Specialty Practice Research Articles

The impact of the COVID-19 pandemic on the perioperative transition to specialty practice program.

To understand how the COVID-19 pandemic impacted nurse educators' and novice nurses' experience with the perioperative transition to specialty practice program. A qualitative descriptive study. Semi-structured interviews were conducted with five perioperative nurse educators and five perioperative transition to specialty practice program participants from a major metropolitan health service in Melbourne. Data were collected between April and July 2021. Interviews were audio-recorded and transcribed verbatim, and data were analysed using reflexive thematic analysis. Five themes were identified. The value of the perioperative transition to specialty practice program in supporting novice nurses was recognized in the theme 'Nurturing our novices'. Widespread changes to clinical practice were demonstrated in the theme 'Every day is different', including changes to elective surgery, redeployment of staff and the transmission risk of COVID-19. 'The perils and joys of online learning' revealed both challenges and benefits of transitioning theoretical education from face-to-face to online delivery. 'Roller coaster of emotions' represented the heightened emotions participants experienced due to the COVID-19 pandemic. 'Looking back to move forward' encompassed participants' reflections on the year, considering the challenges, adaptive strategies and the future of perioperative nursing education. The perioperative transition to specialty practice program was significantly impacted by the COVID-19 pandemic. Participants needed to adapt to rapid and frequent changes, which contributed to feelings of emotional distress, affected consolidation of clinical learning and reduced engagement with theoretical education. Perioperative nurses should acknowledge that opportunities for learning were decreased for transition to specialty practice program participants during the pandemic. Ongoing support and education should be provided, to nurture the future generation of perioperative nurses.

Resident Physician “Moonlighting” for On-call in Transfusion Medicine: Educational Impact and Preparedness for Practice

Abstract Introduction/Objective Resident physician moonlighting is controversial and uncommon in Pathology, usually limited to anatomic pathology grossing support. Due to an acute staffing shortage in our department, we offered senior AP/ CP residents in our program a “moonlighting” opportunity involving partnership with attendings to supervise junior residents for transfusion medicine on-call (TMO) . Given the conflicting claims of educational benefit and detriment of moonlighting, we sought to evaluate impact of TMO moonlighting activities on residents' educational experience and preparedness for clinical practice. Methods/Case Report Residents selected for moonlighting TMO were PGY-3/4, “exceeded expectations” on their transfusion medicine rotation and had taken resident TMO. After initial “boot camp” exercises involving common TMO scenarios, they were added to the attending on-call schedule with a fair financial incentive. They were the first resource and provided in-person support for the TMO resident. Attendings were available for consultation via a secure communications platform (phone and text). After one year, residents were surveyed regarding overall experience, sense of graduated responsibility, impact of financial incentive, preparedness for future practice, and impact on day- time service commitment. "Resident In-Service Examination" (RISE) score was used to estimate impact of TMO on medical knowledge. Results (if a Case Study enter NA) NA. Conclusion Four out of the five residents took the survey. All 4 responded “definite” for positive experience, feeling of graduated responsibility and preparedness for practice. Financial incentive was assessed favorably. No resident reported an adverse impact on their daytime service responsibility. The group median score on RISE transfusion medicine 2022 was 75th percentile with median increase in 10 percentile points. As pathology moves towards sub- specialty practice, working fluency in some areas such as TMO remains a necessity for smaller group practices. Our experience (albeit with a small group of residents) suggests that TMO moonlighting activities may better prepare the residents for this unmet need.

The Impact of Cascading Accountability on Specialty Practices: Time for a Nested Solution

The Center for Medicare and Medicaid Innovation (CMMI) was created by the Affordable Care Act to test new payment and delivery models that would lower spending while maintaining or improving patient care.1 As enacted, the Affordable Care Act appropriated $10 billion for the CMMI for 2011 through 2019 and authorized another $10 billion for the following 10 years through 2029. Over the last decade, Centers for Medicare & Medicaid Services (CMS) has used CMMI to administer several demonstrations, including the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) and the follow-on Pioneer ACO program.

IMPLEMENTING THE ASTHMA IMPAIRMENT AND RISK QUESTIONNAIRE (AIRQ®) AND ASTHMA CHECKLIST INTO DIVERSE CLINICAL PRACTICES

<h3>Introduction</h3> The Asthma Impairment and Risk Questionnaire (AIRQ®) is a 10 item, yes/no, impairment- and risk-based control assessment. Scores of 0-1 indicate well-controlled (WC), 2-4 not-well controlled (NWC), and 5-10 very poorly controlled (VPC) asthma. The Asthma Checklist is a decision support tool designed to facilitate implementation of Guideline and Expert Report recommendations into practice at point-of-care. <h3>Methods</h3> 840 patients with asthma aged ≥13 years completed AIRQ® at the start of a practice implementation study in primary care (n=6), specialty practice (n=6), and an educational asthma coaching program (n=1). Clinicians/educators reviewed AIRQ® responses with their patients in face-to-face or telehealth visits and indicated which Asthma Checklist items they planned to address. Items chosen were compared among AIRQ® control levels and practice types (Chi-square, p≤0.05). <h3>Results</h3> 70.5% were female; age 45.4(±18.4) years; AIRQ®: 42.3% WC, 31.5% NWC, 26.2% VPC. Adherence and appropriate therapy were assessed for the majority of patients, regardless of control (<b>TABLE</b>). Overall and individually for primary and specialty care, all other Asthma Checklist items were assessed more frequently with worsening control (p<0.01, for each). Aside from phenotyping, evaluating alternative diagnoses/hidden comorbidities, and considering advanced/add-on therapies, the educational coaching program assessed more Asthma Checklist items (p<0.01 for each) without regard for control level. <h3>Conclusion</h3> The asthma educational coaching program addressed more concepts from the Asthma Checklist; whereas primary care and specialty clinicians' assessments were more targeted to control level. Longitudinal follow-up is planned to determine the impact of implementing AIRQ® and Asthma Checklist into primary and specialty practices.

Milestones 2.0: An advancement in competency-based assessment for dermatology.

In 2013, Next Accreditation System and Milestones became the competency-based assessment framework required for all specialties accredited by the Accreditation Council for Graduate Medical Education. Dermatology residency programs implemented Milestones 1.0 in the 2013-2014 academic year. The Accreditation Council for Graduate Medical Education committed to review and revise Milestones 1.0 within 3 to 5 years. Subsequently, feedback from key stakeholders influenced the goals for revision, including reducing complexity, enhancing community engagement, and providing additional resources for programs. In 2019, the Dermatology Milestones 2.0 work group streamlined the specialty-specific patient care and medical knowledge subcompetencies. The harmonized milestones allowed for greater uniformity across specialties in systems-based practice, practice-based learning and improvement, professionalism, and interpersonal communication and skills. The work group developed a supplemental guide with specialty-specific context to help program directors, clinical competency committee members, and other faculty understand individual milestones. Dermatology Milestones 2.0 reduces the number of subcompetencies from 28 to 21. Milestones 2.0 represents an advancement in competency-based assessment for dermatology. The first year of reporting for Dermatology Milestones 2.0 is 2021.

Barriers to the Maintenance of COVID 19 Cross Infection Control Protocols among Medical and Dental Practitioners

Objective: To determine the barriers to the maintenance of COVID 19 cross infection control protocols among medical and dental practitioners Methodology: A cross sectional study was conducted in College of Dentistry, Sharif Medical and Dental College, Lahore from July 2021 to July 2022 on medical and dental practitioners. The sampling technique employed was convenient sampling. Medical and dental practitioners irrespective of their age, gender and specialty of practice were included in the study. Data was collected using a pre-validated questionnaire with a Cronbach alpha value of 0.7. Results: There was s statistically significant difference in the scores of barriers to maintenance of COVID 19 cross infection control protocols of overcrowding in the hospital (p= ≤0.001), limitation of infection control material (p=≤0.001), insufficient training in infection control (p=0.05), lack of handwashing (p=0.022), not wearing a mask while examining the patient (p=≤0.001) and lack of knowledge about mode of transmission of COVID 19 (P=0.036) Conclusion: The barriers faced to maintenance of cross infection control protocols pertaining to the hospital administration were reported to be higher for medical practitioners in comparison to the dental practitioners. The barriers faced to maintenance of cross infection control protocols pertaining to the attitude and practices of health care workers were also higher for medical practitioners in comparison to the dental practitioners. Keywords: Cross infection control, COVID 19 pandemic, medical practitioners, dental practitioners

Comorbidity and medication use in patients with angina due to a coronary vasomotion disorder

Abstract Background Microvascular angina and vasospastic angina are disorders of coronary vasomotion. The associations between these conditions, comorbidity and medication use in relatively unselected populations is not well described. Aim To describe the proportions of patients with concomitant morbidity and related medication use in an international, contemporary, clinical database. Methods TriNetX, a global federated health research network with access to anonymized electronical medical records (EMRs) from participating healthcare organizations including academic medical centres, specialty physician practices, and community hospitals, predominantly in the USA was used. The ICD10 code (I20.1) representing “Angina pectoris with documented spasm” was used as a primary search term. ICD10 codes were also used for cardiorenal and metabolic conditions. Medication use was classified as occurring prior to or on the date of the angina episode. The time-period for defining the analysis population was 01.01.2017–31.12.2019. The population age was ≥18 years. Results Data were available on 12,200 individuals (mean (SD) age 63 (13) years; 63% female). The % of individuals with a concomitant diagnosis is described in Table 1. Hypertension occurred in almost two thirds of individuals, an anxiety disorder affected more than one quarter and type 2 diabetes and/or obesity occurred in one fifth. Medication use is described in Table 2. Half of patients received a calcium channel blocker therapy. Nitroglycerin, beta-blockers, and isosorbide mononitrate were less commonly used (45%, 45% and 23%, respectively). Most (58%) patients were prescribed an antacid. Half of patients received statin treatment (50% overall; 36% atorvastatin) and insulin (12%) and metformin (9%) were the most commonly prescribed antidiabetic medications. Conclusions Angina associated with coronary spasm associates with female sex and cardio-metabolic risk factors. Contemporary pharmacotherapy for diabetes and statins appear to be under-used. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): AstraZeneca

S278 Assessing Adherence to Recommending 10-Year Intervals After Normal Screening Colonoscopy in Average-Risk Individuals Based on Specialty and Practice Status

Introduction: After a normal average-risk CRC screening colonoscopy, endoscopists should recommend repeat screening in 10 years. Target is 90% adherence per guidelines, and this has been a priority quality indicator for CMS Medical Incentive Payment System and the ACPs Choosing Wisely Program. Our 2017 quality improvement (QI) project showed poor adherence (less than 40%) among private gastroenterologists and academic surgeons. Prior to commencing a new QI initiative, this project assessed frequency of adherence in 2021 at a single site. Methods: Inclusion criteria: To minimize confounders, patients were limited to: (a) average-risk, 50-82 year old; (b) colonoscopy performed in 2021; (c) sole indication of CRC screening; (d) no biopsy, polypectomy, or reference to abnormal findings on procedure report. Study Setting: Hospital-based “open” endoscopy suite (i.e., utilized by academic/private gastroenterologists and academic surgeons) at an academic tertiary care center. Primary Outcome: Adherence to guideline intervals defined as repeat colonoscopy in 10 years, discontinuation of CRC screening due to patient’s age when bowel preparation is adequate or repeat colonoscopy within 1 year if bowel preparation is poor/inadequate. Adherence rates stratified by specialty and type of practice: academic gastroenterologist (n = 7), academic surgeon (n = 3), or private gastroenterologist (n = 6). Differences in adherence between groups assessed using chi-square analysis. Results: Among 465 eligible patients, mean age was 60.1 +/- 8.2 years, 38.5% male, and 76.8% African American. Adherence surpassed target of 90% adherence for academic gastroenterologists (total=96.0%) with (96.9%) or without GI fellows (88.9%) and was superior to adherence by private gastroenterologists or academic general surgeons (p < 0.001). The latter two groups were adherent in 32.4% and 42.3%, respectively (Figure). Adherence was significantly better with good/excellent bowel preps (71.8%) compared to other bowel prep categories (p< 0.001), and patients with poor, fair, or no documentation of prep were adherent in 42.1% (Table). Conclusion: In this project, adherence among academic gastroenterologist met guideline-specified target of 90% when a gastroenterology fellow participated in the procedure. In all other groups, adherence did not meet the recommended threshold. These data are similar to our 2017 QI project and identify an excellent opportunity for a quality intervention educational and monitoring project to improve performance.Figure 1.: Adherence to Guidelines per Endoscopic Specialty Table 1. - Adherence to Recommended Intervals stratified by Bowel Preparation Bowel Preparation Adherence to Recommended Intervals* P-value No Documentation 42.9% (9/21) < 0.001 Poor/Inadequate 62.2% (28/45) Fair 19.5% (8/41) Good/Excellent 71.8% (257/358) *Adherence to recommended intervals by guidelines defined as a 10-year repeat colonoscopy recommendation if colonoscopy was normal in an average-risk individual, < 1 year was recommended if the bowel preparation was inadequate, or repeat colonoscopy not recommended if patient was ≥66 years at time of normal colonoscopy.

Searching for the Family Doctor

Searching for the Family Doctor

The Future of Assessing Frailty in the Patient With Advanced Heart Failure: A Review of Current Literature.

Frailty is becoming an important component of health care outcomes in patients with a diagnosis of heart failure. A literature search was completed to determine whether a best practice guideline existed to assess frailty in patients who were considering ventricular assist device placement. The literature search revealed that best practice guidelines did not exist. A second comprehensive literature search was completed specifically for frailty including the definition, criteria, assessment, and outcomes. The studies revealed that there were challenges with defining frailty, the age of frailty, assessments tools, and study designs. Cardiologists are primarily interested in screening for frailty, but other physician specialty practices are interested in a frailty screening tool as well. This article discusses the inconsistent research studies and the need for a valid and reliable tool to assess for frailty. It is important that nurse leaders and those working with heart failure patients determine the best practice guidelines for assessing frailty.

Knowledge, Attitude and Practices of Medical and Dental Practitioners Regarding COVID 19 Pandemic

Objective: To assess the knowledge, attitude and practices of medical and dental practitioners regarding COVID-19. Methodology: A cross sectional study was conducted in College of Dentistry, Sharif Medical and Dental College, Lahore from July 2021 to July 2022 on medical and dental practitioners. Medical and dental practitioners irrespective of their age, gender and specialty of practice were included in the study. Participants who refused to give consent to be included in the study were excluded. Informed consent was taken from the participants before data collection. Data was collected using a pre-validated questionnaire Results: There was a statistically significant difference in the scores of attitude (p=≤0.001) and practices (p=≤0.001) while the non-significant difference in the scores of knowledge (p=0.200) across medical and dental practitioners regarding COVID-19 pandemic. Conclusion: The level of knowledge, attitude and practices of dental practitioners was higher in comparison to the medical practitioners. Keywords: COVID 19 pandemic, Dental practitioners, medical practitioners, knowledge, attitude, practice

Infrastructural Limitations in Establishing Neurosurgical Specialty Services in Liberia.

IntroductionLiberia recently employed the first neurosurgeon in the country’s history. In a country with a population of 4.7 million people and staggering rates of cranial and spine trauma, as well as hydrocephalus and neural tube defects, neurosurgery is considered a luxury. Our study documents the experience of a team of neurosurgeons, critical care nurses, scrub technicians, nurses, and biomedical engineers who carried out a series of neurosurgical clinics and complex brain and spine surgeries in Liberia. Specifically, we aim to highlight some of the larger obstacles, beyond staff and equipment, facing the development of a neurosurgical or any other specialty practice in Liberia. MethodsOur institutions, in collaboration with the Korle-Bu Neuroscience Foundation, spent 10 days in Liberia, based in Tappita, and performed 18 surgeries in addition to seeing several hundred clinic patients. This is a retrospective review of the cases performed along with outcomes to investigate obstacles in providing neurosurgical services in the country.ResultsBefore arriving in Liberia, we evaluated, planned, and supplied staff and materials for treating complex neurosurgical patients. Sixteen patients underwent 18 surgeries at a hospital in Tappita, Liberia, in November 2018. Their ages ranged from 1 month to 72 years (average 20 years). Five patients (28%) were female. Ten patients (56%) were under the age of 18. Surgeries included ventriculoperitoneal shunting (VP-shunt), lumbar myelomeningocele repair, encephalocele repair, laminectomy, and a craniotomy for tumor resection. Ten patients (55%) underwent VP-shunting. Two patients (11%) had a craniotomy for tumor resection. Three patients (17%) had laminectomy for lumbar stenosis. Two patients (11%) had repair of lumbar myelomeningocele.ConclusionAfter an aggressive and in-depth approach to planning, conducting, and supplying complex neurosurgical procedures in Liberia, the greatest limiting factor to successful outcomes lie in real-time is access to health care, which is largely limited by overall infrastructure. Our study documents the experience of a team of neurosurgeons, critical care nurses, scrub technicians, nurses, and biomedical engineers who carried out a series of neurosurgical clinics and complex brain and spine surgeries in Liberia. Specifically, we aim to highlight some of the larger obstacles, beyond staff and equipment, facing the development of a neurosurgical or any other specialty procedural practice in the country of Liberia. Most notably, we focus on infrastructure factors, including power, roads, water, education, and overall health care.

Curricular course for medical students at a hematology and oncology specialty practice, 2010-2022.

Aim: For several years now, medical students have also been taught general practice at academic medical teaching practices. Specialty practices have not yet been included in the curricular education. Since 1998, we have conducted a block seminar in hematology twice per semester for eighth-semester medical students. This block seminar was offered from 1998-2001 to students at the Philipps University in Marburg and since 2001 to students at the Johannes Gutenberg University in Mainz. Since 2010 our block seminar has been part of the curriculum at the Johannes Gutenberg University.Method: Standardized course evaluation by students who had attended our block seminar between January 2010 and March 2022. Courses that were held virtually due to corona were not included in the analysis. The questionnaire used to evaluate courses in the medical degree program at the Johannes Gutenberg University served as the evaluation instrument.Results: Since 1998 more than 1,000 students have attended our seminar. The systematic evaluation of the course by 500 students who participated in the curricular, classroom-based seminar sessions since 2010 shows that the highest ratings possible are given for practical relevance, learning atmosphere, teaching and effectiveness.Conclusion: High quality in teaching curricular courses to medical students at a specialty practice is possible. Insights into the possibilities connected with working in the outpatient setting at a medical practice broadens students’ experience. This teaching format facilitates external university instructors in terms of teaching and, at the same time, relieves the university in terms of staff and financial budget.

Outcomes of a Data-Driven Physician Practice Redesign.

This study evaluated a practice redesign to improve access into a specialty practice. The secondary goal was to improve financial performance, while avoiding an increase in physician burnout. Historical demand was utilized to calculate capacity. Next, data-driven schedules were developed for this practice. We also transitioned schedules from five 8-hour to four 10-hour workdays. Access was improved for news (100% increase), consultations (16% increase), and procedures (70% increase). Gross revenue increased by 10.62% and physician burnout reduced by 25%. This project offers insights into improving the efficiency of a resource-constrained practice, while improving financial performance and reducing burnout.

Medical futility is commonly encountered in small animal clinical practice.

To document veterinarians' perceptions and understanding of medical futility and determine the frequency with which medical futility occurs in small animal practice. 477 veterinarians in small animal general and specialty veterinary practice. A cross-sectional study was performed with a 25-question, web-based, confidential, anonymous survey distributed through various professional veterinary specialty associations. Nearly all respondents (469/474 [99.0%]) believed that futile care occurs in veterinary medicine, and 42.4% (201/474) felt it occurred commonly (> 6 times/y). A similar percentage (471/475 [99.2%]) reported encountering futile care within their careers, and 85.0% (402/476) reported encountering it within the past year. A majority (293/477 [61.4%]) reported witnessing futile care occurring in both inpatient and outpatient settings. Most respondents disagreed or strongly disagreed (320/463 [69.1%]) with a statement that providing futile care is always wrong, and only 38 (8.2%) agreed or strongly agreed. Over 70% (329/464 [70.9%]) of respondents agreed that there are situations in which provision of futile care is appropriate. The importance of reaching a consensus definition for medical futility in veterinary medicine is evident given the frequency with which such care is being provided. Most small animal specialist veterinarians will encounter futile care, and the establishment of an ethical framework to navigate questions surrounding medical futility may help reduce moral distress.

Need and baseline for harmonising nursing education in respiratory care: preliminary results of a global survey.

The COVID-19 pandemic confirmed that respiratory nurses are critical healthcare providers. Limited knowledge is available about appropriate education to prepare nurses to deliver high-quality respiratory care. A survey was developed by the International Coalition for Respiratory Nursing (ICRN) group to identify the need for a respiratory nursing core curriculum. A 39-item survey was distributed to 33 respiratory nursing experts in 27 countries. Questions asked about current roles, perception of need, expectations for a core curriculum project and respiratory content in nursing education in their countries. 30 responses from 25 countries were analysed; participants predominantly worked in academia (53.3%, 16/30) and clinical practice (40%, 12/30). In total, 97% (29/30) confirmed a need for a core respiratory nursing curriculum. Post-registration nursing programmes at bachelor (83.3%, 25/30) and masters (63.3%, 19/30) levels include internal/medical nursing care; less than half identified separate respiratory nursing content. The core educational programme developed should include knowledge (70%, 21/30), skills (60%, 18/30), and competencies (50%, 15/30), with separate paediatric and adult content. Survey results confirm a wide variation in nursing education and respiratory nursing education across the world, with many countries lacking any formal educational programmes to prepare nurses capable of providing enhanced quality respiratory care. These findings support the need for a core respiratory curriculum. To advance this significant work the ICRN group plans to conduct a Delphi study to identify core curriculum requirements for respiratory nursing education at pre-registration and advanced educational levels to flexibly meet each country's specific educational requirements for recognition of respiratory nursing speciality practice.

Commercial business and partnership aspects of general practice: the learning needs of First5 general practitioners in NHS Scotland–a qualitative study

ObjectivesTo identify the learning needs of recently qualified general practitioners (GPs) (First5) in National Health Service (NHS) Scotland concerning GP partnership and the commercial business aspects of general practice. It...

Challenges Facing Introduction of Communication Skills into Medical Education in Iraq

Introduction: Communication skills “CS” have no clear curriculum in most Iraqi medical colleges. This shortcoming of education is reflected in a doctor-centered approach in Iraq. Aim: To identify challenges facing introduction of CS into medical education in Iraq. Methods: Feedback form including the main challenges on introducing CS was distributed online to healthcare professionals who have participated in training of CS courses. Results: Ninety-three healthcare professionals responded; 55 males and 38 females; 46 faculty members and 47 practitioners with part-time teaching. Doctors constituted 92 % of the respondents from different disciplines, and 75.2% had more than 15 years’ experience in practice. Frequency of educational and practical challenges were 40% and 44% respectively. Lack of appropriate curriculum constitutes 42% of educational challenges. Challenges include doctors&apos; training in western models which are difficult to transform the interview into a dialogue that harmonizes Iraqi culture and social barriers (16% of respondents). A biomedical approach (22%) and lack of resources (22%) presented other challenges, while 14% of the participants mentioned high proportion of students to faculty members. Challenges related to practice includes a doctor-centered approach (47%) and neglect of patients&apos; psychosocial needs (30%). Factors related to patients revealed that 46% of the challenges were related to health literacy and 26% to patients’ behavior for seeking medical advice. The presence of more than one person at interview was the most difficult factor for successful interview (14%), in addition to the passive role of the patient during interview (13%). There is no significance statistical difference in challenges in relation to specialty, workplace, sex and years of practice. Conclusion: Multiple levels of challenges facing introduction of CS into medical education were revealed which need systematic review in the educational curricula and practice of medicine.

Barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families: Report from a U.S. regional collaborative.

Sickle cell disease (SCD) is an inherited blood disorder that affects about 100,000 people in the U.S., primarily Blacks/African-Americans. A multitude of complications negatively impacts quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD, but is underutilized. Negative and uninformed perceptions of hydroxyurea and barriers to its use hinder adherence and promotion of the medication. As the largest real-world study to date that assessed hydroxyurea use for children and adults with SCD, we gathered and analyzed perspectives of providers, individuals with SCD, and families. Participants provided information about socio-demographics, hospital and emergency admissions for pain, number of severe pain episodes interfering with daily activities, medication adherence, and barriers to hydroxyurea. Providers reported on indications for hydroxyurea, reasons not prescribed, and current laboratory values. We found that hydroxyurea use was reported in over half of eligible patients from this large geographic region in the U.S., representing a range of sickle cell specialty clinical settings and practices. Provider and patient/caregiver reports about hydroxyurea use were consistent with one another; adults 26 years and older were least likely to be on hydroxyurea; and the likelihood of being on hydroxyurea decreased with one or more barriers. Using the intentional and unintentional medication nonadherence framework, we found that, even for patients on hydroxyurea, challenges to taking the medicine at the right time and forgetting were crucial unintentional barriers to adherence. Intentional barriers such as worry about side effects and “tried and it did not work” were important barriers for young adults and adults. For providers, diagnoses other than HgbSS or HgbS-β0 thalassemia were associated with lower odds of prescribing, consistent with evidence-based guidelines. Our results support strengthening provider understanding and confidence in implementing existing SCD guidelines, and the importance of shared decision making. Our findings can assist providers in understanding choices and decisions of families; guide individualized clinical discussions regarding hydroxyurea therapy; and help with developing tailored interventions to address barriers. Addressing barriers to hydroxyurea use can inform strategies to minimize similar barriers in the use of emerging and combination therapies for SCD.

Development of humanistic nursing practice guidelines for stroke patients.

PurposeTo construct humanistic nursing practice guidelines suitable for stroke patients.DesignThis study was a development and validation study of guidelines using multiple methods, including literature review, qualitative research, questionnaire survey, thematic discussion, and Delphi expert consultation.MethodsTwenty-five experts from seven provinces and municipalities in China were interviewed over two rounds from December 2020 to February 2021. The first-level index was scored for importance and rationality, while the second-level index was scored for importance and feasibility using a five-point Likert scale. Delphi data was collected via a paper version of the questionnaire. The coefficients of variation and coordination were used to represent the degree of dispersion of expert opinions.FindingsIn the two rounds of letter consultation, the questionnaire's recovery and effective rates were both 100%, while the opinion submission rates of the two rounds were 84 and 52%, respectively. Moreover, the expert authority coefficient was 0.91, and the coordination coefficients of expert opinions in the first round were as follows: importance of 0.03 and rationality of 0.07 for the first-level index; importance of 0.09 and feasibility of 0.11 for the secondary index. In round two, the coordination coefficients of expert opinions were as follows: importance of 0.04 and rationality of 0.05 for the first-level indicators; importance of 0.12 and feasibility of 0.10 for the secondary index. The results for the secondary index were P < 0.001 for the two rounds. The humanistic nursing practice guidelines for stroke patients that were ultimately formed included five first-level indicators (physiological care, safety care, emotional care, dignity care, and rehabilitation needs) and 46 s-level indicators.ConclusionOur results show that the “Practice Guidelines for Humanistic Nursing for Stroke” established by experts adopts Maslow's hierarchy of needs as its structural framework. It meets people's basic needs and can provide a reference for the construction of a humanistic nursing specialty practice for stroke patients.Clinical relevanceHumanistic nursing guidelines for stroke could provide a reference for the construction of humanistic nursing practice in the stroke specialty.Clinical resourcesCopeptin and long-term risk of recurrent vascular events after transient ischemic attack and ischemic stroke: population-based study https://pubmed.ncbi.nlm.nih.gov/26451023/. Effectiveness and usage of a decision support system to improve stroke prevention in general practice: a cluster randomized controlled trial https://pubmed.ncbi.nlm.nih.gov/28245247/. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association https://pubmed.ncbi.nlm.nih.gov/27145936/.