospective, population-based cohort study. A total of 800 patients were examined before cataract surgery in 1997-1998. Twenty years later, 100 of 133 survivors (75%) participated in the follow-up. An eye examination was performed including assessment for pseudophakodonesis and dislocation of the IOL. The medical records of all included patients at baseline were studied. Main outcome measures were previous IOL exchange or repositioning surgery, significant IOL dislocation, degree of pseudophakodonesis, and visual acuity. Twenty years after the original cataract surgery, 10 of the 800 patients at risk (1.2%) had needed dislocation surgery. Before cataract surgery, 39% of all patients had pseudoexfoliations (PXF). Mean time from cataract surgery to dislocation surgery was 12 years 6months (range 3 years 9months to 19 years 3months). The cumulative incidence over 20 years was 6% in patients with PXF and 2% without PXF at surgery (P= .035). Mean age at cataract surgery in the 10 dislocated cases was 68.3 years (range 58-80). Twenty years after surgery, 5 of 98 (5%) patients had moderate/pronounced pseudophakodonesis. In this population-based cohort, the 20-year cumulative incidence of IOL dislocation needing surgical attention was significantly higher in patients with PXF than without PXF before surgery. The individual patient seems to have a low risk of being affected by this complication, but dislocated IOLs may cause a relatively large public health care burden, because of the large number of people in society with previous cataract surgery.

Medication Exposure Patterns in Primary Care Patients Prescribed Pharmacogenetically Actionable Opioids

Current approaches to assessing medication exposure fail to capture the complexity of the phenomenon and the context in which it occurs. This study's purpose was to develop a typology of subgroups of patients who share common patterns of medication exposure. To create the typology, we used an exemplar sample of 30 patients in a large public healthcare system who had been prescribed the pharmacogenetically actionable opioids codeine or tramadol. Data related to medication exposure were drawn from large data repositories. Using a person-oriented qualitative approach, eight subgroups of patients who shared common patterns of medication exposure were identified. The subgroups had one of five opioid prescription patterns (i.e., singular, episodic, switching, sustained, multiplex), and one of three types of primary foci of medical care (i.e., pain, comorbidities, both). The findings reveal medication exposure patterns that are dynamic, multidimensional, and complex, and the typology offers an innovative approach to assessing medication exposure.

Improving documentation of pain and constipation management within the cancer center of a large public healthcare network.

6596Background: Cancer patients commonly suffer from pain and constipation, and a high number of patients have inadequate control of these symptoms. At the Cancer Center for Excellence at Grady Hea...

Clinic flow for STI, HIV, and TB patients in an urban infectious disease clinic offering point-of-care testing services in Durban, South Africa

BackgroundMany clinics in Southern Africa have long waiting times. The implementation of point-of-care (POC) tests to accelerate diagnosis and improve clinical management in resource-limited settings may improve or worsen clinic flow and waiting times. The objective of this study was to describe clinic flow with special emphasis on the impact of POC testing at a large urban public healthcare clinic in Durban, South Africa.MethodsWe used time and motion methods to directly observe patients and practitioners. We created patient flow maps and recorded individual patient waiting and consultation times for patients seeking STI, TB, or HIV care. We conducted semi-structured interviews with 20 clinic staff to ascertain staff opinions on clinic flow and POC test implementation.ResultsAmong 121 observed patients, the total number of queues ranged from 4 to 7 and total visit times ranged from 0:14 (hours:minutes) to 7:38. Patients waited a mean of 2:05 for standard-of-care STI management, and approximately 4:56 for STI POC diagnostic testing. Stable HIV patients who collected antiretroviral therapy refills waited a mean of 2:42 in the standard queue and 2:26 in the fast-track queue. A rapid TB test on a small sample of patients with the Xpert MTB/RIF assay and treatment initiation took a mean of 6:56, and 40% of patients presenting with TB-related symptoms were asked to return for an additional clinic visit to obtain test results. For all groups, the mean clinical assessment time with a nurse or physician was 7 to 9 min, which accounted for 2 to 6% of total visit time. Staff identified poor clinic flow and personnel shortages as areas of concern that may pose challenges to expanding POC tests in the current clinic environment.ConclusionsThis busy urban clinic had multiple patient queues, long clinical visits, and short clinical encounters. Although POC testing ensured patients received a diagnosis sooner, it more than doubled the time STI patients spent at the clinic and did not result in same-day diagnosis for all patients screened for TB. Further research on implementing POC testing efficiently into care pathways is required to make these promising assays a success.

Building an Alliance: A new future for academic dentistry ‘Down Under’?

A leap of faith took Peter Thomson from years of service in the NHS to an Oral Health Alliance ‘down under’. Here, he talks about oral health and the organisation of dental services in Australia, as well as the drivers of change in academic dentistry that led to the formation of the Alliance between the University and a large public healthcare provider to deliver excellence in teaching, research and clinical practice.

Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care

Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs). RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016. Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18-44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers. Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources. Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up. In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of -0.233 (95% CI=-0.239, -0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, -0.233; 95% CI=-0.019, -0.521). CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern. This study is registered at clinicaltrials.gov NCT01032772.

Community awareness of the availability of health services and information-seeking practices across a large health service district in rural Australia

As part of developing a communications strategy, Murrumbidgee Local Health District (MLHD), a large public statutory healthcare provider in rural southeastern Australia, sorts to quantify community awareness of service availability and residents' information-seeking practices. A proportionally stratified 17-question survey was undertaken in 33 rural towns across the region (n = 1174). The mean accuracy, with which members of the community identified service availability, was 70.4% (95%CI 69.2–71.5%) and kappa score 0.28 (95%CI 0.26 –0.31%). There were wide spatial variations (township accuracy range, 43.5–90.9%). Public awareness of acute, maternity, and paediatric services was moderate, fair for oral health and poor for all other services, particularly mental health. Males and households without children were less aware. The survey examined people's information-seeking practices, sources from where they recalled information and used random effects logistic regression to model the association between the sources of information recall and service awareness after adjusting for demographics. The results provide valuable benchmarks for health services to compare their population's awareness and the demonstrated spatial, demographic, and information source data will enable patient groups, areas, and information media to be more accurately targeted to deliver healthcare information to the population.

Group coaching in a large complex organisation: lessons learnt from experience

This article presents qualitative findings from a pilot group coaching program that was conducted within a large Australian public healthcare organisation. Using Nueman's (2000) three phase coding system and Spector's (1984) methodology, transcripts were analyzed for key themes (from both coachees' and coaches' perspectives) in response to probe questions. These themes included the need for a clear and explicit goal focus; the importance of solid upfront preparation and communication; the vital role of a group coaching process structure; the value of explicit program sponsorship and follow up; and the need to ensure the right people who are genuinely engaged participants.

Amlodipine treatment of hypertension associates with a decreased dementia risk

ABSTRACTHypertension has been shown to be a risk factor for development of dementia. However, medical treatment of hypertension failed to reduce consistently the risk of dementia. Experimental study pointed to the possibility of difference between different calcium channel blockers (CCB) in their neuro-protective effect. The aim of our study was to evaluate the risk of dementia during treatment of hypertension with different CCBs. This is a retrospective cohort study based on electronic database of a large public health care organization. Study period was 11 years and it included patients aged 40–75 years old, having diagnosis of hypertension without diagnosis of dementia at the starting point, treated with either single specific CCB (study group) or with other than CCBs antihypertensive medications (control group) for at least 30 months during the study period. A total of 15,664 patients that satisfied these criteria were identified: 3,884 were treated with amlodipine, 2,062 were treated with nifedipine, 609 were treated with lercanidipine, and 9,109 never received CCBs. Dementia developed in 765 (4.9%) patients. Adjusted hazard ratio (HR) for dementia in patients treated with amlodipine, nifedipine, and lercanidipine was 0.60 (p < 0.001), 0.89 (NS), and 0.90 (NS). Decreased adjusted HR of dementia with amlodipine was demonstrated in the patients aged 60 or more (HR 0.61 [0.49–0.77], p < 0.001), but not in the patients aged less than 60 years old.This study shows that amlodipine therapy may be associated with a decreased dementia risk in hypertensive individuals older than 60 years, compared to those treated without CCBs.

Assessment of sexual activity and dysfunction in medically underserved women with gynecologic cancers

BackgroundSexual dysfunction is a common long-term side effect of treatments for gynecologic cancer. Studies of sexual problems in gynecologic cancer survivors overrepresent White non-Hispanic, highly educated, and married women. Less is known about the sexual health needs of women in medically underserved populations. We therefore conducted a study to characterize sexual activity and sexual function in this population. MethodsWe recruited patients attending two gynecologic oncology clinics in a large public healthcare system that primarily serves uninsured and low-income patients. Participants were invited to complete a one-time survey to assess sexual function, sexual communication, sexual distress, relationship adjustment, depression, anxiety, prior help-seeking and help-seeking preferences, and reasons for sexual inactivity. Data were analyzed using descriptive statistics and multivariate models to predict sexual activity status and sexual dysfunction. ResultsAmong 243 participants, the majority (n=160, 65.8%) were not sexually active in the past 4weeks, most often due to lack of a partner or lack of desire for sex. Just over one-fourth of sexually active participants were identified as likely cases of sexual dysfunction. Greater endorsement of depressive symptoms predicted both sexual inactivity and sexual dysfunction in multivariate analyses. Prior help-seeking for sexual problems was uncommon; however, a significant minority of participants expressed interest in receiving care for sexual problems. ConclusionsGynecologic cancer survivors in our medically underserved population have high rates of sexual inactivity and sexual dysfunction. Future research should identify feasible strategies to address barriers to sexual healthcare in low-resource settings.

Connecting HRM and change management: the importance of proactivity and vitality

Purpose – Organizations are continuously under pressure to adapt to changing circumstances. Job proactivity and vitality are important in changing environments. For instance, vital employees can better deal with change because they possess more energy. However, it is still unclear how organizations can stimulate proactivity and vitality. The purpose of this paper is to connect HRM and change management by analyzing how HRM practices can stimulate job proactivity and vitality. Design/methodology/approach – The authors used survey data collected in three large public healthcare organizations in the Netherlands (n=1,507) to investigate the effects of five important HRM practices on proactivity and vitality. Analyses were performed using structural equation modeling. Findings – Results suggest that three HRM practices are particularly effective for improving proactivity and vitality: high autonomy, high participation in decision making and high quality teamwork. Based on these results, the authors discuss the...

Rheumatic heart disease in modern urban america: A cohort study of immigrant and indigenous patients in Chicago

It is widely reported that the natural history of rheumatic heart disease (RHD) is more aggressive in developing countries, manifesting symptoms and requiring interventions at a younger age than in industrialized nations [1–5]. As the demographics in urban America shift with growing immigrant minorities from Latin America and other developing countries, it is possible that the demographics and natural history of RHD in the U.S. are changing as well. We compared the natural history and disease burden between immigrant and indigenous patients with RHD receiving care at Cook County Health and Hospitals System, a large public health care network serving inner-city Chicago.