Medical Care Plan Research Articles

Factors related to heart rate variability among firefighters.

ObjectivesThe aim of this study was to investigate factors associated with heart rate variability in firefighters working in a metropolitan city in South Korea.MethodsSelf-administered questionnaires including Korean Occupational Stress Scale (KOSS) as well as surveys collecting socio-demographic characteristics and work-related factors were given to 962 firefighters. After exclusion for missing data, 645 firefighters were included, and analysis of covaiance adjusted for the general risk factors and job characteristics were used to assess the relationship between heart rate variability and associated factors.ResultsSDNN and RMSSD and were decreased in the area of occupational climate of the group with high job stress (p = 0.027, p = 0.036). HF(ln) was decreased in the area of organizational system and occupational climate of the group with high stress that statistically significant level (p = 0.034, p = 0.043).ConclusionsOccupational climate and organizational system are associated with reduction of heart rate variability. Preventive medical care plans for cardiovascular disease of firefighters through the analysis and evaluation of job stress factors are needed.

Abstract WP322: Inability to Identify Physician is Associated With Medication and Care Plan Knowledge Gaps Ii Stroke Patients

Introduction: Patient dissatisfaction and medication non-compliance correlate with patient misunderstanding of their medications and care plan. We aimed to assess the degree of these gaps and their associations in hospitalized stroke patients. Methods: A 5-question survey was administered to patients hospitalized on the neuroscience ward of a comprehensive stroke center. Patient understanding of their condition leading to admission, care plan, medications, primary attending physician, and follow-up plan was assessed. If the patient was unable to communicate, then their health care representative was interviewed. Results: A total of 146 patients (55 stroke and 91 general neurology and neurosurgery (non-stroke) patients) or their representatives were interviewed. Stroke patients were less likely to properly identify their primary attending physician (33/55 (60.0%) stroke patients versus 35/91 (38.5%) non-stroke patients; p=0.011). Inability to identify the attending physician was associated with lack of medication and care plan knowledge and was more common in stroke patients, (23/33 (69.7%) stroke patients versus 14/35 (40.0%) non-stroke patients; p=0.014). Conclusion: Despite sharing a common pool of providers, the inability to identify the primary attending physician was significantly more common in stroke patients and was associated with patient knowledge deficits regarding their medication regimen and care plan. This correlation was significantly higher in stroke patients and suggests that stroke patients may require different, extra or more robust communication and education than the general neurology and neurosurgery population. Additionally, emphasis on attending physician identification may improve patient satisfaction and medication compliance.

Health Promotion Interventions for Low-Income Californians Through Medi-Cal Managed Care Plans, 2012.

IntroductionPrevention is the most cost-effective approach to promote population health, yet little is known about the delivery of health promotion interventions in the nation’s largest Medicaid program, Medi-Cal. The purpose of this study was to inventory health promotion interventions delivered through Medi-Cal Managed Care Plans; identify attributes of the interventions that plans judged to have the greatest impact on their members; and determine the extent to which the plans refer members to community assistance programs and sponsor health-promoting community activities.MethodsThe lead health educator from each managed care plan was asked to complete a 190-item online survey in January 2013; 20 of 21 managed care plans responded. Survey data on the health promotion interventions with the greatest impact were grouped according to intervention attributes and measures of effectiveness; quantitative data were analyzed using descriptive statistics.ResultsHealth promotion interventions judged to have the greatest impact on Medi-Cal members were delivered in various ways; educational materials, one-on-one education, and group classes were delivered most frequently. Behavior change, knowledge gain, and improved disease management were cited most often as measures of effectiveness. Across all interventions, median educational hours were limited (2.4 h), and median Medi-Cal member participation was low (265 members per intervention). Most interventions with greatest impact (120 of 137 [88%]) focused on tertiary prevention. There were mixed results in referring members to community assistance programs and investing in community activities.ConclusionManaged care plans have many opportunities to more effectively deliver health promotion interventions. Establishing measurable, evidence-based, consensus standards for such programs could facilitate improved delivery of these services.

A Quality Improvement Project to Increase Nurse Attendance on Pediatric Family Centered Rounds

Family centered rounds (FCR) occur at the bedside and include the patient and their family when creating a daily medical care plan. Despite recommendations that family centered rounds (FCR) with nursing staff be standard practice, nurses were frequently absent from FCR at our institution. To increase nurse attendance on hospitalist FCR to 80% in three months. Secondary outcomes were to investigate the relationship between nurse-to-patient ratio and nurse attendance, and to assess for change in perception toward FCR. This resident driven interrupted time series study included a focus group to identify barriers to nurse attendance on FCR, four plan-do-study-act cycles, and surveys to assess for changes in perceptions toward FCR. Control charts, SHEWHART rules, linear regression and chi squared analysis were used for data analysis. Nurse attendance on FCR improved from 30% to 59%. There was no correlation between nurse-to-patient ratio and nurse attendance on FCR. Surveys indicated increase in the perception that it is helpful to have a nurse present at FCR. A resident driven quality improvement project can increase nurse presence on FCR.

Mass Gathering Medical Care: Resource Document for the National Association of EMS Physicians Position Statement

Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre–event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the community's medical care system, while fulfilling the needs of event participants. Key words: mass gathering medicine; event medicine; event medical care planning; EMS medical director; prehospital

A future care planning initiative to improve the end of life care of patients on the complex care ward of a district general hospital

Medically led, patient-centred, future care planning for patients predicted to be in their last year of life is possible on the complex care ward of an acute hospital, where patients often wait for social care placement into a nursing home. When the patient lacks the mental capacity to engage in the planning discussions themselves, meetings can take place between the multidisciplinary geriatric team and either those close to the patient or an independent mental capacity advocate. Participants in the meeting should use any existing advance care planning information, as appropriate, to develop 'best interests advice' (which can be referred to at a later date when a best interests decision needs to be made for the patient). Any future medical care plan should be reviewed for applicability and validity if the person's condition changes (improves or deteriorates), if the patient or those close to the patient request it, or 6-12 months after the initial plan is made. Education, training and support must be provided to ensure acceptance and understanding of the PEACE (PErsonalised Advisory CarE) process and general end of life care in the community. Specialist palliative care services are often best placed to provide this.

Web-Based Quality of Life Questionnaire Followed by Paper-Based Questionnaire for the Non-Responders: Daily Practice in Patients with Prostate Cancer

Purpose: Patient-related outcome measures (PROMS) play an increasingly important role in the planning and evaluation of medical care. A high response rate is crucial to get a good view of the patient population. Quality of life questionnaires in oncology are important in order to evaluate the impact of the disease or the treatment of cancer patients and guide treatment decisions. The traditional way to collect data is a paper-based questionnaire sent by post. However, online questionnaires seem an attractive and cheap way to send a survey. In this study we describe our experience with the introduction of digital questionnaires in daily practice and study factors that affect the response rate. Methods: The study design was an observational cohort study of patients who had a localized prostate cancer and underwent a Robot Assisted Radical Prostatectomy (RARP) at our institute. Validated questionnaires were mailed to the patients before the RARP and subsequently, 6 months, 1 and 2 years after surgery. After sending twice a digital questionnaire and without any response, we sent the patients a paper-based questionnaire with a stamped return envelope. Results: The response rate was higher when a reminder paperbased questionnaire was sent to the patients who did not respond to the web-based questionnaire. Furthermore, the elderly patients respond significantly more often than younger patients to both questionnaires (web-based or paper-based). Age was the strongest predictive factor for response on quality of life questionnaires. The fact that the patient no longer came to our institute for follow-up had no negative influence on the response rate.

The business case for pediatric asthma quality improvement in low-income populations: examining a provider-based pay-for-reporting intervention.

To measure the return on investment (ROI) for a pediatric asthma pay-for-reporting intervention initiated by a Medicaid managed care plan in New York State. Practice-level, randomized prospective evaluation. Twenty-five primary care practices providing care to children enrolled in the Monroe Plan for Medical Care (the Monroe Plan). Practices were randomized to either treatment (13 practices, 11 participated) or control (12 practices). For each of its eligible members assigned to a treatment group practice, the Monroe plan paid a low monthly incentive fee to the practice. To receive the incentive, treatment group practices were required to conduct, and report to the Monroe Plan, the results of chart audits on eligible members. Chart audits were conducted by practices every 6 months. After each chart audit, the Monroe Plan provided performance feedback to each practice comparing its adherence to asthma care guidelines with averages from all other treatment group practices. Control practices continued with usual care. Intervention implementation and operating costs and per member, per month claims costs. ROI was measured by net present value (discounted cash flow analysis). The ROI to the Monroe Plan was negative, primarily due to high intervention costs and lack of reductions in spending on emergency department and hospital utilization for children in treatment relative to control practices. A pay-for-reporting, chart audit intervention is unlikely to achieve the meaningful reductions in utilization of high-cost services that would be necessary to produce a financial ROI in 2.5 years.

Development of a User-Friendly Graphic Tool to Estimate Individualized Survival Curves for Advanced Cancer Patients in Hospice Care.

This prospective study aimed to develop an individualized prognostic tool for predicting the survival probability at any given point for a hospice patient with advanced cancer. A total of 286 patients with advanced cancer were included in the study. Median observational time was 18 days (range: 1 to 60 days). Cox proportional hazards regression analysis revealed that faster heart rate (hazard ratio [HR] = 1.01), jaundice (HR = 2.32), poorer performance status (HR = 2.01), and antifungal treatment (HR = 1.62) were independent predictors of shorter survival time. Patients with infections who received aminoglycoside treatments (HR = 0.45) were associated with longer survival times. Based on this model, we could construct a covariate-adjusted individualized survival curve for a given patient according to his or her clinical condition. This user-friendly tool for estimating the survival probability of patients with advanced cancer in hospice settings could facilitate clinical decision making and medical care planning.

Growth charts for non-growth hormone treated Prader-Willi syndrome.

The goal of this study was to generate and report standardized growth curves for weight, height, head circumference, and BMI for non-growth hormone-treated white male and female US subjects with Prader-Willi syndrome (PWS) between 3 and 18 years of age and develop standardized growth charts. Anthropometric measures (N = 133) were obtained according to standard methods from 120 non-growth hormone-treated white subjects (63 males and 57 females) with PWS between 3 and 18 years of age. Standardized growth curves were developed for the third, 10th, 25th, 50th, 75th, 90th, and 97th percentiles by using the LMS method for weight, height, head circumference, and BMI for PWS subjects along with the normative third, 50th, and 97th percentiles from national and international growth data. The LMS smoothing procedure summarized the distribution of the anthropometric variables at each age using three parameters: power of the Box-Cox transformation λ (L), median μ (M) and coefficient of variation δ (S). Weight, height, head circumference, and BMI standardized growth charts representing 7 percentile ranges were developed from 120 non-growth hormone-treated white male and female US subjects with PWS (age range: 3-18 years) and normative third, 50th, and 97th percentiles from national and international data. We encourage the use of syndrome-specific growth standards to examine and evaluate subjects with PWS when monitoring growth patterns and determining nutritional and obesity status. These variables can be influenced by culture, individual medical care, diet intervention, and physical activity plans.

Perinatal oxytocin increases the risk of offspring bipolar disorder and childhood cognitive impairment

BackgroundWe tested the hypothesis that perinatal oxytocin, given to pregnant women to induce labor, is related to offspring bipolar disorder (BP) and worse childhood cognitive performance among offspring. We also tested the association between childhood cognition and later BP. MethodsA population-based birth cohort derived from the Child Health and Development Study (CHDS) which included nearly all pregnant women receiving obstetric care from the Kaiser Permanente Medical Care Plan, Northern California Region (KPNC) between 1959 and 1966. Prospectively obtained medical and offspring cognitive performance were used. Potential cases with BP from the cohort were identified by database linkages. This protocol identified 94 cases who were matched 1:8 to controls. ResultsPerinatal oxytocin was associated with a 2.4 times increased odds of later BP. Oxytocin was also associated with decreased performance on the Raven Matrices, but not on the Peabody Picture Vocabulary Test (PPVT). Childhood cognition was not associated with later BP. LimitationsLoss to follow-up must be considered in all birth cohort studies. In addition, the childhood cognitive battery did not include tests related to multiple domains of cognition which have been associated with later BP. A third limitation is the modest sample size of those exposed to oxytocin. ConclusionsThis study provides evidence for a potentially important perinatal risk factor for BP and cognitive impairment in childhood. While the association between perinatal oxytocin and offspring BP must be viewed cautiously until further studies can attempt to replicate the result, it lends support to the broader view that neurodevelopmental factors contribute to BP.

Организация медицинской помощи беременным групп высокого риска

Health indicators in the women and children are the most important indicator of the level of socioeconomic situation of the country and the society development. The course of pregnancy, its maternal and neonatal outcomes are associated with age in the primiparous. Condition of importance for safe motherhood and success delivery is an adequate organization of perinatal care by means of modern medical technology. Study of the medicosocial risk factors of reproductive health is especially relevant for the planning of medical care in pregnant women in the region and for individual project of women´s reproductive health, prevention of complications of pregnancy and childbirth. The purposes of the research are to study the medical and perinatal risk factors, the reproductive health of young primiparous and late primiparous of reproductive age in Voronezh and Voronezh region and to organize medical assistance for these categories of women. Historical, sociological, statistical research methods and the method of expert estimations were used. Complex medical and social research of reproductive health, the medical activity of young primiparous and primiparous late of reproductive age in the Voronezh region, assessment of medical assistance to these categories of women were carried out. Level of somatic and gynecological health in young primiparous and late primiparous women of reproductive age was quite low. Pregnancy and childbirth in these age categories often progress to complications. Newborns in the primiparous teen mothers and primiparous women of late reproductive age have poor health. Young primiparous and primiparous of late reproductive age are classified high perinatal risk and require special attention during regular medical observation and delivery.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

Effect of a care transition intervention by pharmacists: an RCT.

BackgroundPharmacists may improve medication-related outcomes during transitions of care. The aim of the Iowa Continuity of Care Study was to determine if a pharmacist case manager (PCM) providing a faxed discharge medication care plan from a tertiary care institution to primary care could improve medication appropriateness and reduce adverse events, rehospitalization and emergency department visits.MethodsDesign. Randomized, controlled trial of 945 participants assigned to enhanced, minimal and usual care groups conducted 2007 to 2012. Subjects. Participants with cardiovascular-related conditions and/or asthma or chronic obstructive pulmonary disease were recruited from the University of Iowa Hospital and Clinics following admission to general medicine, family medicine, cardiology or orthopedics. Intervention. The minimal group received admission history, medication reconciliation, patient education, discharge medication list and medication recommendations to inpatient team. The enhanced group also received a faxed medication care plan to their community physician and pharmacy and telephone call 3–5 days post-discharge. Participants were followed for 90 days post-discharge. Main Outcomes and Measures. Medication appropriateness index (MAI), adverse events, adverse drug events and post-discharge healthcare utilization were compared by study group using linear and logistic regression, as models accommodating random effects due to pharmacists indicated little clustering.ResultsStudy groups were similar at baseline and the intervention fidelity was high. There were no statistically significant differences by study group in medication appropriateness, adverse events or adverse drug events at discharge, 30-day and 90-day post-discharge. The average MAI per medication as 0.53 at discharge and increased to 0.75 at 90 days, and this was true across all study groups. Post-discharge, about 16% of all participants experienced an adverse event, and this did not differ by study group (p > 0.05). Almost one-third of all participants had any type of healthcare utilization within 30 days post-discharge, where 15% of all participants had a 30-day readmission. Healthcare utilization post-discharge was not statistically significant different at 30 or 90 days by study group.ConclusionThe pharmacist case manager did not affect medication use outcomes post-discharge perhaps because quality of care measures were high in all study groups.Trial registrationClinicaltrials.gov registration: NCT00513903, August 7, 2007.

Adult ADHD outcome audit based on NICE guidelines

Purpose – Adult ADHD is a neuro-developmental disorder. The current prevalence of ADHD in adults is around 1.9-4 per cent. The service for adults with ADHD based on NICE guideline recommendation. Hence, the author decides to audit the Adult ADHD case loads against the gold standard set by the NICE. The paper aims to discuss these issues. Design/methodology/approach – The study was based on a retrospective analysis and collection of data from electronic patient records for a duration of five months between October 2011 and February 2012. The data findings were matched against the NICE standards. There were 15 standards identified. On top of that we used six service outcome questions to improve the Quality of the service provided. Findings – As the service outcomes were set for 100 per cent, the performance fell short in few areas. The service managed to achieve roughly 80-95 per cent in areas such as medication monitoring, transition service and care plan with shared care guidelines for prescription in primary care. The service under performed in areas on non-pharmacological interventions such as cognitive-behavioural therapy (CBT). The service continues to provide a exceptional service for adults with intellectual disability and ADHD. Research limitations/implications – The research was limited by information and recall bias due to the retrospective nature of data analysis. There was also over representation of the numbers in co-morbid cases due to more than two diagnosis. Practical implications – The paper outlines the regional outcome of the audit. However the findings have wider implications. For example the prevalence rate is more common in males than females. CBT is an important resource in the management of ADHD in adults. Priority and importance need to be given for providing a service for CBT in adults with ADHD. Social implications – The cost of sickness and non-employment due to ADHD is significantly high. Treating this complex group with medications and CBT improves the outcome and get them back in employment and reduce recidivism rates in offenders. Originality/value – The author feels the adult ADHD service audit has huge service implications. Currently it is a controversial diagnosis significantly under-resourced. The outcome survey had highlighted the areas of need as a neurodevelopmental disorder.

Integration of palliative care into the care of children with serious illness.

1. Tammy I. Kang, MD, MSCE* 2. David Munson, MD* 3. Jennifer Hwang, MD, MHS* 4. Chris Feudtner, MD, PhD, MPH* 1. *The Children’s Hospital of Philadelphia, Philadelphia, PA * Abbreviations: AAP: : American Academy of Pediatrics CCC: : concurrent care for children NICU: : neonatal intensive care unit PPC: : pediatric palliative care The 2013 American Academy of Pediatrics (AAP) Policy Statement “Pediatric Palliative Care and Hospice Care: Commitments, Guidelines, and Recommendations” urges broader integration of palliative care into overall medical care plans not only for terminally ill infants and children but also for those with life-threatening or life-shortening illnesses. Despite supportive federal legislation, the AAP recommendations have not been implemented consistently because of inadequate training, lack of funding, entrenched professional attitudes, and lack of an evidence base for assessments and interventions. To overcome these barriers, pediatric health care clinicians should educate themselves, their patients, their practices, and their health care systems on the benefits of earlier palliative care intervention. During the past decade the field of pediatric palliative care (PPC) has transformed. Palliative care services, once thought to be suitable only for patients in the last stages of life or reserved for patients engaging hospice services, are now being used much more broadly. No longer restricted to just the provision of end-of-life care, palliative care for children is now best understood as encompassing a combination of medical, psychosocial, and spiritual care that enables children with serious, life-threatening illnesses to maximize quality of life while making medical decisions based on the goals and values of the patient and family. Integrating palliative care into the overall plan of medical care for children with serious illness is a key therapeutic goal. In 2013, the American Academy of Pediatrics (AAP) published a policy statement entitled “Pediatric Palliative Care and Hospice Care: Commitments, Guidelines, and Recommendations” that aimed to promote the welfare of infants and children living with life-threatening or inevitably life-shortening conditions and their …

JUSTIFICATION OF THE RATIONAL NUMBER OF THE CENTERS OF TRANSPLANTATION IN THE RUSSIAN FEDERATION, THEIR GEOGRAPHY AND NOMENCLATURES

Aim: to calculate number of the centers of transplantation according to real requirement of the population and a donor resource, to prove their geography and the nomenclature, providing with donor organs. Methods and results. The analysis and comparison of statistical data on population, number of the centers of transplantation, their transplant activity in Russia and abroad are made. Calculation of number of the centers of transplantation is carried out and justification of their geography is offered. The analysis of statistical data on hospitals in the Russia is made, calculation of a rational number of donor hospitals according to need for a donor resource is carried out. Justification of transplant coordination in territorial subjects of the Russia, in federal districts is offered. Justification of the nomenclature of the centers of transplantation and donor hospitals is offered. Conclusion. Settlement data on a rational number of the centers of transplantation, their geography and the nomenclature, providing with the donor organs, suitable developments for planning of the hi-tech medical care in territorial subjects of the Russia are obtained.

Obesity during childhood and adolescence increases susceptibility to multiple sclerosis after accounting for established genetic and environmental risk factors

To investigate the association between obesity and multiple sclerosis (MS) while accounting for established genetic and environmental risk factors. Participants included members of Kaiser Permanente Medical Care Plan, Northern California Region (KPNC) (1235 MS cases and 697 controls). Logistic regression models were used to estimate odds ratios (ORs) with 95% confidence intervals (95% CI). Body mass index (BMI) or body size was the primary predictor of each model. Both incident and prevalent MS cases were studied. In analyses stratified by gender, being overweight at ages 10 and 20 were associated with MS in females (p<0.01). Estimates trended in the same direction for males, but were not significant. BMI in 20s demonstrated a linear relationship with MS (p-trend=9.60×10(-4)), and a twofold risk of MS for females with a BMI≥30kg/m(2) was observed (OR=2.15, 95% CI 1.18, 3.92). Significant associations between BMI in 20s and MS in males were not observed. Multivariate modelling demonstrated that significant associations between BMI or body size with MS in females persisted after adjusting for history of infectious mononucleosis and genetic risk factors, including HLA-DRB1*15:01 and established non-HLA risk alleles. Results show that childhood and adolescence obesity confer increased risk of MS in females beyond established heritable and environmental risk factors. Strong evidence for a dose-effect of BMI in 20s and MS was observed. The magnitude of BMI association with MS is as large as other known MS risk factors.

Adverse socioeconomic position during the life course is associated with multiple sclerosis

BackgroundAdverse socioeconomic position (SEP) in childhood and adulthood is associated with a proinflammatory phenotype, and therefore an important exposure to consider for multiple sclerosis (MS), a complex neuroinflammatory autoimmune disease....

Child Neglect: Assessment and Intervention

Neglect is often a neglected form of child maltreatment even though it is the most common and deadliest form of child maltreatment. Pediatric nurse practitioners (PNPs) will most likely encounter neglected children in their practice. It is crucial that PNPs recognize child neglect in a timely manner and intervene appropriately. This continuing education article will help PNPs understand and respond to child neglect. Neglect will be defined and risk factors will be discussed. Children who are neglected can experience serious and lifelong consequences. The medical assessment and plan of care for children with concerns of suspected neglect will be discussed.