Significant Increases In Adherence Research Articles

Improving Adherence to Safe Sleep Guidelines for Hospitalized Infants at a Children's Hospital.

Sudden unexpected infant deaths are a major problem nationally. We had poor adherence to safe sleep recommendations locally at our institution. Given the significance of this problem, hospital administration at a tertiary children's hospital tasked a multidisciplinary group of faculty and staff with improving sleep environments for hospitalized infants. Our safe sleep task force implemented targeted interventions using the American Academy of Pediatrics policy statement as the gold standard and based on hospital data to address areas of greatest nonadherence to recommendations. We aimed to improve weekly average adherence to 95% over 12 months. A proportions process control chart (p-chart) tracked average weekly adherence over a 52-week time frame. In addition, we performed Student's t-testing to evaluate differences in adherence over time. There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = -15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= -21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules. Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Impact of a pharmacist-facilitated, evidence-based bundle initiative on Staphylococcus aureus bacteremia management

ObjectiveTo evaluate a pharmacist-facilitated evidence-based bundle (EBB) initiative with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia (SAB). MethodsThis was a before-and-after quasi-experimental study of adult patients with SAB before and after the pharmacist-facilitated EBB initiative, which included IDC, timely definitive antibiotics, source control, echocardiography, and repeat blood cultures. ResultsNinety and 111 patients were included in pre- and post-intervention cohorts, respectively. We observed significant increases in adherence to all 5 (4.4% vs 68.5%, P < 0.001) and 4 (10.0% vs 76.6%, P < 0.001) EBB elements. Time to definitive antibiotics (48 vs 16 hours, P < 0.001), time to IDC (43.5 vs 32 hours, P < 0.001), SAB duration (95 vs 66 hours, P = 0.009), persistent SAB (18.9% vs 9.0%, P = 0.041), and length of stay (14 vs 13 days, P = 0.027) also improved. No statistically significant differences for SAB-related readmission or all-cause mortality were observed. ConclusionsOur pharmacist-facilitated SAB initiative was associated with improved EBB adherence and clinical outcomes.

0636 Using AI To Predict Future CPAP Adherence and the Impact of Behavioral and Technical Interventions

Abstract Introduction Clinical management of CPAP adherence remains an ongoing challenge. Behavioral and technical interventions such as patient outreach, coaching, troubleshooting, and resupply may be deployed to positively impact adherence. Previous authors have described adherence phenotypes that retrospectively categorize patients by discrete usage patterns. We design an AI model that predictively categorizes patients into previously studied adherence phenotypes and analyzes the statistical significance and effect size of several types of interventions on subsequent CPAP adherence. Methods We collected a cross-sectional cohort of subjects (N = 13,917) with 455 days of daily CPAP usage data acquired. Patient outreach notes and resupply data were temporally synchronized with daily CPAP usage. Each 30-days of usage was categorized into one of four adherence phenotypes as defined by Aloia et al. (2008) including Good Users, Variable Users, Occasional Attempters, and Non-Users. Cross-validation was used to train and evaluate a Recurrent Neural Network model for predicting future adherence phenotypes based on the dynamics of prior usage patterns. Two-sided 95% bootstrap confidence intervals and Cohen’s d statistic were used to analyze the significance and effect size of changes in usage behavior 30-days before and after administration of several resupply interventions. Results The AI model predicted the next 30-day adherence phenotype with an average of 90% sensitivity, 96% specificity, 95% accuracy, and 0.83 Cohen’s Kappa. The AI model predicted the number of days of CPAP non-use, use under 4-hours, and use over 4-hours for the next 30-days with OLS Regression R-squared values of 0.94, 0.88, and 0.95 compared to ground truth. Ten resupply interventions were associated with statistically significant increases in adherence, and ranked by adherence effect size using Cohen’s d. The most impactful were new cushions or masks, with a mean post-intervention CPAP adherence increase of 7-14% observed in Variable User, Occasional Attempter, and Non-User groups. Conclusion The AI model applied past CPAP usage data to predict future adherence phenotypes and usage with high sensitivity and specificity. We identified resupply interventions that were associated with significant increases in adherence for struggling patients. This work demonstrates a novel application for AI to aid clinicians in maintaining CPAP adherence. Support

Optimizing Registered Nurse Bedside Shift Report

Compliance with evidence-based shift report practices varies, and handoff processes are often inconsistent, increasing the risk for compromised patient safety. This pilot study evaluated registered nurse adherence to and self-efficacy with evidence-based shift report practices presimulation and postsimulation. Statistically significant increases in adherence to and self-efficacy with shift report practices after simulation were noted. Simulation offers nursing professional development practitioners a feasible method to enhance practice competency and standardization of care during registered nurse shift report.

Does a quality improvement campaign accelerate take-up of new evidence? A ten-state cluster-randomized controlled trial of the IHI\u2019s Project JOINTS

BackgroundA decade ago, the Institute for Healthcare Improvement pioneered a quality improvement (QI) campaign, leveraging organizational and personal social networks to disseminate new practices. There have been few rigorous studies of the QI campaign approach.MethodsProject JOINTS (Joining Organizations IN Tackling SSIs) engaged a network of state-based organizations and professionals in a 6-month QI campaign promoting adherence to three new evidence-based practices known to reduce the risk of infection after joint replacement. We conducted a cluster-randomized trial including ten states (five campaign states and five non-campaign states) with 188 hospitals providing joint replacement to Medicare. We measured adherence to the evidence-based practices before and after the campaign using a survey of surgical staff and a difference-in-difference design with multivariable adjustment to compare adherence to each of the relevant practices and an all-or-none composite measure of the three new practices.ResultsIn the campaign states, there were statistically significant increases in adherence to the three new evidence-based practices promoted by the campaign. Compared to the non-campaign states, the relative increase in adherence to the three new practices in the campaign states ranged between 1.9 and 15.9 percentage points, but only one of these changes (pre-operative nasal screening for Staphylococcus aureus carriage and decolonization prior to surgery) was statistically significant (p < 0.05). On the all-or-none composite measure, adherence to all three evidence-based practices increased from 19.6 to 37.9% in the campaign states, but declined slightly in the comparison states, yielding a relative increase of 23 percentage points (p = 0.004). In the non-campaign states, changes in adherence were not statistically significant.ConclusionsWithin 6 months, in a cluster-randomized trial, a multi-state campaign targeting hospitals and professionals involved in surgical care and infection control was associated with an increase in adherence to evidence-based practices that can reduce surgical site infection.

Stakeholder Buy-In and Physician Education Improve Adherence to Guidelines for Down Syndrome

To assess adherence to the 2011 American Academy of Pediatrics (AAP) health supervision guidelines for Down syndrome, to determine whether pediatrician education improves adherence, and to evaluate stakeholder attitudes toward these guidelines. Twenty-two pediatric care sites participated in chart review of adherence to the components of the AAP guidelines for Down syndrome in this longitudinal cohort study. We analyzed universal recommendations which apply to all children with Down syndrome. Thirteen pediatric practices caring for 82 patients with Down syndrome received educational information. Frequency calculations with Bonferroni adjustment of the P value threshold (P = .05/9 = .0056) were performed. Adherence rates were compared between cohorts and within the individual before and after intervention using 2 × 2 contingency tables and goodness-of-fit tests. Pediatricians and parents of children with Down syndrome completed an anonymous survey regarding their attitudes toward the guidelines. Statistically significant increases in adherence were seen in 5 of the 8 universal recommendations following pediatrician education (P ≤ .002), including cardiology and genetics visits, rates of echocardiography, annual audiology testing, and sleep studies by age 4 years. Both physicians and parents reported generally positive views of the guidelines, yet baseline adherence rates were suboptimal. Pediatrician education preferences include directly integrating the guidelines into an electronic medical record system. Stakeholder attitudes reflect a willingness to follow the AAP guidelines for Down syndrome. Providing rapid access to simple, clear reminders of recommended assessments successfully improved adherence to the AAP guidelines for Down syndrome.

Can You Teach a Teen New Tricks? Problem Solving Skills Training Improves Oral Medication Adherence in Pediatric Patients with Inflammatory Bowel Disease Participating in a Randomized Trial.

Medication nonadherence is associated with higher disease activity, greater health care utilization, and lower health-related quality of life in pediatric inflammatory bowel diseases (IBD). Problem solving skills training (PSST) is a useful tool to improve adherence in patients with chronic diseases but has not been fully investigated in IBD. This study assessed feasibility, acceptability, and preliminary efficacy of PSST in pediatric IBD. Recruitment occurred during outpatient clinic appointments. After completion of baseline questionnaires, families were randomized to a treatment group or wait-list comparison group. The treatment group received either 2 or 4 PSST sessions. Youth health-related quality of life was assessed at 3 time points, and electronic monitoring of oral medication adherence occurred for the study duration. Seventy-six youth (ages 11-18 years) on an oral IBD maintenance medication participated. High retention (86%) and treatment fidelity rates (95%) supported feasibility. High satisfaction ratings (mean values ≥4.2 on 1-5 scale) supported intervention acceptability. Modest increases in adherence occurred after 2 PSST sessions among those with imperfect baseline adherence (d = 0.41, P < 0.10). Significant increases in adherence after 2 PSST sessions were documented for participants aged 16 to 18 years (d = 0.95, P < 0.05). Improvements in health-related quality of life occurred after 2 PSST sessions. No added benefit of 4 sessions on adherence was documented (d = 0.05, P > 0.05). Phone-delivered PSST was feasible and acceptable. Efficacy estimates were similar to those of lengthier interventions conducted in other chronic illness populations. Older adolescents benefited more from the intervention than their younger counterparts.

Educational intervention to improve adherence to the Mediterranean diet among parents and their children aged 1-2 years. EniM clinical trial.

The objective of the present study was to evaluate the effectiveness of an educational programme on healthy alimentation, carried out in day-care centres and aimed at the parents of children from 1 to 2 years of age, regarding the acquisition of healthy eating habits among themselves and their children. We performed a multicentre, multidisciplinary, randomized controlled study in a community setting. The EniM study (nutritional intervention study among children from Mataró) was performed in twelve day-care centres in Mataró (Spain). Centres were randomized into a control group (CG) and an intervention group (IG). IG received four or five educational workshops on diet, CG did not have workshops. Children, not exclusively breast-fed, from 1 to 2 years of age, in the participating day-care centres and the persons responsible for their alimentation (mother or father). Thirty-five per cent of the IG did not attend the minimum of three workshops and were excluded. The CG included seventy-four children and seventy-two parents and the IG seventy-five children and sixty-seven parents. Both groups were comparable at baseline. Basal adherence to the Mediterranean diet was 56·4 % in parents (Gerber index) and 7·7 points in children (Kidmed test). At 8 months, Mediterranean diet adherence had improved in the IG by 5·8 points in the Gerber index (P=0·01) and 0·6 points in the Kidmed test (P=0·02) compared with the CG. This educational intervention performed in parents at the key period of incorporation of a 1-2-year-old child to the family table showed significant increases in adherence of the parents to the Mediterranean diet, suggesting future improvement in different indicators of health and an expected influence on the diet of their children.

A Mixed-Methods Approach to Investigating the Adoption of Evidence-Based Pain Practices in Nursing Homes

This mixed methods study examined perceived facilitators and obstacles to adopting evidence-based pain management protocols vis-a-vis documented practice changes that were measured using a chart audit tool. This analysis used data from a subgroup of four nursing homes that participated in a clinical trial. Focus group interviews with staff yielded qualitative data about perceived factors that affected their willingness and ability to use the protocols. Chart audits determined whether pain assessment and management practices changed over time in light of these reported facilitators and barriers. Reported facilitators included administrative support, staff consistency, and policy and procedure changes. Barriers were staff attitudes, regulatory issues, and provider mistrust of nurses' judgment. Overall, staff reported improvements in pain practices. These reports were corroborated by modest but significant increases in adherence to recommended practices. Change in clinical practice is complex and requires attention to both structural and process aspects of care.

Baseline medication adherence and response to an electronically delivered health literacy intervention targeting adherence

Medication adherence in persons treated for human immunodeficiency virus (HIV) continues to be an important focus for intervention. While high levels of adherence are required for good clinical outcomes, research shows many patients do not achieve these levels. Despite multiple interventions to improve adherence, most require multiple sessions delivered by trained clinicians. Cost and lack of trained personnel limit the availability of these interventions. Alternatives to clinician-delivered interventions are interventions provided via electronic devices (eg, personal/tablet computers and smartphones). Modern technology allows devices to provide tailoring of content to patient characteristics and learning needs, and to be excellent platforms to deliver multimedia teaching content. The intervention reported drew on research on health literacy in persons with HIV and the relation of health literacy to medication adherence in persons treated for HIV to develop an electronically delivered application. Using the Information-Motivation-Behavioral Skills model as a conceptual framework for understanding patients' information needs, a computer-delivered intervention was developed, its usability and acceptability was assessed, and medication adherence in 118 patients for 1 month before and after they completed the intervention was evaluated. Changes in participant adherence were evaluated in sequential models with progressively lower levels of baseline medication adherence. Results show that although changes in adherence in the entire sample only approached statistical significance, individuals with adherence less than 95% showed significant increases in adherence over time. Participants' self-reported knowledge and behavioral skills increased over the course of the study. Their change in information predicted their post-intervention adherence, suggesting a link between the intervention's effects and outcomes. A computer-delivered intervention targeting HIV-related health literacy may thus be a useful strategy for improving patient adherence.

Influence of Irrigation Regimens on the Adherence of Enterococcus faecalis to Root Canal Dentin

Enterococcus faecalis is frequently associated with post-treatment endodontic infections. Because adherence of bacteria to a substrate is the earliest stage in biofilm formation, eliciting the factors that links adherence of this bacterium to dentin would help in understanding its association with treatment-failed root canals. This investigation aimed to study the effects of endodontic irrigants on the adherence of E. faecalis to dentin. The bacteria adherence assay was conducted by using fluorescence microscopy, and the adhesion force was measured by using atomic force microscopy. There were significant increases in adherence and adhesion force after irrigation of dentin with ethylenediaminetetraacetic acid (EDTA), whereas sodium hypochlorite (NaOCl) reduced it. With the use of chlorhexidine (CHX), the force of adhesion increased, but the adherence assay showed a reduction in the number of adhering bacteria. The irrigation regimen of EDTA, NaOCl, and CHX resulted in the least number of adhering E. faecalis cells. This study highlighted that chemicals that alter the physicochemical properties of dentin will influence the nature of adherence, adhesion force, and subsequent biofilm formation of E. faecalis to dentin.

Results of an Antiretroviral Adherence Intervention: STAR (Staying Healthy: Taking Antiretrovirals Regularly)

A randomized 2-group medication adherence intervention is evaluated with HIV-infected adults (N = 141) assessed at baseline, 3-, and 9-month follow-ups. Cognitive (self-efficacy, behavioral intent), mental health (depression, well-being), and substance use indicators were the outcome measures. In addition, a posttest-only analysis from 3 to 9 months evaluates intervention impact on antiretroviral adherence, measured through Medication Event Monitoring System and pill counts. Compared to the standard care group, the intervention group showed significant increases in adherence self-efficacy and behavioral intent at 3 and 9 months and marginal improvements in mental health. Although the standard care group had higher adherence at 3 months (no baseline data were available prior to intervention), intervention group patients showed significant increases in adherence from 3 to 9 months. Although adherence levels achieved by intervention patients may not be sufficient for virological control, this is one of the first studies to provide promising results of longer term effectiveness of a behavioral adherence intervention.

Administration of Salmonella enteritidis‐immune lymphokine to day‐old turkeys by subcutaneous, oral, and nasal routes: A comparison of effects on Salmonella enteritidis liver invasion, peripheral blood heterophilia and heterophil activation

Previous experiments have shown that the administration by intraperitoncal (i.p.) injection of Salmonella enteritidis‐immune Iymphokines (LK) derived from chicken splenic T cells protect both chicks and turkey poults from Salmonella enteritidis (SE) organ invasion. This protection was mediated by the avian heterophil. The present experiments evaluated the ability of SE‐immune Iymphokines derived from a virally transformed chicken T cell line (VILK) in protecting day‐old turkeys against SE liver invasion, inducing peripheral blood heterophilia, and functionally activating heterophils when delivered by subcutaneous (s.c), oral (p.o.) or intranasal (i.n.) routes when compared to i.p. injection. All routes of administration of VILK showed dramatic reductions in SE liver invasion (P < 0.01) and significant elevations in the number of heterophils in the peripheral blood (P < 0.01). The rise in peripheral blood heterophils was accompanied by a significant increase in the functional activity of the heterophils. Chemotactic movement of heterophils from all VILK groups was two to three times that observed in the control heterophils using chicken serum and recombinant human interleukin‐8 (rhuIL‐8) as the chemoattractants (P<0.01). The number of heterophils phagocytizing SE and the number of bacteria per heterophil were significantly higher in all VILK administered groups (P < 0.01). Adherence to bovine serum albumin (BSA) revealed significant increases in adherence of heterophils from all VILK administered groups when compared to control heterophils from poults (P<0.01). The results of these experiments clearly show that VILK delivered s.c, p.o. and i.n. is as effective in protecting day‐old poults from SE invasion as an i.p. injection and that this protection is also mediated by the activation of an increased number of heterophils in the circulation.

Functional responses of neonatal chicken and turkey heterophils following stimulation by inflammatory agonists

Abstract Objective To determine functional responses of neonatal chicken and turkey heterophils to various inflammatory agonists. Animals 100 one-day-old chickens and turkeys. Procedure Blood heterophils were isolated and stimulated for 30 minutes at 39 C with ionomycin, phorbol myristate acetate (PMA), opsonized zymosan (OZ), or formyl-methionyl-leucyl-phenylalanine (FMLP). Functional responses (shape change, adherence, phagocytosis, influx of intracellular calcium, and oxidative burst) of stimulated heterophils were measured and compared with responses of unstimulated (control) heterophils. Results Turkey and chicken heterophils did not respond to FMLP stimulation. Stimulation of chicken and turkey heterophils with ionomycin resulted in significant increases in adherence, percentage of cells with a shape change, phagocytosis, intracellular calcium concentration, and oxidative burst. Turkey heterophils did not respond to PMA stimulation, whereas stimulation of chicken heterophils with PMA resulted in significant increases in adherence, percentage of cells with a shape change, phagocytosis, and oxidative burst but not intracellular calcium concentration. Stimulation of chicken and turkey heterophils with OZ resulted in significant increases in oxidative burst. Conclusions Mechanisms regulating initiation of heterophil activation in neonatal chicken and turkey heterophils are consistent with those described for heterophils isolated from mature birds. The biochemical and cytoskeletal systems of neonatal avian heterophils undergo functional alterations following stimulation with inflammatory agonists. Clinical Relevance Understanding heterophil activation and regulation should eventually lead to methods for controlling bacterial diseases in poultry. (Am J Vet Res 1998;59:1404–1408)