Nonclinical Factors Research Articles

‘You just emotionally break’: understanding COVID-19 narratives through public health humanities

News reports that feature the experiences of healthcare workers have shaped public conversations about the pandemic from its earliest days. For many, stories of the pandemic have been an introduction...

The Influence of Out-of-Pocket Cost on Wrist Fracture Treatment Selection

Patient-centered care prioritizes patients' specific health needs and desired outcomes based on their preferences, values, and goals. The aim of this study was to evaluate nonclinical factors that affect decision-making related to wrist fracture treatment options. A discrete choice experiment was administered via Amazon Mechanical Turk. Participants chose between two treatment options for theoretical wrist fractures. Each choice set contained three levels for four attributes-total out-of-pocket cost, length of cast immobilization, time to return to work, and number of posttreatment follow-up visits-determined using Medicare national average out-of-pocket costs and a range of standard treatment options. Financial stress was evaluated using the InCharge Financial Distress/Financial Well-Being Scale. A total of 232 responses were collected. The average financial stress score was 6.29 (SD, 1.97), with 22% (52/232) being classified as financially distressed (score < 5.00). Twenty-eight percent of the participants (n= 64) always chose the lowest cost option, and two participants (0.01%) always chose less time in a cast. Over one-third of the participants chose the cheaper monetary option 80% of the time or more. The odds of choosing a lower cost option were 1.06 times greater per $100 decrease in cost in the entire cohort and 1.03 times greater among 166 participants who did not always choose the least expensive option. In monetary terms, relative importance showed that the participants were willing to pay $19.48 and $58.37 for a week less of cast immobilization and out of work, respectively. This study demonstrates the important role that out-of-pocket cost plays in decision-making compared with the nonclinical components of two equivalent treatment options. Providers should be cognizant of the cost associated with treatment options so that information on treatment cost can be incorporated into counseling and shared decision-making with patients undergoing hand surgery.

Antibiotic prescription practices among dentists treating children in the UK

Introduction There are limited paediatric specific data on antibiotic prescribing practices, which have been cited as one of the causes of general overuse and misuse of antibiotics in young patients. The aim of this study was to investigate prescribing practices among dentists with an interest in paediatric dentistry in the UK. Methods A prospective cross-sectional survey was distributed electronically to members of the British Society of Paediatric Dentistry between February and May 2021. The questions and scenarios were based on antibiotic prescribing guidelines in the UK. Results Two hundred and six dentists completed the survey (45% response rate). Most participants (93%) conformed to guidelines and prescribed amoxicillin as a first-line antibiotic for an odontogenic infection. For patients with a penicillin allergy, 16% of dentists reported clindamycin as their first-choice antibiotic. Seventeen per cent of those surveyed stated that they would prescribe antibiotics for local swelling without any additional factors indicating a persistent or spreading bacterial infection. Further insights into prescribing practices for prophylaxis, paediatric doses and non-clinical factors are described. Conclusions Antibiotics are part of the armamentarium that dentists can use to treat patients. The results of this survey highlight some positive trends as well as some variation in prescribing practice that requires correction and discussion for future research.

Plan–Do–Check–Act Method to Reduce Cesarean Section Deliveries at a Tertiary Hospital: A Teaching Case Study

Abstract According to the World Health Organization (WHO), cesarean section (C-Section) rates &gt;10–15 is not justifiable in any setting. However, the number of C-sections performed has steadily increased in both affluent and low- and middle-income nations in the past three decades. About 21% increase in the number of C-sections was observed from the National Family Health Surveys 4 to 5 in India. Studies have clearly shown a disparity in C-section rates between rural–urban, private–public health institutions, and high–low educated women. The present teaching case study details of quality improvement project using plan–do–check–act (PDCA) for reducing C-section in a tertiary care hospital. The case study highlights the implementation of PDCA cycle using team approach, capacity building, standardizing of clinical protocols, audit, and addressing nonclinical factors associated with C-section. Proven methods for path to change for improvement from the literature are used for designing of PDCA cycle. Hospitals planning to reduce elective C-section deliveries can adopt and adapt the plans and methods described in this teaching case study.

ASSESSMENT OF FACTORS AFFECTING THE HEALTH-RELATED QUALITY OF LIFE IN PATIENTS ON MAINTENANCE HEMODIALYSIS

BackgroundQuality of life is an important parameter that needs to be considered when evaluating the outcome of patientsreceiving healthcare; this is especially the case for patients with long-term chronic diseases. Furthermore, withthe increasing medical ability to prolong life, the patient’s quality of life has become an increasingly legitimatemedical outcome. Therefore, assessment of patients’ quality of life not only helps assess the quality of thedialysis but also is useful to guide nephrologists to develop better interventions and plans of care for the future. ObjectivesTo assess the quality of life and factors affecting hemodialysis patients. Patients and MethodsAn observational, cross-sectional study was conducted among (209) patients on maintenance hemodialysisat six major hemodialysis centres in Sulaimani Governorate. They are using a questionnaire face-to-faceinterview for ten months, from 7/Sep./2021 to 10/Jun/2022. Data analysis by the IBM SPSS program,quantitative variables are expressed as mean ± standard deviation (M±SD), median and interquartile, andresults from qualitative variables are expressed as percentages. P-value &lt; 0.05 assume the significance forresults. ResultsOverall mean quality of life was near (37%) in (100%) of normal persons, with an SD (of 13.26). Over one-thirdwere in the age group of (50-64) years, and the number increased by age. Nearly equal male-to-female ratio(50.2male, while 49.8 female). (46.4%) were illiterates, and (67%) were Unemployed. Claimed that they had noincome (65.6 %) and diabetes mellitus among patients (45.9%). Demographic factors, dialysis adequacy, andclinical factors are among the factors that affect the quality of life. ConclusionDespite regular hemodialysis, the patient’s quality of life on maintenance hemodialysis is severely affected.Both clinical and nonclinical factors, such as demographic factors, Dialysis adequacy, comorbidities, andothers, were severely affecting the quality of life of patients on maintenance hemodialysis, especially physicalactivities.

RARE-02. OBSERVATIONAL REGISTRY STUDY OF TREATMENT PRACTICES AND LONG-TERM OUTCOMES OF CHILDREN WITH NEUROFIBROMATOSIS TYPE 1 (NF1) AND PLEXIFORM NEUROFIBROMAS (PN) INITIATING SELUMETINIB IN REAL-WORLD PRACTICE IN THE UNITED STATES (US): STUDY DESIGN AND METHODOLOGY

Abstract Selumetinib (ARRY-142886, AZD6244) is an oral, allosteric MEK1/2 inhibitor approved in the US for children aged ≥2 years with NF1 and symptomatic, inoperable PN, based on results from the pivotal SPRINT study. Aims of the US Selumetinib Registry study [NCT05683678] include understanding treatment practices and assessing short- and long-term safety and effectiveness outcomes of selumetinib treatment in children with NF1-PN in real-world US practice. Clinical and non-clinical factors affecting outcomes will also be explored. This observational registry study of pediatric patients with NF1-PN will be conducted in up to 22 US centers. Eligible patients will be 2–18 years old at the time of selumetinib initiation (on/after April 10, 2020), and not currently participating in a clinical trial. Patients will be divided into three cohorts: Cohort 1 – treatment discontinued before enrollment, Cohort 2 – treatment initiated before enrollment and currently on treatment, Cohort 3 – treatment initiation intended within 3 months of enrollment. Patients will be followed for ≥36 and up to 60 months. Primary objectives are to describe patient demographics and disease characteristics (including diagnosis criteria and related manifestations, diagnostic tests and results, and PN-related morbidities), selumetinib treatment course, short- and long-term effectiveness and safety, and disease course and treatment following discontinuation. Key secondary objectives include measures of quality of life, pain and physical functioning before, during, and after selumetinib. Target enrollment is 200 patients with a 24-month enrollment period and will begin in 2023. The US Registry study will facilitate understanding of treatment practices and assess short and long-term outcomes of selumetinib for NF1-PN in a real-world setting.

Linking the demographic, socio-economic and oral health status to oral health-related quality of life of the sudanese older adults: a cross sectional study

BackgroundOral Health-Related Quality of Life (OHRQoL) is an important measure of patients’ needs and progress. Identifying the links between clinical and non-clinical factors with OHRQoL in a specific population will facilitate the development of effective preventive strategies. The aim of the study was to assess the OHRQoL of Sudanese older adults, and to identify the possible relations between clinical and non-clinical predictors with OHRQoL using Wilson and Cleary model.MethodsThis cross-sectional study was conducted among older adults attending the out-patient clinics in Khartoum State’s Health Care Centers, Sudan. OHRQoL was assessed using the Geriatric Oral Health Assessment Index (GOHAI). Two modifications of Wilson and Cleary’s conceptual model were tested using structural equations modeling including: oral health status, symptom status, perceived difficulty of chewing, oral health perceptions, and OHRQoL.Results249 older adults participated in the study. Their mean age was 68.24 (± 6.7) years. The mean GOHAI score was 53.96 (± 6.31) and trouble biting/chewing was the most commonly reported negative impact. Wilson and Cleary models showed that pain, Perceived Difficulty Chewing (PDC), and Perceived Oral Health had a direct effect on OHRQoL. In model 1, age and gender had direct effects on oral health status, while education had direct effects on OHRQoL. In model 2, poor oral health status is associated indirectly with poor OHRQoL.ConclusionsThe OHRQoL of the studied Sudanese older adults was relatively good. The study partially confirmed Wilson and Cleary model as Oral Health Status was related directly to PDC and indirectly to OHRQoL through functional status.

Abstract 20: Clinical and Non-Clinical Determinants of Cervical Cancer Mortality: A Retrospective Cohort Study in Lagos, Nigeria

Abstract Purpose: Cervical cancer (CCa) is the fourth most frequent and a common cause of cancer mortality in women, the majority of whom live in low- and middle-income countries. Data on CCa mortality and its determinants have been poorly studied in Nigeria, resulting in a paucity of information that can assist patient management and cancer control policy. The purpose of this study was to assess the mortality rate among CCa patients in Nigeria as well as the major factors influencing CCa mortality. Methods: Data from the medical records of 343 CCa patients seen at the Lagos University Teaching Hospital and NSIA-LUTH Cancer Center from 2015 to 2021 were used in a retrospective cohort analysis. The hazard ratios (HR) and confidence intervals (CI) associated with the exposure variables and CCa mortality were calculated using Cox proportional hazard regression. Results: The CCa mortality rate was 30.5 per 100 women-years after 2.2 years of median follow-up. Clinical factors such as HIV/AIDS (adjusted HR [aHR]: 11.9; 95% CI: 4.6, 30.4), advanced clinical stage (aHR: 2.7; 95% CI: 1.5, 4.7), and anemia at presentation (aHR: 1.8; 95% CI: 1.1, 3.0) were associated with a higher mortality risk, as were non-clinical factors such as age at diagnosis &amp;gt;50 years (aHR: 1.4; 95% CI: 1.0, 1.9) and family history of CCa (aHR: 3.5; 95%CI: 1.1, 11.1) Conclusion: CCa has a high mortality rate in Nigeria. Incorporating these clinical and non-clinical factors into CCa management and control policies may improve women’s outcomes. Citation Format: Idris Ola, Adebola Okunowo, Muhammad Habeebu, Junmei Miao Jonasson. Clinical and Non-Clinical Determinants of Cervical Cancer Mortality: A Retrospective Cohort Study in Lagos, Nigeria [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 20.

Trends in the use of maintenance therapy in ovarian cancer.

6585 Background: Emerging maintenance therapies in advanced ovarian cancer (OC) remain of high interest since 70% of patients (pts) will relapse and ultimately succumb to OC. This study analyzes nonclinical factors associated with maintenance therapy (MT) in OC. We define MT in OC as the use of polyADP-ribose polymerase inhibitors (PARPi) and/or bevacizumab (bev) following platinum-based chemotherapy. Methods: We used data from Optum’s de-identified Clinformatics Data Mart Database F to conduct an analysis of OC pts with Medicare or commercial health insurance. Pts were included if they had 1 inpatient or 2 outpatient diagnosis codes for OC from 01/2017 to 12/2020 and received platinum-based chemotherapy after diagnosis. Pts were excluded if they did not have continuous coverage from diagnosis until 6 months after completion of platinum-based chemotherapy or death. MT was identified by insurance claims for PARPi or bev received within 6 months after completion of platinum-based chemotherapy. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to evaluate associations between pts’ nonclinical characteristics and MT use. Trends in MT use were reviewed by year. Subgroup analysis comparing trends in PARPi use to bev use was also performed. The median time from last chemotherapy until initiation of MT was 22 days. Results: 5,652 pts were included in the study with a median age of 70 years. The majority were white (70.7%), Medicare-insured (71.8%), and treated in the South (42.8%). 33.6% of pts received MT and 66.4% of pts received neither PARPi nor bev. More pts received bev alone (19.6%) compared to PARPi alone (10.3%) or combination MT (3.7%). Olaparib was the most commonly prescribed PARPi. After adjusting for insurance type, both PARPi and bev use increased significantly over time from 2017 to 2021. Pts with more comorbidity burdens (i.e. higher Elixhauser comorbidity index) were more likely to receive MT compared to pts with less comorbidity [OR (95% CI): 1.44 (1.26-1.65)]. MT use was significantly associated with treatment in the South compared to the Northeast [1.22(1.01-1.46)] and younger age, pts &gt; 76 years were less likely to use MT compared to pts &lt; 56 years old [0.78 (0.62-0.98)]. In the subgroup analysis, PARPi use was significantly associated with age, race and region compared with no MT use, while bev use was not associated with these factors. Conclusions: Age, comorbidity status, and geographic location of treatment were associated with MT use. The increasing use of MT over time is consistent with published data since both agents have demonstrated a progression free survival advantage and have tolerable toxicity profiles. With increasing focus on MT in OC, a better understanding of nonclinical factors associated with MT use is imperative to eliminating potential disparities in OC outcomes.

(311) Socioeconomic Risk-Adjustment with Area Deprivation Index (ADI) Predicts Delays to Urethroplasty for Patients with Urethral Stricture Disease

Abstract Introduction Treatment of urethral stricture disease with multiple repeated endoscopic procedures has been shown to be both ineffective and costly. While a number of patient and provider factors are known to be associated with likelihood of undergoing multiple endoscopic, little is known about non-clinical factors that can impact care. Objective As social inequalities such as living in a disadvantaged neighborhood are known to be associated with poorer overall health, worse health outcomes, and decreased quality of care, the aim of this study was to assess whether neighborhood deprivation is associated with delays to definitive care for urethral stricture disease. Methods This study identified patients treated by a single surgeon with urethroplasty between 9/4/2019 and 12/29/2021. Patients with a previous history of urethroplasty, under the age of 18, and those with insufficient follow-up data were excluded from the study. Area deprivation index (ADI) is a composite comprised of 17 factors describing income, education, employment and housing quality based on subject 9-digit ZIP code and obtained from the University of Wisconsin School of Medicine and Public Health Neighborhood Atlas. Scores are normalized to a percentile from 0 to 100, with higher numbers representing higher levels of disadvantage. Patient addresses were geocoded and assigned a national ADI rank based on residential census block group. For the present study, ADI rank was sub-grouped into least disadvantaged (lower 50%) and most disadvantaged (upper 50%). Multivariate logistic regression was performed to assess impact of ADI score on likelihood of receiving multiple endoscopic procedures prior to urethroplasty. Final model was assessed for multicollinearity and goodness of fit via Hosmer-Lemeshow goodness-of-fit test. Results 104 patients were included in the final analysis. 44% of patients had undergone multiple prior endoscopic procedures. Patients who had undergone ≥2 endoscopic procedures tended to be older, have higher ADI scores, and were more likely to be white. Median time to urethroplasty was significantly higher in those who had undergone multiple prior endoscopic procedures (88 mos vs 12 mos, p&amp;lt;0.001). On multivariate analysis adjusting for age, ADI classification, and insurance status, patients in the more disadvantaged group were significantly more likely to have undergone multiple endoscopic procedures prior to urethroplasty (OR 2.79), as were older patients (OR 1.04). Conclusions Neighborhood disadvantage as assessed by the ADI provides an alternative methodology to identify disparities in health services utilization in patients with urethral stricture disease. These findings highlight needs to increase provision of urologic resources and care to disadvantaged communities. Disclosure No

Investigating potential disparities in clinical trial eligibility and enrollment at an NCI-designated comprehensive cancer center.

Although barriers to trial accrual are well-reported, few studies have explored trial eligibility and trial offers as potential drivers of disparities in cancer clinical trial enrollment. We identified patients with gastrointestinal (GI) or head/neck (HN) malignancies who were seen as new patients at the University of Michigan Health Rogel Cancer Center in 2016. By exhaustive review of the electronic medical record, we assessed the primary outcomes: (1) eligibility for, (2) documented offer of, and (3) enrollment in a clinical trial. All 41 of the clinical trials available to these patients were considered. Independent variables included clinical and non-clinical patient-related factors. We assessed associations between these variables and the primary outcomes using multivariable regression. Of 1446 patients, 43% were female, 15% were over age 75, 6% were Black. 305 (21%) patients were eligible for a clinical trial. Among eligible patients, 154 (50%) had documentation of a trial offer and 90 (30%) enrolled. Among the GI cohort, bivariate analyses demonstrated that older age was associated with decreased trial eligibility. Bivariate analyses also demonstrated that Black race was associated with increased trial offer. After adjustment, patients 75 or older were less likely to be eligible for a clinical trial in the GI cohort; however, we found no significant associations between race and any of the outcomes after adjustment. Among eligible GI patients, we found no significant associations between non-clinical factors and enrollment. Among the HN cohort, bivariate analyses demonstrated that female sex, older age, Black race, and unpartnered marital status were associated with decreased likelihood of trial offer; however, we found no significant associations between race, age, and marital status and any of the outcomes after adjustment. We found no significant associations between non-clinical factors and eligibility after adjustment; however, women were less likely to be offered and to enroll in a clinical trial in the HN cohort. Factors associated with eligibility, documented offer, and enrollment differed between disease site cohorts at our institution. Future work is needed to ensure the equitable inclusion of women and elderly patients in clinical trials.

A Statewide Analysis of Predictors of Trauma Center Transfer: The Burden of Non-Clinical Factors.

There is a perception, with mixed literary support, that patients are transferred from community hospitals to tertiary medical centers for non-clinical reasons (ie, payor, race, and admission time). Over-triage risks unequally burdening the tertiary medical centers within a trauma system. This study aims to identify potential non-clinical factors associated with the transfer of injured patients. Using the 2018 North Carolina State Inpatient Database, patients with a primary diagnosis of spine, rib or extremity fractures, or TBI were identified using ICD-10-CM code and admission type of "Urgent," "Emergency," or "Trauma." Patients were divided into cohorts of "retained" (at community hospital) or "transferred" (Level-1 or 2 trauma centers). 11,095 patients met inclusion criteria; 2432 (21.9%) patients made up the transfer cohort. The mean ISS for all retained patients was 2.2 (±.9) and 2.9 (±1.4) for all transferred patients. The transfer cohort was younger (mean age 66 v 75.8), underinsured, and more likely to be admitted after 1700 (P < .001). Similar differences were seen regardless of injury pattern. Patients transferred to trauma centers were more likely to be underinsured and be admitted outside of normal business hours. These transferred patients had longer lengths of stay and higher mortality rates. Across all cohorts, similar ISS suggests that a portion of the transfers could be managed at a community hospital. After hours transfers suggest a need for more robust community hospital coverage. Intentional triage of the injured patient encourages appropriate utilization of resources and is crucial to maintaining high-functioning trauma centers and systems.

Planning management for complex colorectal polyps: a qualitative assessment of factors influencing decision-making among colonoscopists

ObjectiveEndoscopic therapy is the recommended primary treatment for most complex colorectal polyps, but high colonic resection rates are reported. The aim of this qualitative study was to understand and compare...

Gender differences among long-stay inpatients with schizophrenia in China: A cross-sectional study

ObjectiveWe sought to examine the independent correlates of long-term hospitalization in a sample of Chinese inpatients with schizophrenia (SCZ) from a gender-based perspective. MethodsThis was a cross-sectional study that was carried out in a tertiary psychiatric hospital. All adult inpatients in this hospital were screened from January to March 2020, 251 of whom were identified as long-stay inpatients with SCZ (LSIS) and 224 as short-stay inpatients with SCZ (SSIS). Demographic and clinical information of the two groups was collected through medical records, scale assessments and interviews. Gender differences were analyzed, and independent correlates of long-stay between genders were explored by logistic regression analyses. ResultsCompared to SSIS, greater proportions of LSIS patients were male (64.1%), single (82.1%), unemployed (81.7%) and had no family caregivers (54.2%). For LSIS per se, proportionally more males were single (88.8%), had no family caregiver (65.8%), had concomitant physical disease (65.2%) and had a history of hazardous behavior (27.3%) than their female counterparts. For females, the top independent risk factors for a long stay included poor functioning (OR = 5.9, 95% CI: 2.9–12.0), older age (OR = 4.3, 95% CI: 2.1–9.1) and being single (OR = 3.9, 95% CI: 1.8–8.4). Similar to women, both older age (OR = 5.3, 95% CI: 2.5–11.2) and poor functioning (OR = 4.0, 95% CI: 2.1–7.9) were also independent factors for long-term hospitalization of male patients; however, having no family caregiver (OR = 10.2, 95% CI: 4.6–22.6) was the primary risk factor for men. ConclusionsBoth clinical and nonclinical factors play important roles in long-term hospitalization in Chinese patients with schizophrenia. There are overlaps and distinctions across genders with respect to the independent factors of long stays. These findings provide clues for developing better service strategies for this population, and highlight the importance of paying attention to gender differences in further research in this field.

Transplantation Referral Patterns for Patients with Newly Diagnosed Higher-Risk Myelodysplastic Syndromes and Acute Myeloid Leukemia at Academic and Community Sites in the Connect® Myeloid Disease Registry: Potential Barriers to Care

Hematopoietic stem cell transplantation (HCT) is indicated for patients with higher-risk (HR) myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Age, performance status, patient frailty, comorbidities, and nonclinical factors (eg, cost, distance to site) are all recognized as important clinical factors that can influence HCT referral patterns and patient outcomes; however, the proportion of eligible patients referred for HCT in routine clinical practice is largely unknown. This study aimed to assess patterns of consideration for HCT among patients with HR-MDS and AML enrolled in the Connect® Myeloid Disease Registry at community/government (CO/GOV)- or academic (AC)-based sites, as well as to identify factors associated with rates of transplantation referral. We assessed patterns of consideration for and completion of HCT in patients with HR-MDS and AML enrolled between December 12, 2013, and March 6, 2020, in the Connect Myeloid Disease Registry at 164 CO/GOV and AC sites. Registry sites recorded whether patients were considered for transplantation at baseline and at each follow-up visit. The following answers were possible: "considered potentially eligible," "not considered potentially eligible," or "not assessed." Sites also recorded whether patients subsequently underwent HCT at each follow-up visit. Rates of consideration for HCT between CO/GOV and AC sites were compared using multivariable logistic regression analysis with covariates for age and comorbidity. Among the 778 patients with HR-MDS or AML enrolled in the Connect Myeloid Disease Registry, patients at CO/GOV sites were less likely to be considered potentially eligible for HCT than patients at AC sites (27.9% versus 43.9%; P < .0001). Multivariable logistic regression analysis with factors for age (<65 versus ≥65 years) and ACE-27 comorbidity grade (<2 versus ≥2) showed that patients at CO/GOV sites were significantly less likely than those at AC sites to be considered potentially eligible for HCT (odds ratio, 1.6, 95% confidence interval, 1.1 to 2.4; P = .0155). Among patients considered eligible for HCT, 45.1% (65 of 144) of those at CO/GOV sites and 35.7% (41 of 115) of those at AC sites underwent transplantation (P = .12). Approximately one-half of all patients at CO/GOV (50.1%) and AC (45.4%) sites were not considered potentially eligible for HCT; the most common reasons were age at CO/GOV sites (71.5%) and comorbidities at AC sites (52.1%). Across all sites, 17.4% of patients were reported as not assessed (and thus not considered) for HCT by their treating physician (20.7% at CO/GOV sites and 10.7% at AC sites; P = .0005). These findings suggest that many patients with HR-MDS and AML who may be candidates for HCT are not receiving assessment or consideration for transplantation in clinical practice. In addition, treatment at CO/GOV sites and age remain significant barriers to ensuring that all potentially eligible patients are assessed for HCT.

An exploration of barriers to access to trial of labor and vaginal birth after cesarean in the United States: a scoping review.

Increasing the number of vaginal birth after cesarean (VBAC) deliveries is one strategy to reduce the cesarean rate in the United States. Despite evidence of its safety, access to trial of labor after cesarean (TOLAC) and VBAC are limited by many clinical and non-clinical factors. We used a scoping review methodology to identify barriers to access of TOLAC and VBAC in the United States and extract potential leverage points from the literature. We searched PubMed, Embase, Cochrane, and CINAHL for peer-reviewed, English-language studies published after 1990, focusing on access to TOLAC and/or VBAC in the United States. Themes and potential leverage points were mapped onto the Minority Health and Health Disparities Research Framework. The search yielded 21 peer-reviewed papers. Barriers varied across levels of influence and included factors related to restrictive clinical guidelines, provider reluctance, geographic disparities, and midwifery scopes of practice. While barriers varied in levels of influence, the majority were related to systemic and interpersonal factors. Barriers to TOLAC and VBAC exist at many levels and are both clinical and non-clinical in nature. The existing body of literature can benefit from more research examining the impact of recent revisions to clinical guidelines related to VBAC as well as additional qualitative studies to more deeply understand the complexity of provider reluctance.

Tobacco consumption and non-communicable diseases in Ghana; Identifying accentuating factors and further evidence from 2014 Ghana demographic and health survey

BackgroundNon-communicable diseases such as hypertension, diabetes, strokes, cancers and chronic kidney conditions have caused disabilities and negatively impacted on economic development. While greater efforts of controlling these non-communicable diseases are clinically motivated, the non-clinical factors such as behavioural lifestyle and the associated accentuating factors have not been given due attention. It has been established elsewhere that, tobacco use which is a risk factor for non-communicable diseases occurrence is influenced by individual's residential status, educational status, occupational status, income level and access to media projections. This study therefore sought to identify associations between accentuating factors and tobacco use and its implications for the occurrence of non-communicable diseases prevalent in Ghana. MethodsThis was a mixed method study involving in part, use of secondary data from the Ghana Demographic and Health Survey 2014 with a sample of 4,122 respondents and primary qualitative interviews of 32 respondents respectively, from 4 Regions of Ghana. Descriptive statistics, probit regression and content thematic analysis were used for data analysis for both the quantitative and qualitative arms respectively. ResultsThe study found that, there was statistically significant association between educational status and tobacco use [X2 (5, 4,123)=164.5619; p = 0.000], income levels and tobacco use [X2 (7, 4,123)=68.5615; p = 0.001), occupational status and tobacco use [X2 (8, 4,123)=195.6919; p = 0.000], residential status and tobacco [X2 (3, 4,134) = 82.7824; p = 0.000)] and finally, access to mass media and tobacco use [X2 (2, 4,134)= 1.2352, p = 0.009]. Again, the regression result shows that, the accentuating factors determine about 51% (50.579) of the tobacco use by individuals in the relation [R2 = 0.305, F(17, 4,077) = 50.579, p = 0.000]. Moreover, 62.4 percent of females were less likely to smoke than males. Within the educational levels, secondary school completion category influence smoking by 82.8 percent. Also, assessing the relations between wealth quintiles and smoking, the study found that, the middle class income earners category influence smoking by 53.4 percent. Lastly, in the residential status, living in rural area contributed 41 percent to tobacco use. The implication is that, urban dwellers are more likely to use tobacco than rural dwellers. ConclusionThe study concludes that, educational status, residential status, occupational status, wealth quintiles and access to media accentuates tobacco use within a population with implications for the occurrence and control of non-communicable diseases. The study calls for a strengthening of the WHO Framework Convention on Tobacco Control in Ghana.

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones. We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis. Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue. The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

Acute Kidney Injury Survivor Care Following Hospital Discharge: A Mixed-Methods Study of Nephrologists and Primary Care Providers.

Widespread delivery of high-quality care for acute kidney injury (AKI) survivors after hospital discharge requires a multidisciplinary team. We aimed to compare management approaches between nephrologists and primary care providers (PCPs) and explored strategies to optimize collaboration. Explanatory sequential mixed-methods study using a case-based survey followed by semi-structured interviews. Nephrologists and PCPs providing AKI survivor care at 3 Mayo Clinic sites and the Mayo Clinic Health System were included. Survey questions and interviews elucidated participants' recommendations for post-AKI care. Descriptive statistics were used to summarize survey responses. Qualitative data analysis used deductive and inductive strategies. A connecting and merging approach was used for mixed-methods data integration. 148 of 774 (19%) providers submitted survey responses (24/72 nephrologists and 105/705 PCPs). Nephrologists and PCPs recommended laboratory monitoring and follow-up with a PCP shortly after hospital discharge. Both indicated that the need for nephrology referral, and its timing should be dictated by clinical and non-clinical patient-specific factors. There were opportunities for improvement in medication and comorbid condition management in both groups. Incorporation of multidisciplinary specialists (eg, pharmacists) was recommended to expand knowledge, optimize patient-centered care, and alleviate provider workload. Survey findings may have been affected by non-response bias and the unique challenges facing clinicians and health systems during the COVID-19 pandemic. Participants were from a single health system, and their views or experiences may differ from those in other health systems or serving different populations. A multidisciplinary team-based model of post-AKI care may facilitate implementation of a patient-centered care plan, improve adherence to best practices, and reduce clinician and patient burden. Individualizing care for AKI survivors based on clinical and non-clinical patient-specific factors is needed to optimize outcomes for patients and health systems.

Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania.

The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings. This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated. Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively. Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.