System-level Strategies Research Articles

A “Sense”-ational HPV Vaccination Quality Improvement Project in a Family Medicine Residency Practice

BackgroundHuman papillomavirus (HPV) vaccination uptake for adolescents and young adults in the United States remains far from national goals. Using a multi-component intervention aligned with community-wide efforts, we implemented a quality improvement project to increase HPV vaccinations among 9-26 year-old male and female patients in an urban, low income, minority population family medicine residency practice. MethodsThe pre-intervention year was November 2, 2014 to October 31, 2015 and the intervention year was November 1, 2015 to October 31, 2016. Based on community input and published literature, the interventions were creative, practice-specific provider-, patient-, and system-level strategies. To compare pre- and post-intervention vaccinations, HPV vaccination data were extracted from an electronic medical record request for age-eligible patients seen in the practice during the intervention year. Chi-square, McNemar’s and 2-tailed, 2-sample Z tests were used to test differences in vaccination initiation (≥1 dose) and completion (3 doses) across groups and over time. ResultsDespite high pre-intervention rates (58% and 75%), HPV vaccine initiation significantly increased 12.8 percentage points (PP) for males and 10.6 PP for females from pre- to post-intervention (P < 0.001). HPV vaccine completion also significantly increased 16 PP for males and 10.9 PP for females (P < 0.001). Young adult patients (18-26 years-old) had significant increases in completion rates (9.9 PP; P < 0.001), not observed among adolescents (20 PP; ns). ConclusionsConsistent and abundant positive HPV vaccination messaging, low-cost sensory rewards, process change, and community, clinician, and nonclinical staff engagement were associated with higher HPV vaccine initiation and completion, especially among young adults.

The (t, k)-diagnosability of shuffle-cubes under PMC model

ABSTRACTSystem-level diagnosis aims to identify faulty processors in a multiprocessor system by analysing the test results among the processors. The -diagnosis requires to identify and repair at least k faulty processors in each iteration until that all t faulty processors are found where . It is one of the most important system-level diagnosis strategies. Meanwhile, shuffle-cube , a variant of hypercube for multiprocessor systems, has some good combinatorial properties and fault-tolerant properties. In this paper, we propose a -diagnosis algorithm for n-dimensional shuffle-cube , and then we show that is -diagnosable. Moreover, we prove that the proposed algorithm can identify at most faulty nodes under the condition that it can identify at least n faulty nodes in each iteration.

Factors contributing to racial disparities in influenza vaccinations.

BackgroundRacial/ethnic disparities in rates of influenza vaccinations in the US remain an issue even among those with access, no out-of-pocket costs, and after adjusting for confounders. We used an approach called the Oaxaca-Blinder (OB) decomposition method to ascertain the contribution of covariates individually and in aggregate to the racial disparity in influenza vaccination.MethodsWe included members > = 18 years of age as of 05/01/2014 with continuous enrollment through 04/30/2015. Influenza vaccination was defined by diagnosis, procedure, or medication codes, or documentation in the immunization table. Characteristics were reported by race. Logistic regression models estimated the odds of vaccination associated with: (1) race; and (2) covariates stratified by race. The Oaxaca-Blinder (OB) method calculated the contribution of covariates to the difference or disparity in vaccination between Blacks and Whites.ResultsWe found that among adults, 44% were vaccinated; 55% were Black; and 45% were White. Black members have 42% lower odds of vaccination than White members. The contribution of the differences in the average value of the study covariates between Black and White members (the OB covariate effect) accounted for 29% of the racial disparity. The contributions to the total White-Black disparity in vaccination included: age (16%), neighborhood median income (11%), and registration on the online patient portal (13%). The contribution of the differences in how the covariates impact vaccination (OB coefficient effect) accounted for 71% of the disparity in vaccination between Blacks and Whites.ConclusionIn conclusion, equalizing average covariate values in Blacks and Whites could reduce the racial disparity in influenza vaccination by 29%. For health system vaccine campaigns, improving registration on the patient portal may be a target component of an effective system-level strategy to reduce racial disparities in vaccination. Additional information on patient-centered factors could further improve the value of the OB approach.

Characterization of Biometric Template Aging in a Multiyear, Multivendor Longitudinal Fingerprint Matching Study

Biometric features are known to change over time, presenting a challenge for their use in identity management systems. Viewed as an instrumentation and measurement problem, these changes represent a potential source of measurement or calibration error that needs to be addressed at the system level in order to guarantee performance over the lifetime of the system. In this paper, we develop a novel metric, biometric permanence, to characterize the stability of biometric features. First, we define permanence in terms of the change in a false nonmatch rate (FNMR) over a repeated sequence of enrollment and verification events for a given population. However, since changes in the FNMR are expected to be small, any variability in the biometric capture over time will camouflage the changes of interest. To address this issue, we propose a robust methodology that can isolate the visit-to-visit variability and substantially improve the estimation. We develop and characterize a heuristic statistical model for a biometric capture system, and apply it to a large data set of fingerprint biometrics collected over a period of seven years on a variety of commercially available capture devices. We discuss how this methodology can be used to isolate the effect of biometric template aging and to develop system-level strategies for dealing with it.

Strategies to Improve Follow-up After Positive Fecal Immunochemical Tests in a Community-Based Setting: A Mixed-Methods Study.

OBJECTIVES:The effectiveness of fecal immunochemical test (FIT) screening for colorectal cancer depends on timely colonoscopy follow-up of positive tests, although limited data exist regarding effective system-level strategies for improving follow-up rates.METHODS:Using a mixed-methods design (qualitative and quantitative), we first identified system-level strategies that were implemented for improving timely follow-up after a positive FIT test in a large community-based setting between 2006 and 2016. We then evaluated changes in time to colonoscopy among FIT-positive patients across 3 periods during the study interval, controlling for screening participant age, sex, race/ethnicity, comorbidity, FIT date, and previous screening history.RESULTS:Implemented strategies over the study period included setting a goal of colonoscopy follow-up within 30 days of a positive FIT, tracking FIT-positive patients, early telephone contact to directly schedule follow-up colonoscopies, assigning the responsibility for follow-up tracking and scheduling to gastroenterology departments (vs primary care), and increasing colonoscopy capacity. Among 160,051 patients who had a positive FIT between 2006 and 2016, 126,420 (79%) had a follow-up colonoscopy within 180 days, including 67% in 2006–2008, 79% in 2009–2012, and 83% in 2013–2016 (P < 0.001). Follow-up within 180 days in 2016 varied moderately across service areas, between 72% (95% CI 70–75) and 88% (95% CI 86–91), but there were no obvious differences in the pattern of strategies implemented in higher- vs lower-performing service areas.CONCLUSIONS:The implementation of system-level strategies coincided with substantial improvements in timely colonoscopy follow-up after a positive FIT. Intervention studies are needed to identify the most effective strategies for promoting timely follow-up.

Lessons Learned to Aid in Developing Fatigue Risk Management Plans for Resident Physicians

Phenomenon: Fatigue is a significant risk factor for deterioration in performance, which may lead to medical errors and reduced well-being in resident physicians (residents). Sleep deprivation, which has been studied extensively, is only one contributor to fatigue. Given the complexity of fatigue and its relationship with resident performance, the National Steering Committee on Resident Duty Hours in Canada recommends that all residency education programs develop a fatigue risk management plan (FRMP) for their residents. The purpose of this study was to explore the impact of residents’ experiences of fatigue and the strategies they use to manage it. Approach: This single-site study investigated the perceptions of resident physicians. Residents were recruited through purposive sampling to ensure representation from a variety of programs, postgraduate year level, and gender. Recruitment was managed with support from the residency programs; however, data collection and analysis were conducted by the Office of Postgraduate Medical Education to ensure participant anonymity. Program directors and administrators assisted in relaying the information about the study to the residents; however, they were not made aware if their residents participated in the study. Interview and focus group data were collected all at once, then transcribed, and then subsequent thematic analysis of these data was conducted using a quasi-constant comparison approach until thematic saturation was reached. Two researchers coded the data using thematic content analysis. Findings: Fifty-seven residents participated in a focus group or interview. There was representation from more than half of the 58 residency programs and from 15 of 16 departments. Overall, there was consensus that fatigue impacts residents’ physical, cognitive, and emotional states. These impacts were reported as influencing resident performance including those related to patient care. Residents reported that fatigue led them to be less productive in their personal and professional lives. Three major themes were identified for which strategies could be developed for fatigue risk management: self, program, and system. Together with self-, program-, and system-level strategies that complement and enhance each other, specific targeted FRMPs could be developed. Insights: Fatigue is a multifaceted phenomenon experienced by residents that requires management beyond extended duty hours and adequate amounts of sleep. FRMPs that encompass strategies used by the resident, the residency-training program, and the healthcare system in which they work could assist with managing fatigue in residents and support enhanced resident well-being and patient care.

Design of polydopamine-encapsulation multiporous MnO cross-linked with polyacrylic acid binder for superior lithium ion battery anode

Investigating independent active materials is inadequate to settle the technological challenges involved in the booming lithium ion battery industry. The further development of energy-storage properties with both high energy density and superior cycling lifespan are highly dependent on the overall system optimization, which highlights the study of the interface between different components in a system. Herein, a system-level strategy of engineering MnO-based anode build on the plentiful electrolytic manganese dioxide are developed via a microwave-assisted carbothermic reduction, combined with a succeeding in-situ aggregation of polydopamine (PD) onto MnO along with chemical binding with polyacrylic acid (PAA) binder. Fourier transform IR spectra, X-ray photoelectron spectroscopy spectra validate the formation of cross-linking reaction between the PD buffer and PAA binder. Benefited from the prominent structure stability which endowed by well-connected three-dimensional porous structure, as well as two steady interfaces between MnO and PD buffer and between PD buffer and PAA binder, the cross-linked MnO anode exhibit a reversible capacity of 687 mAh g−1 at 300 mA g−1 and high Coulombic efficiency of 99% over 500 cycles and impressive rate capability of 320 mAh g−1 at 3000 mA g−1.

396: Medication adherence in women with gestational diabetes and its effect on pregnancy outcomes

Treatment of gestational diabetes (GDM) is associated with improved pregnancy outcomes. Obstacles to taking prescribed medications can lead to non-compliance. The objective was to determine the challenges that lead to low medication adherence and whether this increases the rate of adverse pregnancy outcomes in women with GDM. A prospective, observational study was performed of women with GDM treated with metformin, glyburide or insulin at a tertiary care center. Women greater than 16 weeks gestation and treated for a minimum of 2 weeks were included. Women with pre-DM were excluded. Women completed a validated survey, MMAS-8 (low: score <6 and high: score 7-8), to identify women with low and high medication adherence. Information resulting in medication compliance was collected. The primary outcome was neonatal birth weight >4,000g. Secondary outcomes included factors with medication adherence, adherence rates for each medication and neonatal outcomes. Of 79 women who met study criteria, 42 reported high and 37 reported low adherence. Birth weight >4,000g were similar in each group, (low: 16.2% vs. high: 7.1%, p = 0.292). Women prescribed metformin had the highest rate of high adherence (38.1%) and women on glyburide had the highest rate of low adherence (46%). The rate of neonatal hypoglycemia was significantly higher in women with low adherence compared to high adherence, (low: 70.3% vs high 42.9%, p = 0.023). There were similar rates of induction of labor, cesarean section, NICU admissions, and neonatal respiratory complications. There were no cases of shoulder dystocia, Erb’s palsy, or major neonatal morbidities. Obstacles to medication adherence were documented in 14% of women including prescription error, insurance difficulties and delay in dispensing the medications. Adverse effects to medication were reported in 10-20% of women. Although there were no differences in neonatal birthweight between groups, low medication adherence was associated with neonatal hypoglycemia. Challenges to compliance with prescribed medications occurred in 14% of GDM women and up to 1 in 5 women reported a medication side effects. Further studies are needed to investigate patient-specific and system-level strategies to improve medication adherence in women with GDM.

Electrical power management and optimization with nonlinear energy harvesting structures

In recent years, great advances in understanding the opportunities for nonlinear vibration energy harvesting systems have been achieved giving attention to either the structural or electrical subsystems. Yet, a notable disconnect appears in the knowledge on optimal means to integrate nonlinear energy harvesting structures with effective nonlinear rectifying and power management circuits for practical applications. Motivated to fill this knowledge gap, this research employs impedance principles to investigate power optimization strategies for a nonlinear vibration energy harvester interfaced with a bridge rectifier and a buck-boost converter. The frequency and amplitude dependence of the internal impedance of the harvester structure challenges the conventional impedance matching concepts. Instead, a system-level optimization strategy is established and validated through simulations and experiments. Through careful studies, the means to optimize the electrical power with partial information of the electrical load is revealed and verified in comparison to the full analysis. These results suggest that future study and implementation of optimal nonlinear energy harvesting systems may find effective guidance through power flow concepts built on linear theories despite the presence of nonlinearities in structures and circuits.

Synthesis of Monitors for Networked Systems With Heterogeneous Safety Requirements

Complex embedded systems such as automobiles and IoT-systems feature a wide range of applications with varying degrees of safety relevance. As many applications on these devices interlace more and more, new ways to guarantee sufficient isolation between safety levels become necessary. Previous work only regarded monitoring of timing properties for individual tasks on single resources and neglected functional cause-effect chains. This makes their application costly because nearly every task would require monitoring due to unknown system-level timing dependencies. We present cross-layer dependency analysis of timing properties and system-level synthesis strategies for monitors utilizing a reachability formulation of the problem. Our approach regards distributed cause-effect chains on networked platforms for which the accuracy of timing parameters can vary and heterogeneous safety requirements can be specified.

System-level Trade-offs and Optimization for Data-Driven Applications

Abstract Data-driven applications are becoming increasingly important, fueled by the rapid rise of the Internet of Things (IoT) and Artificial Intelligence (AI). Systems must now be able to store, process and act swiftly on increasingly large amounts of data, while consuming minimum possible power. This shifts the focus to system-level integration and optimization – especially as Moore's Law slows down, and technology development at 5nm and beyond becomes increasingly harder and more expensive. SEMI has built a cross-supply-chain collaborative platform specifically to enable an early assessment of trade-offs and future technologies (5–8 years out). The first project focused on interconnect strategies, which are critical to most computing systems. We examined the performance limits for the best possible options for on-chip interconnects at technology nodes &amp;lt;= 20 nm. These limits highlight the need for system-level strategies, and we studied these by comparing a two-dimensional (2D) system with an interposer-based system (2.5D) to quantify the impact of the latter on the energy-delay product for various applications, especially data-driven ones.

Building an Antibiotic Stewardship Program: An Interactive Teaching Module for Medical Students.

Given the increasing importance of antibiotic stewardship, an understanding of the basic tenets of antibiotic prescribing is critical for all medical students. This engaged learning module focuses on terminology and foundational concepts in antibiotic stewardship while assisting learners with application in their early clinical practice. This module was developed for third-year internal medicine clerkship students at the University of South Dakota, Sanford School of Medicine. The students participated in an introductory discussion of the harms of antibiotic overuse in a large-group format, followed by small-group work to develop a miniature antibiotic stewardship program. Upon completion of the small-group portion, the large group reconvened to share antibiotic stewardship strategies and to complete the session with additional training regarding individual provider and system-level antibiotic stewardship strategies. Approximately 150 students have participated in this module. Through use of the module, students have been highly engaged in identifying antibiotic stewardship interventions in their early practice and creating potential solutions. Themes identified during analysis of one-minute paper responses demonstrated student learning around the rationale for antibiotic stewardship programs, implementation strategies, and patient education. This module was primarily developed for medical students, but it could easily be adapted for use with learners of varying levels. Additionally, it could be implemented as an interprofessional exercise to leverage the expertise of trainees in pharmacy and nursing.

Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana.

BackgroundPoor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage (HIC) alone versus a nurse-led task shifting strategy for hypertension control (TASSH) plus HIC on systolic blood pressure (SBP) reduction among patients with uncontrolled hypertension in Ghana.Methods and findingsUsing a pragmatic cluster randomized trial, 32 community health centers within Ghana’s public healthcare system were randomly assigned to either HIC alone or TASSH + HIC. A total of 757 patients with uncontrolled hypertension were recruited between November 28, 2012, and June 11, 2014, and followed up to October 7, 2016. Both intervention groups received health insurance coverage plus scheduled nurse visits, while TASSH + HIC comprised cardiovascular risk assessment, lifestyle counseling, and initiation/titration of antihypertensive medications for 12 months, delivered by trained nurses within the healthcare system. The primary outcome was change in SBP from baseline to 12 months. Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months. Of the 757 patients (389 in the HIC group and 368 in the TASSH + HIC group), 85% had 12-month data available (60% women, mean BP 155.9/89.6 mm Hg). In intention-to-treat analyses adjusted for clustering, the TASSH + HIC group had a greater SBP reduction (−20.4 mm Hg; 95% CI −25.2 to −15.6) than the HIC group (−16.8 mm Hg; 95% CI −19.2 to −15.6), with a statistically significant between-group difference of −3.6 mm Hg (95% CI −6.1 to −0.5; p = 0.021). Blood pressure control improved significantly in both groups (55.2%, 95% CI 50.0% to 60.3%, for the TASSH + HIC group versus 49.9%, 95% CI 44.9% to 54.9%, for the HIC group), with a non-significant between-group difference of 5.2% (95% CI −1.8% to 12.4%; p = 0.29). Lifestyle behaviors did not change appreciably in either group. Twenty-one adverse events were reported (9 and 12 in the TASSH + HIC and HIC groups, respectively). The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits, if any, of the TASSH + HIC group.ConclusionsProvision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone, among patients with uncontrolled hypertension in Ghana. Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost–benefit analysis.Trial registrationClinicalTrials.gov NCT01802372

Elements of integrated care approaches for older people: a review of reviews

ObjectiveThe World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge...

A mm-Sized Wireless Implantable Device for Electrical Stimulation of Peripheral Nerves.

A wireless electrical stimulation implant for peripheral nerves, achieving >10× improvement over state of the art in the depth/volume figure of merit, is presented. The fully integrated implant measures just 2mm × 3mm × 6.5mm (39mm3, 78 mg), and operates at a large depth of 10.5 cm in a tissue phantom. The implant is powered using ultrasound and includes a miniaturized piezoelectric receiver (piezo), an IC designed in 180 nm HV BCD process, an off-chip energy storage capacitor, and platinum stimulation electrodes. The package also includes an optional blue light-emitting diode for potential applications in optogenetic stimulation in the future. A system-level design strategy for complete operation of the implant during the charging transient of the storage capacitor, as well as a unique downlink command/data transfer protocol, is presented. The implant enables externally programmable current-controlled stimulation of peripheral nerves, with a wide range of stimulation parameters, both for electrical (22 to 5000μA amplitude, ∼14 to 470 μs pulse-width, 0 to 60Hz repetition rate) and optical (up to 23mW/mm2 optical intensity) stimulation. Additionally, the implant achieves 15 V compliance voltage for chronic applications. Full integration of the implant components, end-to-end in vitro system characterizations, and results for the electrical stimulation of a sciatic nerve, demonstrate the feasibility and efficacy of the proposed stimulator for peripheral nerves.

Strategies to support pressure injury best practices by the inter-professional team: A systematic review.

Optimal pressure injury (ulcer) management by the inter-professional team requires appropriate health care system and organisational resources, infrastructure, and policies. A systematic review was conducted on pressure injury care-related education and health care system-/organisation-level strategies. A search for relevant articles published between January 2006 and October 2014 was applied to 8 databases. Ultimately, 22 articles pertaining to education and training and 12 articles pertaining to health care system and organisation supports for pressure injury care were included in the systematic review. A lack of pressure injury assessment and management knowledge by health care professionals was an overriding theme in the education literature. Some of the methods preferred for pressure injury education among nurses and physicians included information technology (eg, e-learning) with technology support and the use of high-quality wound pictures. Although the evidence is scarce, the literature did highlight specific system- and organisation-level barriers and enablers that influence practice change, including inter-professional communication and human resource investments. In conclusion, (1) the current evidence on the education and system-level enablers, barriers, and strategies to optimise pressure injury best practices requires further investigation, and (2) multi-faceted, up-stream, evidence-based approaches for pressure injury care are essential to improve health care and patient-related outcomes.

Electrolytic CO2 Reduction in a Flow Cell.

Electrocatalytic CO2 conversion at near ambient temperatures and pressures offers a potential means of converting waste greenhouse gases into fuels or commodity chemicals (e.g., CO, formic acid, methanol, ethylene, alkanes, and alcohols). This process is particularly compelling when driven by excess renewable electricity because the consequent production of solar fuels would lead to a closing of the carbon cycle. However, such a technology is not currently commercially available. While CO2 electrolysis in H-cells is widely used for screening electrocatalysts, these experiments generally do not effectively report on how CO2 electrocatalysts behave in flow reactors that are more relevant to a scalable CO2 electrolyzer system. Flow reactors also offer more control over reagent delivery, which includes enabling the use of a gaseous CO2 feed to the cathode of the cell. This setup provides a platform for generating much higher current densities ( J) by reducing the mass transport issues inherent to the H-cells. In this Account, we examine some of the systems-level strategies that have been applied in an effort to tailor flow reactor components to improve electrocatalytic reduction. Flow reactors that have been utilized in CO2 electrolysis schemes can be categorized into two primary architectures: Membrane-based flow cells and microfluidic reactors. Each invoke different dynamic mechanisms for the delivery of gaseous CO2 to electrocatalytic sites, and both have been demonstrated to achieve high current densities ( J > 200 mA cm-2) for CO2 reduction. One strategy common to both reactor architectures for improving J is the delivery of CO2 to the cathode in the gas phase rather than dissolved in a liquid electrolyte. This physical facet also presents a number of challenges that go beyond the nature of the electrocatalyst, and we scrutinize how the judicious selection and modification of certain components in microfluidic and/or membrane-based reactors can have a profound effect on electrocatalytic performance. In membrane-based flow cells, for example, the choice of either a cation exchange membrane (CEM), anion exchange membrane (AEM), or a bipolar membrane (BPM) affects the kinetics of ion transport pathways and the range of applicable electrolyte conditions. In microfluidic cells, extensive studies have been performed upon the properties of porous carbon gas diffusion layers, materials that are equally relevant to membrane reactors. A theme that is pervasive throughout our analyses is the challenges associated with precise and controlled water management in gas phase CO2 electrolyzers, and we highlight studies that demonstrate the importance of maintaining adequate flow cell hydration to achieve sustained electrolysis.

Efficient Approach to System-Level Reliability-Based Design Optimization of Large-Scale Uncertain and Dynamic Wind-Excited Systems

AbstractThis paper is focused on the development of an efficient system-level reliability-based design optimization strategy for uncertain wind-excited building systems characterized by high-dimens...

Cost-effectiveness of a complex workplace dietary intervention: an economic evaluation of the Food Choice at Work study

ObjectiveTo evaluate the costs, benefits and cost-effectiveness of complex workplace dietary interventions, involving nutrition education and system-level dietary modification, from the perspective of healthcare providers and employers.DesignSingle-study economic evaluation of...

Addressing Childhood Trauma in School Settings: A Framework for Evidence-Based Practice

Supporting evidence and intervention resources for addressing childhood trauma are growing, with schools indicated as a potentially critical system for service delivery. Multiple points for prevention and intervention efforts in schools are possible, but in this manuscript, we review evidence on trauma-specific interventions targeted to students exhibiting negative symptoms. Trauma-specific interventions with evidence and utility for school-based delivery are highlighted, along with key considerations in selection. In addition, we discuss the potential to maximize the impact of trauma-specific interventions for individual students when delivered as part of a school-wide trauma-informed approach that incorporates system-level prevention and intervention strategies. Future directions for research on trauma-specific interventions and trauma-informed approaches in school settings are discussed.