Nevin Manimala

J Am Assoc Nurse Pract. 2022 Dec 14. doi: 10.1097/JXX.0000000000000809. Online ahead of print.

ABSTRACT

Many interdisciplinary oral health education programs have been implemented for pediatric primary care providers (e.g., pediatric nurse practitioner [PNP]) to raise awareness and gain skills related to the prevention of early childhood caries (ECC). However, no studies have evaluated if these educational programs provided to PNPs during their training resulted in clinical practice behavior changes. A 33-item survey was designed on a web-based platform (Survey Monkey) and distributed to 71 PNP graduates. The survey included demographics, current clinical practice, clinical practice behaviors, and perceived barriers to practice. Descriptive statistics were used to assess the survey items and thematic analyses on the open-ended questions. The survey response rate was 70% (50/71 PNPs). Most practicing PNPs were in acute care or specialty clinics (n = 33; 66%) where oral health was not part of the focused visit. Majority used knowledge learned in assessment and anticipatory guidance skills. However, only 14% of primary care providers were applying fluoride varnish with 10% billing for this procedure. Barriers to application were time, available supplies, COVID protocols, lack of support staff, or not billing due to minimal reimbursement. Many primary care-trained PNPs were practicing in acute or subspecialty areas where prevention of ECC is not viewed as part of their focused visit. Pediatric nurse practitioners working in primary care demonstrated some clinical practice changes. However, areas for improvement are time to perform a risk assessment and application of fluoride varnish, access to these supplies, and standard billing and insurance reimbursement for these preventable services.

PMID:36729598 | DOI:10.1097/JXX.0000000000000809

J Cardiopulm Rehabil Prev. 2022 Dec 14. doi: 10.1097/HCR.0000000000000745. Online ahead of print.

ABSTRACT

PURPOSE: Obstructive sleep apnea (OSA)-related pulmonary hypertension (PH) can often be reversed with treatment of OSA via continuous positive airway pressure. We hypothesized that treatment of OSA would be associated with a greater improvement in exercise capacity (EC) with cardiac rehabilitation (CR), especially in patients with PH as compared with those who are untreated.

METHODS: We reviewed medical records of 315 consecutive patients who participated in CR. Pulmonary hypertension status was assessed on the basis of peak tricuspid regurgitant velocity (>2.8 m/sec) on pre-CR echocardiograms. The OSA status (no, untreated, or treated OSA) was determined on the basis of results from sleep studies, continuous positive airway pressure device data, and physician notes. Exercise capacity was assessed by measuring metabolic equivalents (METs) using a treadmill stress test before and after CR.

RESULTS: We included 290 patients who participated in CR with available echocardiographic data: 44 (15%) had PH, and 102 (35%) had known OSA (30 treated and 72 untreated). Patients with OSA versus those with no OSA were more likely to have PH (P = .06). Patients with PH versus no-PH were associated with significantly lower baseline METs in crude and adjusted analyses (P ≤. 004). The PH and OSA status in isolation were not associated with changes in METs (P > .2) with CR. There was a significant interaction between OSA treatment and PH in crude and adjusted analyses (P ≤.01): treatment vs no treatment of OSA was associated with a clinically and statistically greater improvement in METs in patients who participated in CR with but not without PH.

CONCLUSION: Baseline PH was associated with decreased baseline EC but did not attenuate CR-related improvements in METs. However, in the subset of OSA patients with PH, OSA therapy was associated with improved EC after CR.

PMID:36729594 | DOI:10.1097/HCR.0000000000000745

Clin Orthop Relat Res. 2022 Dec 13. doi: 10.1097/CORR.0000000000002489. Online ahead of print.

ABSTRACT

BACKGROUND: Price variations in healthcare can be caused by quality or factors other than quality such as market share, negotiating power with insurers, or hospital ownership model. Efforts to improve care value (defined as the ratio between health outcomes and price) by making healthcare prices readily accessible to patients are driven by the assumption this can help patients more easily identify high-quality, low-price clinicians and health systems, thus reducing price variations. However, if price variations are driven by factors other than quality, then strategies that involve payments for higher-quality care are unlikely to reduce price variation and improve value. It is unknown whether prices for total joint arthroplasty (TJA) are correlated with the quality of care or whether factors other than quality are responsible for price variation.

QUESTIONS/PURPOSES: (1) How do prices insurers negotiate for TJA paid to a single, large health system vary across payer types? (2) Are the mean prices insurers negotiate for TJA associated with hospital quality?

METHODS: We analyzed publicly available data from 22 hospitals in a single, large regional health system, four of which were excluded owing to incomplete quality information. We chose to use data from this single health system to minimize the confounding effects of between-hospital reputation or branding and geographic differences in the cost of providing care. This health system consists of large and small hospitals serving urban and rural populations, providing care for more than 3 million individuals. For each hospital, negotiated prices for TJA were classified into five payer types: commercial in-network, commercial out-of-network, Medicare Advantage (plans to which private insurers contract to provide Medicare benefits), Medicaid, and discounted cash pay. Traditional Medicare plans were not included because the prices are set statutorily, not negotiated. We obtained hospital quality measures from the Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services quality measures included TJA-specific complication and readmission rates in addition to hospital-wide patient survey star rating (measure of patient care experience) and total performance scores (aggregate measure of clinical outcomes, safety, patient experience, process of care, and efficiency). We evaluated the association between the mean negotiated hospital prices and Centers for Medicare and Medicaid Services quality measures using Pearson correlation coefficients and Spearman rho across all payer types. Statistical significance was defined as p < 0.0025.

RESULTS: The mean ± SD overall negotiated price for TJA was USD 54,500 ± 23,200. In the descriptive analysis, the lowest negotiated prices were associated with Medicare Advantage (USD 20,400 ± 1800) and Medicaid (USD 20,300 ± 8600) insurance plans, and the highest prices were associated with out-of-network care covered by commercial insurance plans (USD 78,800 ± 9200). There was no correlation between the mean negotiated price and TJA complication rate (discounted cash price: r = 0.27, p = 0.29; commercial out-of-network: r = 0.28, p = 0.26; commercial in-network: r = -0.07, p = 0.79; Medicare Advantage: r = 0.11, p = 0.65; Medicaid: r = 0.03, p = 0.92), readmission rate (discounted cash price: r = 0.19, p = 0.46; commercial out-of-network: r = 0.24, p = 0.33; commercial in-network: r = -0.13, p = 0.61; Medicare Advantage: r = -0.06, p = 0.81; Medicaid: r = 0.09, p = 0.74), patient survey star rating (discounted cash price: r = -0.55, p = 0.02; commercial out-of-network: r = -0.53, p = 0.02; commercial in-network: r = -0.37, p = 0.13; Medicare Advantage: r = -0.08, p = 0.75; Medicaid: r = -0.02, p = 0.95), or total hospital performance score (discounted cash price: r = -0.35, p = 0.15; commercial out-of-network: r = -0.55, p = 0.02; commercial in-network: r = -0.53, p = 0.02; Medicare Advantage: r = -0.28, p = 0.25; Medicaid: r = 0.11, p = 0.69) for any of the payer types evaluated.

CONCLUSION: There is substantial price variation for TJA that is not accounted for by the quality of care, suggesting that a mismatch between price and quality exists. Efforts to improve care value in TJA are needed to directly link prices with the quality of care delivered, such as through matched quality and price reporting mechanisms. Future studies might investigate whether making price and quality data accessible to patients, such as through value dashboards that report easy-to-interpret quality data alongside price information, moves patients toward higher-value care decisions.

CLINICAL RELEVANCE: Efforts to better match the quality of care with negotiated prices such as matched quality and price reporting mechanisms, which have been shown to increase the likelihood of choosing higher-value care in TJA, could improve the value of care.

PMID:36729581 | DOI:10.1097/CORR.0000000000002489

Am J Phys Med Rehabil. 2022 Dec 14. doi: 10.1097/PHM.0000000000002168. Online ahead of print.

ABSTRACT

OBJECTIVES: Neck pain (NP) is extremely common and represents a substantial economic burden to our society. We aimed to investigate risk factors for non-disabling and disabling neck pain in a large cohort of Italian adolescents with a cross-sectional study.

DESIGN: Six thousand, two hundred eighty-one students (14-19 years old) answered an online questionnaire, investigating: anthropometric data, lifestyle-related items, NP frequency and intensity, need for medical examination and several risk factors. Students who had to give up social activities due to neck complaints constituted the disabling NP group (DIS-NP).

RESULTS: Our findings revealed that sex, age, sports practice, hours of sleep and family history were risk factors (p < 0.001) for NP in our cohort. Moreover, DIS-NP suffered from NP more frequently (p < 0.001) and with higher levels of pain (p < 0.001) compared to the non-disabling group. The number of hours of sleep was the only risk factor that showed a trend to differ comparing the DIS-NP group with the non-disabling NP one (p = 0.057).

CONCLUSION: Different risk factors for NP were detected in a very large cohort of adolescents.This study may pave the way for future prospective studies and for the development of preventive strategies for NP in adolescents.

PMID:36729580 | DOI:10.1097/PHM.0000000000002168

J Am Assoc Nurse Pract. 2022 Dec 14. doi: 10.1097/JXX.0000000000000821. Online ahead of print.

ABSTRACT

BACKGROUND: High-flow oxygen therapy (HFOT) has been successful in treating acute hypoxic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS). Successful treatment with noninvasive ventilation and avoidance of mechanical ventilation (MV) has been associated with decreased mortality and positive patient outcomes. It is unclear whether the evidence supports the use of HFOT to treat coronavirus disease 2019 (COVID-19)-induced AHRF and ARDS.

OBJECTIVES: To determine whether the use of HFOT decreases the need for intubation or decreases mortality compared with MV in patients with AHRF due to COVID-19.

DATA SOURCES: A literature search was conducted in March 2022 using CINAHL, Embase, PubMed, and Scopus bibliographic databases. Ten studies comparing HFOT and MV in COVID-19 respiratory failure met inclusion criteria.

CONCLUSIONS: Nine studies found a statistically significant reduction in the need for intubation; eight studies found significantly decreased morality in patients who received HFOT. Study design and methodologies limited the findings.

IMPLICATIONS FOR PRACTICE: Based on the available evidence, the use of HFOT positively affected mortality and incidence of the need for intubation and MV. Further research needs to be conducted before HFOT is adopted as the standard of care for COVID-19-induced AHRF and ARDS. Nurse practitioners should be informed regarding the various respiratory support modalities and evaluate risk versus benefit when caring for patients with COVID-19-induced AHRF and ARDS.

PMID:36729579 | DOI:10.1097/JXX.0000000000000821

JMIR Mhealth Uhealth. 2023 Feb 2;11:e40844. doi: 10.2196/40844.

ABSTRACT

BACKGROUND: Chronic pain (CP) is 1 of the leading causes of disability worldwide and represents a significant burden on individual, social, and economic aspects. Potential tools, such as mobile health (mHealth) systems, are emerging for the self-management of patients with CP.

OBJECTIVE: A systematic review was conducted to analyze the effects of mHealth interventions on CP management, based on pain intensity, quality of life (QoL), and functional disability assessment, compared to conventional treatment or nonintervention.

METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed to conduct a systematic review of randomized controlled trials (RCTs) published in PubMed, Web of Science, Scopus, and Physiotherapy Evidence Database (PEDro) databases from February to March 2022. No filters were used. The eligibility criteria were RCTs of adults (≥18 years old) with CP, intervened with mHealth systems based on mobile apps for monitoring pain and health-related outcomes, for pain and behavioral self-management, and for performing therapeutic approaches, compared to conventional treatments (physical, occupational, and psychological therapies; usual medical care; and education) or nonintervention, reporting pain intensity, QoL, and functional disability. The methodological quality and risk of bias (RoB) were assessed using the Checklist for Measuring Quality, the Oxford Centre for Evidence-Based Medicine Levels of Evidence, and the Cochrane RoB 2.0 tool.

RESULTS: In total, 22 RCTs, involving 2641 patients with different CP conditions listed in the International Classification of Diseases 11th Revision (ICD-11), including chronic low back pain (CLBP), chronic musculoskeletal pain (CMSP), chronic neck pain (CNP), unspecified CP, chronic pelvic pain (CPP), fibromyalgia (FM), interstitial cystitis/bladder pain syndrome (IC/BPS), irritable bowel syndrome (IBS), and osteoarthritis (OA). A total of 23 mHealth systems were used to conduct a variety of CP self-management strategies, among which monitoring pain and symptoms and home-based exercise programs were the most used. Beneficial effects of the use of mHealth systems in reducing pain intensity (CNP, FM, IC/BPS, and OA), QoL (CLBP, CNP, IBS, and OA), and functional disability (CLBP, CMSP, CNP, and OA) were found. Most of the included studies (18/22, 82%) reported medium methodological quality and were considered as highly recommendable; in addition, 7/22 (32%) studies had a low RoB, 10/22 (45%) had some concerns, and 5/22 (23%) had a high RoB.

CONCLUSIONS: The use of mHealth systems indicated positive effects for pain intensity in CNP, FM, IC/BPS, and OA; for QoL in CLBP, CNP, IBS, and OA; and for functional disability in CLBP, CMSP, CNP, and OA. Thus, mHealth seems to be an alternative to improving pain-related outcomes and QoL and could be part of multimodal strategies for CP self-management. High-quality studies are needed to merge the evidence and recommendations of the use of mHealth systems for CP management.

TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42022315808; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=315808.

PMID:36729570 | DOI:10.2196/40844

J Med Internet Res. 2023 Feb 2;25:e39325. doi: 10.2196/39325.

ABSTRACT

BACKGROUND: The diabetes disease burden in China is heavy, and medical standards such as diabetes guidelines are the core reference guidelines for diabetes management for health care providers and patients. However, patients’ guideline compliance is too low, which correlates with the gap between guidelines and patients’ self-management needs. Incorporating patient needs into the guideline development would reduce this gap.

OBJECTIVE: We sought to capture the needs of patients with diabetes for self-management in everyday situations and to clarify the contradictions and misalignments between medical standards, such as guidelines, and patient needs.

METHODS: This study collected crawler-based data from 4 online health communities. We selected 1605 text records collected from Chinese patients with diabetes between March 2020 and July 2020 for analysis. The text analysis applied grounded theory to separate issues that concerned patients into 3 themes, 7 subthemes, and 25 entries.

RESULTS: Altogether, 69.03% (1108/1605) of texts were related to issues concerning disease treatment (theme B) and mainly inquired about medication use (B2 and B3; 686/1108, 61.91%), including medication choice, change in medication administration, side effects, and postmedication effects. In addition, 222 (N=1605, 13.8%) texts (theme A) concerned the explanation of disease etiology and knowledge of diabetes, and 275 (N=1605, 17.1%) texts (theme C) discussed lifestyle changes and various restrictions on life brought about by the disease.

CONCLUSIONS: Our findings suggest an urgent need to improve diabetes health education and guideline development strategies and to develop health management strategies from a patient perspective to bridge the misalignment between patient needs and current medical standards.

PMID:36729569 | DOI:10.2196/39325

Plast Reconstr Surg. 2022 Dec 19. doi: 10.1097/PRS.0000000000010066. Online ahead of print.

ABSTRACT

BACKGROUND: There remains a lack of clarity surrounding the benefits, risks and outcomes between two-stage expander/implant reconstruction and single-stage direct-to-implant reconstruction. This study utilised a national dataset to examine real-world outcomes of two-stage and DTI reconstructions.

METHODS: A cohort study was conducted examining patients in the Australian Breast Device Registry from 2015-2018 who underwent prosthetic breast reconstruction post-mastectomy. Direct-to-implant and two-stage cohorts after definitive implant insertion were compared. Rate of revision surgery, reasons for revision and patient-reported outcome measures were recorded. Statistical analysis was undertaken using Fisher’s exact or chi-square, Wilcoxon rank-sum or student t-tests, Nelson-Aalen cumulative incidence estimates and Cox proportional hazards regression.

RESULTS: 5,152 breast reconstructions were recorded, including 3,093 two-stage and 2,059 direct-to-implant reconstructions. Overall revision surgery rates were 15.6% for direct-to-implant (median follow-up 24.7 months), compared with 9.7% in the two-stage cohort (median follow-up 26.5 months) (p<0.001). Most common reasons for revision for DTI and two-stage were capsular contracture (25.2% vs 26.7%, p=0.714) and implant malposition (26.7% vs 34.3%, p=0.045). Multivariate analysis found acellular dermal matrix usage (p=0.028) was significantly associated with a higher risk of revision. The influence of radiotherapy on revision rates was unable to be studied. Patient satisfaction levels were similar between reconstructive groups; however, patient experience was better in direct-to-implant than two-stage.

CONCLUSIONS: The Australian Breast Device Registry dataset demonstrated that direct-to-implant reconstruction had a higher revision rate than two-stage, but with comparable patient satisfaction and better patient experience. Capsular contracture and device malposition were leading causes of revision in both cohorts.

PMID:36729564 | DOI:10.1097/PRS.0000000000010066

J Acquir Immune Defic Syndr. 2022 Dec 15. doi: 10.1097/QAI.0000000000003139. Online ahead of print.

ABSTRACT

BACKGROUND: To address challenges with delivery of an evidence-based HIV care coordination program (CCP), the New York City (NYC) Health Department initiated a CCP redesign. We conducted a site-randomized stepped-wedge trial to evaluate effectiveness of the revised versus the original model.

SETTING: The CCP is delivered in NYC hospitals, community health centers, and community-based organizations, to people experiencing or at risk for poor HIV outcomes.

METHODS: The outcome, timely viral suppression (TVS), was defined as achievement of viral load <200 copies/mL within four months, among enrollees with unsuppressed viral load (≥200 copies/mL). Seventeen original-CCP provider agencies were randomized within matched pairs to early (August 2018) or delayed (May 2019) starts of revised-model implementation. Data from three periods were examined to compare revised versus original CCP effects on TVS. The primary analysis of the intervention effect applied fully conditional maximum likelihood estimation together with an exact, conditional P-value and an exact test-based 95% confidence interval (CI). We assigned each trial enrollee the implementation level of their site (based on a three-component measure), and tested for association with TVS, adjusting for period and study arm.

RESULTS: Over three nine-month periods, 960 individuals were eligible for trial inclusion (intention to treat). The odds ratio of TVS versus no TVS comparing revised to original CCP was 0.88 (95%CI 0.45, 1.7). Thus, the revised program yielded slightly lower TVS, though the effect was statistically non-significant. TVS was not significantly associated with revised-CCP implementation level.

CONCLUSION: Program revisions did not increase TVS, irrespective of implementation level.

PMID:36729538 | DOI:10.1097/QAI.0000000000003139

J Dev Behav Pediatr. 2022 Dec 15. doi: 10.1097/DBP.0000000000001159. Online ahead of print.

ABSTRACT

OBJECTIVE: Differences of sex development (DSD) are congenital conditions in which individuals are discordant in their chromosomal, phenotypic, and/or gonadal sex. Treatment of DSD can involve surgical intervention to external genitalia to make anatomy seem male-typical (i.e., male genitoplasty). Caregiver-perceived decisional regret regarding young boys with DSD was explored quantitatively and qualitatively.

METHOD: Participants (N = 39) were caregivers of infants (N = 23) diagnosed with DSD (mean age = 8.9 months, standard deviation = 5.9 months) reared male participating in a longitudinal investigation of psychosocial outcomes. Qualitative data were collected at 6 to 12 months after baseline enrollment to evaluate caregiver decision-making corresponding to levels of regret concerning their child’s treatment. All but one infant received genital surgery before caregiver reporting on their decisional regret. Quantitative exploratory analyses evaluated longitudinal predictors of decisional regret at 6 to 12 months.

RESULTS: When completing a write-in item inquiring about decision-making and potential regret, most caregivers (n = 16, 76%) reported that their child’s genital surgery was their first medical decision. Two caregivers referenced gender assignment as a decision point. One-third of caregivers reported some level of decisional regret (33%), with 67% reporting no regret. No hypothesized predictors of decisional regret were statistically significant.

CONCLUSION: Many caregivers of infants with DSD reared male view genital surgery as a first health care decision. Approximately one-third of caregivers reported some level of decisional regret. Further research is warranted to explore long-term decisional regret; it will be particularly important to investigate the decisional regret of patients with DSD.

PMID:36729523 | DOI:10.1097/DBP.0000000000001159