Use In Patient Care Research Articles

Use of Patient-Reported Outcome Measures in Athletic Training: Common Measures, Selection Considerations, and Practical Barriers.

Current evidence suggests that a low percentage of athletic trainers (ATs) routinely use patient-reported outcome measures (PROMs). An understanding of the perceptions of ATs who use (AT-USE) and who do not use (AT-NON) PROMs as well as any differences due to demographic characteristics (eg, use for patient care or research, job setting, highest education level) may help facilitate the use of PROMs in athletic training. To describe commonly used PROMs by AT-USE, the criteria by which AT-USE select PROMs, and reasons for non-use by AT-NON. Cross-sectional study. Online survey. A convenience sample of 1784 ATs (response rate = 10.7% [1784/17972]; completion rate = 92.2% [1784/1935]) who worked in a variety of settings. Participants completed an anonymous electronic online survey. Descriptive statistics were used to describe commonly used PROMs, PROM selection criteria, and reasons for PROM non-use. Participants were classified as AT-USE (n = 370, 20.7%) or AT-NON (n = 1414, 79.3%). For the AT-USE group, the most common type of PROMs used were specific (eg, region, joint; n = 328, 88.6%), followed by single-item (n = 258, 69.7%) and generic (n = 232, 62.7%). Overall, the PROMs most frequently endorsed by the AT-USE group were the Numeric Pain Rating Scale (n = 128, 34.6%); Lower Extremity Functional Scale (n = 108, 29.2%); Disability of the Arm, Shoulder and Hand (n = 96, 25.9%); Owestry Disability Index (n = 80, 21.6%); and Foot and Ankle Ability Measure (n = 78, 21.1%). The most important criteria reported by AT-USE for selecting PROMs were that the measure was valid and reliable, easy for patients to understand, and easy for clinicians to understand and interpret. Common reasons for non-use were that PROMs were too time consuming for the clinician, too time consuming for the patient, and more effort than they were worth. The Numeric Pain Rating Scale; Lower Extremity Functional Scale; Disability of the Arm, Shoulder and Hand; Owestry Disability Index; and Foot and Ankle Ability Measure were the PROMs most commonly endorsed by AT-USE and should be considered for athletic training use. To further facilitate the use of PROMs in athletic training, future authors should identify strategies to address organizational and time-constraint obstacles. Interpretation of our study findings may require caution due to a relatively low response rate and because "routine use" was not operationalized.

Sociodemographic and Hospital Level Disparities in Palliative Care Utilization Among Terminally Ill Patients with Multiple Myeloma

Background. The National Comprehensive Cancer Network guidelines recommend that physicians discuss end-of-life planning with patients with incurable cancer and a life expectancy of less than 1 year. Integration of palliative medicine approaches to end-of-life care improves quality of life, patient and caregiver satisfaction, and significantly reduces health care costs. However, there is a paucity of data regarding end-of-life and palliative care use in patients with multiple myeloma. This study aimed to evaluate trends in the incidence of palliative care use and explore patient and hospital level disparities in palliative care use in terminally ill patients with multiple myeloma.Methods. We performed a population-based cross-sectional study using data from the Nationwide Inpatient Sample from 2008 through 2014. International Classification of Diseases-9-Clinical Modification codes were used to identify hospitalized patients (aged ≥ 18 years) with multiple myeloma who died in the hospital. Sociodemographic, comorbidities, and hospital level characteristics were compared using chi square tests and independent sample t tests. Trends in palliative care use were assessed using the Cochrane-Armitage test. Multivariate logistic regression analysis was used to create a predictive model of palliative care use.Results. Of the 7789 patients with multiple myeloma who died in the hospital during the study period, 32.5% received palliative care. Utilization of palliative care increased annually, from 17.3% in 2008 to 43.0% in 2014 (trend P < .001). After adjustment for multiple patient and hospital level covariates in logistic regression, we found a lower likelihood of palliative care use in Black race (odds ratio [OR] = 0.72, 95% Confidence Interval [CI] = 0.62 - 0.82), Hispanic race (OR = 0.48, 95% CI = 0.38 - 0.60), and patients with higher Elixhauser comorbidity index (OR = 0.88, 95% CI = 0.86 - 0.91) whereas higher likelihood of palliative care use were found among uninsured patients (OR = 2.17, 95% CI = 1.73 - 2.72) and patients with Do Not Resuscitate (DNR) status (OR = 3.35, 95% CI = 2.97 - 3.78). Independent hospital level correlates of palliative care use included: admission to teaching vs. non-teaching (OR = 1.29, 95% CI = 1.15 - 1.45), admission to larger vs. small sized hospitals (OR = 1.24, 95% CI = 1.05 - 1.46), and admission to hospitals located in Midwest (OR = 1.33 95% CI = 1.14 - 1.54) and West (OR = 1.63, 95% CI = 1.41 - 1.90) vs South.Conclusion: There is a nationally increasing trend in palliative care utilization over the last decade. This study highlights disparities across race/ethnicity, insurance status, geographic region, and other hospital level factors in palliative care use in terminally ill patients with multiple myeloma. While some of the hospital-level disparities can be explained by the relative lack of palliative services in small non-teaching hospitals, barriers to accessing palliative care services needs to be thoroughly investigated and addressed to ensure equal access to this important aspect of care in terminally ill cancer patients. [Display omitted] DisclosuresSanfilippo:Bristol-Myers Squibb: Speakers Bureau.

Healthcare in the Age of Interoperability: The Promise of Fast Healthcare Interoperability Resources.

The first article of this series (see "About This Series") mentioned that, after the success of its new messaging standard for electronic health record (EHR) systems, Health Level 7 (HL7) found it difficult to develop and widely deploy a standard for the rich representation of clinical data for use in patient care. This was due, in large part, to the complexity of medicine and the resulting complexity of the clinical terminologies developed to represent it.

Poor Knowledge of Colorectal Cancer Screening and Surveillance Guidelines in a National Cohort of Digestive Disease Specialists.

Colorectal cancer (CRC) screening is cost-effective and prevents death from CRC if used appropriately. Physicians do not recommend CRC screening according to guidelines. Physician-related factors associated with CRC screening knowledge are unknown. We tested the accuracy of CRC screening knowledge in a nationwide cohort of practicing and trainee physicians and assessed respondent's interest in a mobile app to improve appropriate CRC screening use. An electronic survey was emailed to practicing gastroenterology professionals and medical and surgical trainees. We assessed accuracy of responses compared to CRC screening and surveillance guidelines. We assessed factors associated with higher accuracy of knowledge, frequency of workplace smartphone use, and interest in a smartphone app to aid CRC screening and surveillance recommendations. In total, 1432 responses were received. Hundred percent accuracy was noted in 22% of respondents for screening and 37% for surveillance. Factors associated with higher accuracy of screening guidelines included more recent training completion; academic practice; performing 21-100 colonoscopies per month (vs. < 21 or > 100). Higher accuracy of surveillance guidelines was associated with more recent training completion; academic practice; being a third-year fellow. In total, 53% use smartphones at least "often" in patient care. In total, 87% would use a CRC screening and surveillance smartphone app. Accuracy in applying CRC screening guidelines by gastroenterologists is poor. Smartphone use for patient care is prevalent. Our data show a high interest in a CRC screening/surveillance mobile app. Mobile tools appear an opportunity for rapid access and an increased adherence to CRC screening guidelines.

Three-dimensional (3D) Printed Model to Plan the Endoscopic Treatment of Upper Airway Stenosis.

Endoscopic management of tracheal stenosis may be challenging, especially in the case of complex stenosis placed near the vocal folds, and needing stent placement. Herein, we evaluated the utility of the three-dimensional (3D) airway model for procedural planning in a consecutive series of patients with complex airway stenosis and scheduled for endoscopic treatment. This strategy was applied to 7 consecutive patients with tracheal stenosis unfit for surgery. The model was printed in a rubber-like material, and almost 7 hours were needed to create it. All patients presented respiratory failure with a mean value of 3.4±0.4 Medical Research Council (MRC) dyspnea scale, 47±3.9 forced expiratory volume in 1 second (FEV1%), and an impairment in the 6-minute walking test (6MWT) (mean value, 175±53 m). The mean length of the stenosis was 19±3.4 mm; 3 of the 7 (43%) patients presented a subglottic stenosis. In 4/7 (57%) patients the stenosis was >5 mm, but its treatment required the placement of a stent because of the presence of tracheal cartilage injury. The mean operation time was 22.7±6.6 minutes. No complications were observed during and after the procedure. A significant increase of MRC (3.4±0.4 vs. 1.6±0.5; P=0.003), of FEV1% (47±3.9 vs. 77±9.7; P=0.001), and of 6MWT (175±53 vs. 423±101; P=0.0002) was observed after the procedure (mean follow-up, 11.1±8.8 mo). Our 3D airway model in the management of airway stenosis is useful for procedural planning, rehearsal, and education. The fidelity level of the 3D model remains the main concern for its wider use in patient care. Thus, our impressions should be confirmed by future prospective studies.

Associations Between Physical Therapy Continuity of Care and Health Care Utilization and Costs in Patients With Low Back Pain: A Retrospective Cohort Study.

Patients who consult a physical therapist for low back pain (LBP) may receive initial and subsequent management from different therapists. The impact that physical therapy provider continuity has on health care use in patients with LBP is insufficiently studied. The objective of this study was to examine the impact of continuity of the physical therapy provider on health care use and costs in patients with LBP referred from primary care. The study design included a retrospective analysis of claims data. Data from an all-payer claims database were examined. Logistic regression was used to evaluate the association between physical therapy provider continuity and health care use during the 1-year period following a visit with a primary care provider for LBP. Patients who experienced greater physical therapy provider continuity had a decreased likelihood of receiving lumbar surgery. They also paid less (mean=${\$}$1737 [95% confidence interval, ${\$}$1602-${\$}$1871]) than those who experienced less physical therapy provider continuity (mean=${\$}$2577 [95% confidence interval, ${\$}$2008-${\$}$3145]). The degree of causality between any predictor and outcome variables cannot be determined due to the observational nature of the study. Greater continuity of the physical therapy provider appears to be associated with a decreased likelihood of surgical treatment for LBP and lower health care costs related to LBP.

Depression and Health Care Use in Patients With Inflammatory Bowel Disease

Depression frequently co-occurs in patients with inflammatory bowel disease [IBD] and is a driver in health care costs and use. This study examined the associations between depression and total health care costs, emergency department [ED] visits, computed tomography [CT] during ED/inpatient visits, and IBD-related surgery among IBD patients. Our sample included 331772 IBD patients from a national administrative claims database [Truven Health MarketScan® Database]. Gamma and Poisson regression analyses assessed differences related to depression, controlling for key variables. Approximately 16% of the IBD cohort was classified as having depression. Depression was associated with a $17,706 (95% confidence interval [CI] [$16,892, 18,521]) increase in mean annual IBD-related health care costs and an increased incidence of ED visits (adjusted incidence rate ratio [aIRR] of 1.5; 95% CI [1.5, 1.6]). Among patients who had one or more ED/inpatient visits, depression was associated with an increased probability of receiving repeated CT [one to four scans, adjusted odds ratio [aOR] of 1.6; 95% CI [1.5, 1.7]; five or more scans, aOR of 4.6; 95% CI [2.9, 7.3]) and increased odds of undergoing an IBD-related surgery (aOR of 1.2; 95% CI [1.1, 1.2]). Secondary analysis with a paediatric subsample revealed that approximately 12% of this cohort was classified as having depression, and depression was associated with increased costs and incidence rates of ED visits and CT, but not of IBD-related surgery. Quantifiable differences in health care costs and patterns of use exist among patients with IBD and depression. Integration of mental health services within IBD care may improve overall health outcomes and costs of care.

Reappraisal of Reported Genes for Sudden Arrhythmic Death: Evidence-Based Evaluation of Gene Validity for Brugada Syndrome.

Implicit in the genetic evaluation of patients with suspected genetic diseases is the assumption that the genes evaluated are causative for the disease based on robust scientific and statistical evidence. However, in the past 20 years, considerable variability has existed in the study design and quality of evidence supporting reported gene-disease associations, raising concerns of the validity of many published disease-causing genes. Brugada syndrome (BrS) is an arrhythmia syndrome with a risk of sudden death. More than 20 genes have been reported to cause BrS and are assessed routinely on genetic testing panels in the absence of a systematic, evidence-based evaluation of the evidence supporting the causality of these genes. We evaluated the clinical validity of genes tested by diagnostic laboratories for BrS by assembling 3 gene curation teams. Using an evidence-based semiquantitative scoring system of genetic and experimental evidence for gene-disease associations, curation teams independently classified genes as demonstrating limited, moderate, strong, or definitive evidence for disease causation in BrS. The classification of curator teams was reviewed by a clinical domain expert panel that could modify the classifications based on their independent review and consensus. Of 21 genes curated for clinical validity, biocurators classified only 1 gene ( SCN5A) as definitive evidence, whereas all other genes were classified as limited evidence. After comprehensive review by the clinical domain Expert panel, all 20 genes classified as limited evidence were reclassified as disputed with regard to any assertions of disease causality for BrS. Our results contest the clinical validity of all but 1 gene clinically tested and reported to be associated with BrS. These findings warrant a systematic, evidence-based evaluation for reported gene-disease associations before use in patient care.

An alternative approach to implementing patient-reported outcome measures

BackgroundObtaining patients’ views of their health and outcomes of interventions utilising patient-reported outcome measures (PROMs) is a well-established method, but there is still uncertainty about the impact of PROMs on services and patient care. Studies are now needed of alternative ways of implementing PROMs. This paper describes a case study of the introduction of a new PROM to assess musculoskeletal (MSK) problems, known as the Musculoskeletal Health Questionnaire (MSK-HQ).MethodsFollowing an invitation from the Arthritis Research UK (ARUK), 11 groups and organisations agreed to become ‘partners’ in piloting the MSK-HQ. Twenty-nine interviews and a focus group were carried out with key informants from the partners. Interviews were supplemented with some documentary evidence of partners’ meetings. Data were coded and analysed with NVivo software V.10. Analysis was carried out via a framework method.ResultsParticipants reported positive evidence that the MSK-HQ is feasible and practical for use in patient care with content that helped health professionals identify and address patients’ main presenting problems. Although mediated and reported through health professionals’ judgments, the questionnaire was also seen as very relevant and acceptable to a wide spectrum of patients.There was also broad support for the view that whilst the MSK-HQ is relevant to individual patient care, it could also, when aggregated, reflect the experiences of patients as a group and be used as evidence for third parties concerned with the provision and commissioning of services.The main difficulties revealed by the case study were in the form of logistics and sustainability. It was recognised that electronic systems would be more effective for administration and data processing but they were not feasible to develop and implement within reasonable timelines and available budgets. A sustainable approach to using the PROM required significant long-term commitment of budget, a coherent system, and active support from diverse organisations.ConclusionsThe current study supports the view that a bottom-up approach is a promising method to generate PROM-related insights that are relevant to patients and health professionals. The partnership approach to developing and using PROMs may have wider relevance and potential as a model of implementation.

Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution.

Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.

Gastric Peroral Endoscopic Pyloromyotomy Reduces Symptoms, Increases Quality of Life, and Reduces Health Care Use For Patients With Gastroparesis

Gastric peroral endoscopic pyloromyotomy (GPOEM) is becoming a promising treatment option for patients with refractory gastroparesis. We aimed to systematically assess the efficacy of GPOEM and its effects on health care use. We performed a retrospective study on 30 patients with refractory gastroparesis who underwent GPOEM from June 2015 through July 2017 at a tertiary center. We compared outcomes with those of 7 patients with refractory gastroparesis who did not undergo the procedure (controls). The primary outcomes were patient-reported reductions in symptoms, based on the gastroparesis cardinal symptom index (GCSI), and increases in 8 aspects of quality of life, based on Short Form 36 (SF-36) scores. Data were collected on the day of the procedure (baseline) and at 1 month, 6 months, 12 months, and 18 months afterward. Secondary outcomes included visits to the emergency department or hospitalization for gastroparesis-related symptoms. GPOEM was technically successful in all patients and significantly reduced GCSI scores in repeated-measure analysis of variance (F2.044, 38.838= 22.319; P < .0005). The mean score at baseline was 3.5 ± 0.6, at 1 month after GPOEM was 1.8 ± 1.0 (P < .0005), at 6 months after was 1.9 ± 1.2 (P < .0005), at 12 months after was 2.6 ± 1.5 (P < .026), and at 18 months after was 2.1 ± 1.3 (P < .016). GPOEM was associated with improved quality of life: 77.8%, 76.5%, and 70% of patients had significant increases in SF-36 scores, compared with baseline, at 1 month, 6 months, and 12 months after GPOEM, respectively (F1.71,18.83= 14.16; P < .0005). Compared with controls, patients who underwent GPOEM had significant reductions in GCSI, after we controlled for baseline score and duration of the disease (F1,31= 9.001; P= .005). Patients who received GPOEM had significant reductions in number of emergency department visits (from 2.2 ± 3.1 times/mo at baseline to 0.3 ± 0.8 times/mo; P= .003) and hospitalizations (from 1.7 ± 2 times/mo at baseline to 0.2 ± 0.4 times/mo; P= .0002). In a retrospective study of patients who underwent GPOEM for refractory gastroparesis, we found the procedure significantly improved symptoms, increased quality of life, and reduced health care use related to gastroparesis.

Development and validation of a survey instrument to measure factors that influence pharmacist adoption of prescribing in Alberta, Canada.

Objective:Study objectives were to develop a questionnaire to assess factors influencing pharmacists’ adoption of prescribing (i.e., continuing, adapting or initiating therapy), describe use of pre-incentive and mixed mode survey, and establish survey psychometric properties.Methods:Questions were developed based on prior qualitative research and Diffusion of Innovation theory. Expert review, cognitive testing, survey pilot, and main survey were used to test the questionnaire. Six content experts reviewed the questionnaire to establish face and content validity. Ten pharmacists from diverse practice settings were purposefully recruited for a cognitive interview to verify question readability. Content analysis was used to analyze the results. A pre-survey introduction letter with a monetary incentive was mailed via post to 100 (i.e. pilot) and 700 (i.e., main survey) randomly selected pharmacists. This was followed by an e-mail with a personalized link to the online questionnaire, e-mail reminders, and a telephone reminder if required. The psychometric properties of scales were evaluated with an exploratory factor analysis and Cronbach’s alpha. Scale responses were described.Results:Engagement of six experts and ten pharmacists clarified definitions (e.g., prescribing), terminology, recall periods, and response options for the 34-item response scale. Fifty-six pharmacists completed the online pilot survey. Based on this data, ambiguous questions and routing issues were addressed. Three hundred and seventy-eight pharmacists completed the online main survey for a response rate of 54.6%. The factors analysis resulted in 27 questions in eight scales: (1) self-efficacy, (2) support from practice environment, (3) support from interprofessional relationship, (4) impact on professionalism, (5) impact on patient care), (6) prescribing beliefs, (7) technical use of electronic health record (EHR) and (8) patient care use of the EHR. Prescribing beliefs and technical use of the EHR scales had low reliability while the remaining six scales had strong evidence for reliability and validity.Conclusion:Through a multi-stage process, a survey instrument was developed to capture pharmacists’ perceptions of prescribing influences. This questionnaire may support future research to develop interventions to enhance adoption of prescribing and enhance direct patient care by pharmacists.

Education and Knowledge in Pharmacogenomics: Still a Challenge?

A number of barriers exist for adoption of pharmacogenomics into practice. Physicians, pharmacists, and nurses report limited knowledge about pharmacogenomics and its use in patient care. Lack of pharmacogenomics education curricula as part of professional schools or postgraduate training programs has been reported as a potential cause. Understanding pharmacogenomics is further complicated by a complex and nonstandard lexicon, limited medication guidelines, rapidly changing evidence, and insufficient awareness of test availability and utility.

La terminología ATIC como herramienta de soporte a la gestión

This article is intended to continue the one published in the previous journal issue (“ATIC Terminology: Considerations of use in patient care”). Based on the same theoretical-conceptual framework, and in the healthcare setting, the first article was targeted to placing ATIC from the perspective of patient care, and the objective of this second article is to state the considerations and review the evidence for the use of the ATIC terminology as a support tool for the healthcare and administrative management of patient care. To this aim, there has been an adaptation of the mixed, narrative, adjacent method, where the outcomes of study review are presented sequentially, together with their essential considerations. ATIC offers an adequate support for building data models and standards for patient care provision and management. It also guarantees semantic interoperability, by implementing mapping with those of other controlled vocabularies. It offers an adequate conceptual coverage, and minimizes the underuse effect, with a noticeable level of satisfaction by users. At the same time, it suggests new data models, and orientates emerging formulas for measuring the intensity and complexity of patient care. The evidence supporting and demonstrating the use of ATIC as support tool for patient care management seems to support the scenario that ATIC offers a range of new tools, even though the method used in this article leaves conclusions to be drawn by each reader.

Tru-cut/core Biopsy versus FNAC: Pulmonary Tumors.

Primary lung epithelial malignancies are the most common neoplasms among all pulmonary tumors. Lung cancer (LC) is the leading cause of cancer-related mortality for which a histologic or cytologic confirmation of malignancy is required before treatment. Specimen management is an important task for pathologists in the field of LC. Biopsy and fine needle aspiration are comparable. It is desirable to have both for diagnosis and mutation testing to maximize their use for patient care.

Internet use for patient care and health research: A cross-sectional study among physicians in a teaching hospital of Eastern India.

Background:Internet is the world's largest network of information and communication services. The internet is widely used in medicine and had a significant impact on research, training, and patient care.Objectives:(1) To assess internet use to obtain health information for patient care among physicians of a medical college hospital. (2) To investigate the utilization of the internet during their daily practice and to know the reasons for its use and nonuse.Materials and Methods:A hospital-based cross-sectional study was conducted for a period of 2 months of May and June 2015 in a Medical College Hospital of Eastern India. A convenient sample of 200 physicians was included in the study. Data regarding access of internet in workplace, time spent on the internet for medical and nonmedical purposes, opinions regarding use of the internet to update medical knowledge, obstacles that affect its use, etc., were collected. The data were analyzed using SPSS software version 20.Results:It was seen that 47% doctors use laptop for accessing internet, followed by mobiles (34%). E-mail was the main purpose (41%) of internet use, followed by research (32.5%). Majority told that e-mail was the main purpose of last internet use (46.5%), followed by browsing medical resources (23%), research (15.5%), and patient care (12.5%). 97.5% agreed that they had ever browsed internet for patient care and 85.5% doctors agreed that they had obtained relevant information. 26.5% told that they need training for accessing free full-text electronic journals and 25% need training to access the sources for best clinical evidence for patient care. Other training needs were literature search (18%), downloading textbooks and other resources (15.5%), and searching internet sites for medical information (10%).Conclusion:Providing training for improvement of searching skills for obtaining up-to-date medical information, and evidence-based medicine from internet will improve their practice of medicine.

Utilization of palliative care in intubated patients with metastatic cancer: A 10-year nationwide analysis.

69 Background: Due to improved survival, an increasing number of patients with advanced cancer are eligible for aggressive ICU care, including intubation. The American Society of Clinical Oncology recommends early integration of palliative care in patients with advanced cancer. We analyzed 10-year trends in the utilization of palliative care, and predictors of palliative care use in patients with metastatic cancer undergoing intubation using the National Hospital Discharge Survey database from 2001-2010. Methods: Diagnosis and procedure codes were utilized to identify adult patients with metastatic cancer who underwent intubation, and received palliative care. Demographics, diagnoses, length of stay (LOS), and discharge information were extracted. T-tests and χ^2 tests were used to compare medians and proportions respectively in patients that did or did not receive palliative care. Multivariate regression models with weighted analysis were conducted to study predictors of palliative care use. Results: Over the 10-year study period, 200,350 patients with metastatic cancer and intubation were identified, mean age 65.3 years, 46.2% male. Of these, 6690 (3.3%) received palliative care. There was a significant increase in the use of palliative care from 2001 (0%) to 2010 (17.4%), p for trend &lt; 0.001. In multivariate analysis, patients who received palliative care were more likely to have age &gt; 65 years, be white vs non-white, be hospitalized in 2009-2010 vs 2000-2001, and be admitted to hospitals in the Western part of the US. The overall inpatient mortality rate was 57.3%, discharge to a care facility (DTCF) rate was 15.2%, and mean LOS was 11.1 days. The LOS and DTCF rates were similar in patients with and without palliative care. Patients with palliative care had higher rates of inpatient mortality (adjusted OR 9.6, 95% CI 2.2- 42.0). Conclusions: There was a dramatic increase in the use of palliative care in intubated patients with metastatic cancer. Studies to address the racial and geographic discrepancies in palliative care use are warranted. The higher mortality in palliative care group suggests it is being used for the sickest patients. Early (vs end of life) palliative care may be more beneficial.

Progress In Interoperability: Measuring US Hospitals' Engagement In Sharing Patient Data.

Achieving an interoperable health care system remains a top US policy priority. Despite substantial efforts to encourage interoperability, the first set of national data in 2014 suggested that hospitals' engagement levels were low. With 2015 data now available, we examined the first national trends in engagement in four domains of interoperability: finding, sending, receiving, and integrating electronic patient information from outside providers. We found small gains, with 29.7percent of hospitals engaging in all four domains in 2015 compared to 24.5percent in 2014. The two domains with the most progress were sending (with an increase of 8.1 percentage points) and receiving (an increase of 8.4 percentage points) information, while there was no change in integrating systems. Hospitals' use for patient care of data from outside providers was low, with only 18.7percent of hospitals reporting that they "often" used these data. Our results reveal that hospitals' progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions.

421 Patterns of Non-English Language Use for Patient Care in a Public Emergency Department

In public emergency departments (ED), many patients have limited English proficiency (LEP). Many EDs, however, report persistently low rates of language assistance use in the setting of a high volume of LEP patients. One possible explanation is that ED employees use their own non-English language (NEL) skills to supplement formal language assistance.The objective of this study is to describe employee use of NELs for patient care in a public ED. Study Design: Prospective, anonymous survey questionnaire of ED employees. Setting: A public emergency department with an estimated 50,000 visits per year where the majority of patients are LEP and language assistance is available via videoconference and phone 24/7. Subjects: All ED staff with substantial patient contact including MDs, NPs, RNs, NAs, research assistants, radiology techs, registration workers and respiratory therapists. Measures and outcomes: ED role, native language, languages spoken with patients, comfort level and frequency of NEL use, formal coursework in the NEL, bilingual certification, frequency of interpreting for others and comfort with medical terminology in the NEL. Prior formal training in interpretation (assistance with spoken language) and translation (assistance with written language) was also considered. Analysis: Descriptive statistics were used for analysis. Of the 354 total ED employees, 261 were approached and 259 agreed to participate, which represents a 73% response rate (259/354). MDs comprised 88/259 (33.9%) of participants. The native language of employees was 161/259 (62%) English, followed by Spanish 50/259 (19%), Tagalog 23/259 (8.9%) and Armenian 14/259 (5.4%). When communicating with patients, 24/259 (9.2%) of employees speak only English, 194/259 (75%) use one non-English language (NEL) and 41/259 (15.8%) use two NELs. Frequency of NEL use was categorized as often to every day for 205/233 (88%) of participants. Only 49/233 (21%), however, were certified by the hospital system to use their NEL with patients. Of those using NELs, 151/234 (64.5%) had past formal coursework and 81/233 (34.8%) were uncomfortable with medical terminology. Although 196/235 (83.4%) of participants stated they speak Spanish with patients, only 133/235 (56.6%) stated they feel comfortable doing so. Further, only 7/228 (3%) had prior training in how to interpret and 5/229 (2%) had training in how to translate. In this public ED, providers use their own NEL skills frequently in patient care, but without certification. Very few have training on how to interpret or translate. If the NEL skills of employees are to comprise part of the institutional plan for language assistance for LEP patients, certification and training must be implemented to assure that LEP patients receive the same high quality care as their English-speaking counterparts.

From Donor to Recipient: Considerations for Blood Transfusion Outcomes Research.

Donated blood can be broken down into blood components for use in patient care. This article focuses primarily on packed red blood cells (PRBCs), as they experience breakdown during storage that may adversely impact patient outcomes. Patients require PRBC transfusions for a number of clinical reasons. Although transfusions of PRBCs provide some clinical benefit, they are also associated with increased morbidity and mortality across multiple patient populations, albeit the mechanisms underlying this relationship remain unclear. With an aging, more acutely ill population requiring aggressive treatment and a lack of transfusion alternatives, research focused on PRBCs has gained momentum. Proper interpretation of research findings on the part of clinicians depends on accurate data collection that includes aspects of both the transfused blood components and the recipients. The purpose of this article is to examine stored PRBC factors, blood-donor characteristics, transfusion-specific factors, and patient-specific characteristics as they relate to patient outcomes research. Challenges associated with performing and interpreting outcomes of transfusion-related research are presented. Implications of current evidence for patient care, such as awareness of benefits as well as risks associated with blood component transfusion, are also provided.