A preoperative use of manual therapy in a patient with idiopathic pulmonary fibrosis awaiting lung transplant: a case report.

INTRODUCTION: This case report describes the outcomes of a patient with idiopathic pulmonary fibrosis (IPF) treated with manual therapy (MT) in an outpatient physical therapy setting. IPF is a life-threatening interstitial lung disease, often requiring lung transplant for prolonged health related quality of life and survival. There is little literature to support use of MT for IPF. CLINICAL FINDINGS: The patient was a 66-year-old male with IPF and on the Organ Procurement and Transplant Network (OPTN). The patient was dependent on oxygen and referred to physical therapy with neck pain, shoulder pain, and headaches. Evaluation revealed impairments classified as thoracic hypomobility paired with upper extremity referred pain, shoulder impairments and neck pain. Headaches were classified as cervicogenic in nature. OUTCOMES: Improved objective measures of cardiovascular function and quality of life pre- and post- transplant were observed in this patient after 14 treatment visits. DISCUSSION: The utilization of MT appeared to address the patient's impairments, improved quality of life, improved pulmonary function and improved transplant outcomes.

Becoming an anti-racist interprofessional healthcare organization: Our journey.

The COVID-19 pandemic amplified the egregious disproportionate burden of disease based on race, ethnicity, and failure of organizations to address structural racism. This paper describes a journey by members of the National Academies of Practice (NAP) who came together to address diversity, equity, and inclusion (DEI). Through collaborative efforts, a virtual, interactive workshop was designed and delivered at NAP's 2021 Virtual Forum to facilitate discussions about DEI priorities across professions and to initiate a sustainable action plan toward achieving inclusive excellence. Resulting discoveries and reflections led us to the essential question: can we truly become an anti-racist interprofessional healthcare organization?

Lower AM-PAC 6-Clicks Basic Mobility Score Predicts Discharge to a Postacute Care Facility Among Patients in Cardiac Intensive Care Units.

OBJECTIVE: The objective of this study was to determine the ability of the Activity Measure for Post-Acute Care "6-Clicks" Basic Mobility Short Form to predict patient discharge destination (home vs postacute care [PAC] facility) from the cardiac intensive care unit (ICU), including patients from the cardiothoracic surgical ICU and coronary care unit. METHODS: This retrospective cohort study utilized electronic medical records of patients in cardiac ICU (n = 359) in an academic teaching hospital in the southeastern region of United States from September 1, 2017, through August 31, 2018. RESULTS: The median interquartile range age of the sample was 68 years (75-60), 55% were men, the median interquartile range 6-Clicks score was 16 (20-12) at the physical therapist evaluation, and 79% of the patients were discharged to home. Higher score on 6-Clicks indicates improved function. A prediction model was constructed based on a machine learning approach using a classification tree. The classification tree was constructed and evaluated by dividing the sample into a train-test split using the Leave-One-Out cross-validation approach. The classification tree split the data into 4 distinct groups along with their predicted outcomes. Patients with a 6-Clicks score >15.5 and a score between 11.5 and 15.5 with primary insurance other than Medicare were discharged to home. Patients with a 6-Clicks score between 11.5 and 15.5 with Medicare insurance and those with a score ≤11.5 were discharged to a PAC facility. CONCLUSION: Patients with lower 6-Clicks scores were more likely to be discharged to a PAC facility. Patients without Medicare insurance had to be significantly lower functioning, as indicated by lower 6-Clicks scores for PAC facility placement than those with Medicare insurance. IMPACT: The ability of 6-Clicks along with primary insurance to determine discharge destination allows for early discharge planning from cardiac ICUs.

Building, scaling, and sustaining a learning health system for surgical quality improvement: A toolkit.

This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.

Statewide Prehabilitation Program and Episode Payment in Medicare Beneficiaries.

BACKGROUND: Prehabilitation has been shown to improve postoperative outcomes in a variety of patient populations undergoing major operations. The feasibility, generalizability, and value of broad implementation of prehabilitation outside the research environment are unknown. METHODS: Medicare claims data from 2014 to 2017 were used to conduct a multicenter (21 Michigan hospitals) pragmatic cohort study. Patients and controls were followed for the duration of their index surgical hospitalization and for 90 days postoperatively. Medicare beneficiaries older than 18 years who underwent inpatient surgical procedures at a participating hospital during the study time period were eligible for inclusion. The prehabilitation program involved a home-based walking program with supplementary education on nutrition, smoking cessation, and psychological preparation for surgical procedure. Data were analyzed with an intention-to-treat approach using t-tests and Wilcoxon rank sum tests. Propensity score matching used comorbidities and demographic factors to match controls to patients in a 2:1 manner with an exact match required for operation type. RESULTS: Patients (n = 523) and controls (n = 1,046) had no significant differences in demographic factors or comorbidities. Patients had significantly shorter median hospital length of stay (6 vs 7 days; p < 0.01) than controls and were more likely to be discharged to home (65.6% vs 57.0%, p < 0.01). Total episode payments were significantly lower for patients compared with controls ($31,641 vs $34,837; p = 0.04). Patients had significantly lower post-acute care payments for skilled nursing facility ($941 vs $1,566; p = 0.02) and home health ($829 vs $960; p = 0.03) services. CONCLUSIONS: Participation in a prehabilitation program in Michigan was associated with shorter length of stay and lower total episode payments after operation. Payers and hospitals should invest in the implementation of simple home-based prehabilitation programs.

Effect of exercise-based cardiac rehabilitation on multiple atherosclerotic risk factors in patients taking antidepressant medication.

Antidepressants might increase compliance with cardiovascular disease risk reduction interventions. However, antidepressants have been linked to deleterious metabolic effects. In the present multicenter study, we sought to determine whether patients who take antidepressants derive the expected benefits from cardiac rehabilitation in terms of improvements in multiple atherosclerotic risk factors. A cohort of 26,957 patients who had completed a baseline assessment before participating in an exercise-based cardiac rehabilitation program constituted the study population. The patients were stratified into 3 cohorts (i.e., nondepressed, depressed unmedicated, and depressed medicated) at baseline according to a self-reported history of depression and the current use of antidepressants. Risk factors were assessed at baseline and after ∼12 weeks of program participation. A self-reported history of depression was present at baseline in 5,172 patients (19.2%). Of these patients, 2,147 (41.5%) were taking antidepressants. Patients in the nondepressed cohort (49.4% completion) were more likely (p <0.001) to complete the exit assessment than patients in the depressed unmedicated (44.5% completion) or depressed medicated (43.5% completion) cohorts. Patients in all 3 cohorts who completed the exit assessment showed significant improvement in multiple risk factors. Moreover, the magnitude of improvement in blood pressure, serum lipids and lipoproteins, fasting glucose, weight, and body mass index was similar (p >0.05) in patients taking antidepressants and those who were not. In conclusion, our study is the first to show that antidepressants do not offset the average magnitude of improvement in multiple atherosclerotic risk factors that occurs with completion of a cardiac rehabilitation program.

Herbal, vitamin, and mineral supplement use in patients enrolled in a cardiac rehabilitation program.

PURPOSE: The use of complementary and alternative medicine is common and continues to rise each year, both in the general population and among those with cardiovascular disease. While some supplements may incur risk, particularly when used concomitantly with cardiovascular medications, others have proven benefits. However, supplements such as antioxidants and many herbs can have significant interactions with cardiovascular medications. This study aimed to identify the percentage of patients enrolled in a cardiac rehabilitation program taking herbal, vitamin, and mineral supplements. METHODS: Electronic and paper charts of 235 patients enrolled in a phase 3 cardiac rehabilitation program were reviewed. Their demographics, medical history, and medications were stratified in an Excel chart, using a large matrix from which data were imported into Matlab for analysis. Custom Matlab programs were created and compiled to determine variables of interest, including percentages of patients with a specific medical condition taking certain supplements. RESULTS: Sixty-seven percent of patients enrolled in the cardiac rehabilitation program were taking vitamins, with or without minerals (67%, 158 of 235). Multivitamin is the most common form of supplement (51%, 119 of 235), followed by fish oil/omega-3 polyunsaturated fatty acids (27%, 64 of 235). CONCLUSION: The majority of patients in a phase 3 cardiac rehabilitation program are taking some form of herbal, vitamin, or mineral supplement. Given frequent, complicated patient medication regimens, it is important to educate patients on the potential benefits as well as lack of evidence and possible dangers of supplements.

Predictors of early and late enrollment in cardiac rehabilitation, among those referred, after acute myocardial infarction.

BACKGROUND: Cardiac rehabilitation (CR) after acute myocardial infarction (AMI) is a Class I recommendation. Although referral to CR after an AMI has recently become a performance measure, many patients may not participate. To illuminate potential barriers to participation, we examined the prevalence of, and patient-related factors associated with, CR participation within 1 and 6 months after an AMI. METHODS AND RESULTS: We studied 2096 AMI patients enrolled from 19 US sites in the Prospective Registry Evaluating outcomes after Myocardial Infarction: Events and Recovery (PREMIER) registry. Analyses were limited to those patients referred for CR at the time of AMI hospitalization. A multivariable, conditional logistic regression model, stratified by hospital, was used to identify sociodemographic, comorbidity, and clinical factors independently associated with CR participation within 1 and 6 months of AMI hospital discharge. Only 29% (419/1450) and 48.25% (650/1347) of AMI patients who received referral for CR participated within 1 and 6 months after discharge, respectively. Women (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.44-0.86), uninsured (OR, 0.39; 95% CI, 0.21-0.71), and patients with hypertension (OR, 0.58; 95% CI, 0.43-0.78) and peripheral arterial disease (OR, 0.43; 95% CI, 0.22-0.85) were less likely to participate at 1 month. At 6 months after AMI, older patients (OR, 0.85 for each 10-year increment; 95% CI, 0.74-0.97), smokers (OR, 0.59; 95% CI, 0.44-0.80), and patients with economic burden (OR, 0.56; 95% CI, 0.38-0.81) were less likely to participate. Caucasians (OR, 1.73; 95% CI, 1.16-2.58) and educated patients (OR, 1.81; 95% CI, 1.42-2.30) were more likely to participate at 6 months. Patients with previous percutaneous interventions were less likely to participate at both 1 and 6 months post-AMI. CONCLUSIONS: Among patients referred for CR post-AMI, participation remains low both at 1 and 6 months after AMI. Because CR is associated with beneficial changes in cardiovascular risk factors and better outcomes after AMI, more aggressive efforts are needed to increase CR participation after referral.

Metabolic abnormalities in adults with cystic fibrosis.

BACKGROUND AND OBJECTIVE: Survival of patients with cystic fibrosis (CF) has improved, resulting in increased exposure of patients to cardiovascular risk factors. Diabetes mellitus is common in patients with CF; however, less is known about lipid abnormalities in this population. In this study, the prevalence of lipid abnormalities was investigated in a contemporary population of adults with CF. METHODS: Clinical and laboratory data on 221 adult patients with CF were collected retrospectively. Fasting serum glucose levels and lipid profiles were recorded. The age-specific values for healthy individuals, as reported by the National Health and Nutrition Examination Surveys, were used for comparison. RESULTS: The mean age of the patients was 30 +/- 10 years, 55.1% were men and the mean FEV(1)% was 68 +/- 25%. Sixty-nine patients (31.2%) had CF-related diabetes mellitus and 52 (23.5%) were receiving insulin therapy. In addition, 36 patients (16.3%) had impaired glucose tolerance. Triglyceride levels were similar to those of historical control subjects (mean +/- SEM, 1.37 +/- 0.05 and 1.39 +/- 0.02 mmol/L, respectively, P = 0.75). However, in the 30-39 years age group of CF patients, triglyceride levels were increased relative to those of their control counterparts (1.79 +/- 0.14 vs 1.38 +/- 0.04 mmol/L, P = 0.006). Total cholesterol levels were lower in the CF patients compared with control subjects, across all age groups. CONCLUSIONS: Abnormalities of glucose metabolism are highly prevalent in CF patients, and are accompanied by hypertriglyceridaemia in the 30-39 years age group. Prospective studies are required to confirm lipid abnormalities and investigate possible cardiovascular complications in patients with CF.

A randomized controlled trial of multiple tailored messages for smoking cessation among callers to the cancer information service.

Self-help materials computer-tailored to the specific needs of smokers have shown promise as a high-reach, low-cost intervention for smoking cessation. Adding tailored cessation materials to telephone-based cessation counseling may be a way of generating greater efficacy in promoting and maintaining cessation. The objective of this study is to assess the efficacy of adding different types of behavioral smoking cessation materials to brief telephone-based cessation counseling.A total of 1,978 smokers calling the National Cancer Institute's (NCI's) Cancer Information Service (CIS) for help in quitting smoking initially received brief cognitive-behavioral cessation counseling from a CIS information specialist. Following a baseline interview administered by the information specialist, subjects were randomly assigned to one of four conditions, each delivered by U.S. mail: a single, untailored smoking cessation guide (SU); a single, tailored smoking cessation guide (ST); a series of four (multiple) printed materials tailored only to baseline data (MT); and a series of four (multiple) printed materials tailored to baseline as well as retailored using 5-month interim progress data (MRT). The primary outcome measure was 7-day point prevalence abstinence rates assessed using a computer-assisted telephone interview (CATI) at 12-month follow-up.At 12-month follow-up, using intent-to-treat, imputed, and per-protocol analyses, no differences were found among the four experimental conditions (linear trend), or when the ST, MT, and MRT groups were compared with the control (SU) group. Participants in the two multiple message group conditions combined (MT + MRT), however, had significantly higher abstinence rates than participants in the two single message group conditions combined (SU + ST). Moreover, among subjects who reported quitting at the 5-month follow-up, participants receiving the MRT materials reported higher abstinence rates at 12 months than the other three groups combined (SU + ST + MT). The results of this study support the effectiveness, over and above a single telecounseling interaction, of multiple tailored print material contacts on cessation. These effects, however may be due to tailoring, or the longitudinal nature of the two multiple tailored conditions, or both. The strongest evidence for tailoring occurred in the MRT condition for relapse prevention, suggesting that print materials tailored to interim progress may be especially effective in this context. The qualities of specific psychosocial and communication elements in tailored materials should receive attention in future research.

Provider response to different formats of the adult immunization schedule.

BACKGROUND: Providers' failure to administer vaccines in accordance with established recommendations is a well-recognized barrier to national immunization efforts. This study evaluated the ease of use of two different formats of the Centers for Disease Control and Prevention's (CDC) adult immunization schedule by physicians in private practice, where the majority of adult immunizations are administered. METHODS: A series of focus groups was conducted with 94 physicians and other clinical staff in 11 private practices (family medicine and internal medicine) in six U.S. cities. Each session was based on a structured set of questions that explored barriers to adult immunizations, followed by three mock clinical scenarios to examine how each of two graphical depictions of the 2003-2004 adult immunization schedule (one from the CDC's Advisory Committee on Immunization Practices, and the other from the Immunization Action Coalition) might facilitate assessments of recommended immunizations. Group dialogue and individual participants' written responses to the scenarios and the alternate schedule formats were analyzed. RESULTS: Providers perceived multiple barriers to adult immunization independent of immunization schedule formats, chiefly patients' low interest in immunization and refusal of vaccines. Most participants were not familiar with either format of CDC's adult immunization schedule before the study, but quickly developed strong preferences for one versus the other (usually the second format that they encountered). About half of the providers changed their vaccine recommendations for clinical scenarios when they consulted either schedule format, although some of the changes were not clinically appropriate. Participants suggested several ways to enhance the availability of the information contained in the schedule formats, especially through electronic means. CONCLUSIONS: This qualitative study suggests ways in which graphic depictions of an adult immunization schedule may address adult immunization barriers. Greater provider familiarity with schedule formats will be critical to their appropriate application in clinical encounters.