Parameters for Orally Feeding Neonates Who Require Noninvasive Ventilation: A Systematic Review.

PURPOSE: Infants hospitalized in the neonatal intensive care unit (NICU) may be orally fed while receiving noninvasive ventilation (NIV), but the practice is variable and decision criteria are not well understood. This systematic review examines the evidence regarding this practice, including type and level of NIV used during NICU oral feeding, protocols, and safety of this practice. METHOD: The PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched to identify publications relevant to this review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure the appropriate inclusion of articles. RESULTS: Fourteen articles were included. Seven studies (50%) were retrospective. Two were quality improvement projects, and the remaining five (35.7%) were prospective. Continuous positive airway pressure and high-flow nasal cannula were commonly used. Levels of respiratory support were variable between studies, if reported at all. Three studies (21.4%) included feeding protocols. Six studies (42.9%) identified use of feeding experts. While many studies commented that orally feeding neonates on NIV is safe, the only study to instrumentally assess swallow safety found that a significant number of neonates silently aspirated during feeding on continuous positive airway pressure. CONCLUSIONS: Strong data supporting practices related to orally feeding infants in the NICU who require NIV are scarce. The types and levels of NIV, and decision-making criteria, are variable across studies and preclude clinically useful conclusions. There is a pressing need for additional research pertaining to orally feeding this population so that an evidence-based standard of care can be established. Specifically, this research should elucidate the impact of different types and levels of NIV on the mechanistic properties of swallowing as defined via instrumental assessment.

A Tutorial on Diagnostic Benefit and Radiation Risk in Videofluoroscopic Swallowing Studies.

The videofluoroscopic swallowing study (VFSS) is a key tool in assessing swallowing function. As with any diagnostic procedure, the probable benefits of the study must be weighed against possible risks. The probable benefit of VFSS is an accurate assessment of swallowing function, enabling patient management decisions potentially leading to improved patient health status and quality of life. A possible (though highly unlikely) risk in VFSS is carcinogenesis, arising from the use of ionizing radiation. Clinicians performing videofluoroscopic swallowing studies should be familiar with both sides of the risk benefit equation in order to determine whether the study is medically justified. The intent of this article is to provide the necessary background for conversations about benefit and risk in videofluoroscopic swallowing studies.

Incidence of Poststroke Depression in Patients With Poststroke Dysphagia.

PURPOSE: Poststroke dysphagia and poststroke depression (PSD) can have devastating effects on stroke survivors, including increased burden of care, higher health care costs, poor quality of life, and greater mortality; however, there is a dearth of research examining depression in patients diagnosed with dysphagia after stroke. Thus, we aimed to study the incidence of PSD in patients with poststroke dysphagia to provide foundational knowledge about this patient population. METHOD: We conducted a retrospective, cross-sectional study of individuals with a primary diagnosis of acute ischemic stroke (AIS) and secondary diagnoses of dysphagia and/or depression using administrative claims data from the 2017 Medicare 5% Limited Data Set. RESULTS: The proportion of depression diagnosis in patients with poststroke dysphagia was significantly higher than the proportion of depression diagnosis in those without poststroke dysphagia during acute hospitalization: 12.01% versus 9.52%, respectively (p = .003). CONCLUSIONS: Our results demonstrated that persons with poststroke dysphagia were as, or slightly more, likely to have PSD compared to the general stroke population, and to our knowledge, they establish the first reported incidence of PSD in Medicare patients with dysphagia after AIS. Future research is warranted to further explore the effects of PSD on poststroke dysphagia.

The Prognostic Utility of Electroencephalography in Stroke Recovery: A Systematic Review and Meta-Analysis.

BACKGROUND: Improved ability to predict patient recovery would guide post-stroke care by helping clinicians personalize treatment and maximize outcomes. Electroencephalography (EEG) provides a direct measure of the functional neuroelectric activity in the brain that forms the basis for neuroplasticity and recovery, and thus may increase prognostic ability. OBJECTIVE: To examine evidence for the prognostic utility of EEG in stroke recovery via systematic review/meta-analysis. METHODS: Peer-reviewed journal articles that examined the relationship between EEG and subsequent clinical outcome(s) in stroke were searched using electronic databases. Two independent researchers extracted data for synthesis. Linear meta-regressions were performed across subsets of papers with common outcome measures to quantify the association between EEG and outcome. RESULTS: 75 papers were included. Association between EEG and clinical outcomes was seen not only early post-stroke, but more than 6 months post-stroke. The most studied prognostic potential of EEG was in predicting independence and stroke severity in the standard acute stroke care setting. The meta-analysis showed that EEG was associated with subsequent clinical outcomes measured by the Modified Rankin Scale, National Institutes of Health Stroke Scale, and Fugl-Meyer Upper Extremity Assessment (r = .72, .70, and .53 from 8, 13, and 12 papers, respectively). EEG improved prognostic abilities beyond prediction afforded by standard clinical assessments. However, the EEG variables examined were highly variable across studies and did not converge. CONCLUSIONS: EEG shows potential to predict post-stroke recovery outcomes. However, evidence is largely explorative, primarily due to the lack of a definitive set of EEG measures to be used for prognosis.

Clinical and translational research workforce education survey identifies needs of faculty and staff.

Developing the translational research workforce is a goal established by the National Center for Advancing Translational Science for its network of Clinical and Translational Science Award Program hubs. We surveyed faculty and research staff at our institution about their needs and preferences, utilization of existing trainings, and barriers and facilitators to research training. A total of 545 (21.9%) faculty and staff responded to the survey and rated grant development, research project development, and professional development among their top areas for further training. Faculty prioritized statistical methods and dissemination and implementation, while staff prioritized research compliance and research administration. Faculty (73.9%; n = 119) and staff (87.3%; n = 165) reported that additional training would give them more confidence in completing their job responsibilities. Time and lack of awareness were the most common barriers to training. Our results indicate the value of training across a range of topics with unique needs for faculty and staff. This pre-COVID survey identified time, awareness, and access to training opportunities as key barriers for faculty and staff. The shift to remote work spurred by the pandemic has further heightened the need for effective and readily accessible online trainings to enable continuous development of the clinical and translational research workforce.

Impact of Community Health Workers on Access to Care for Rural Populations in the United States: A Systematic Review.

Community Health Worker (CHW) interventions have shown potential to reduce inequities for underserved populations. However, there is a lack of support for CHW integration in the delivery of health care. This may be of particular importance in rural areas in the Unites States where access to care remains problematic. This review aims to describe CHW interventions and their outcomes in rural populations in the US. Peer reviewed literature was searched in PubMed and PsycINFO for articles published in English from 2015 to February 2021. Title and abstract screening was performed followed by full text screening. Quality of the included studies was assessed using the Downs and Black score. A total of 26 studies met inclusion criteria. The largest proportion were pre-post program evaluation or cohort studies (46.2%). Many described CHW training (69%). Almost a third (30%) indicated the CHW was integrated within the health care team. Interventions aimed to provide health education (46%), links to community resources (27%), or both (27%). Chronic conditions were the concern for most interventions (38.5%) followed by women's health (34.6%). Nearly all studies reported positive improvement in measured outcomes. In addition, studies examining cost reported positive return on investment. This review offers a broad overview of CHW interventions in rural settings in the United States. It provides evidence that CHW can improve access to care in rural settings and may represent a cost-effective investment for the healthcare system.

Patient barriers to cancer clinical trial participation and navigator activities to assist.

Clinical research is vital to the discovery of new cancer treatments that can enhance health and prolong life for cancer patients, but breakthroughs in cancer treatment are limited by challenges recruiting patients into cancer clinical trials (CT). Only 3-5% of cancer patients in the United States participate in a cancer CT and there are disparities in CT participation by age, race and gender. Strategies such as patient navigation, which is designed to provide patients with education and practical support, may help to overcome challenges of CT recruitment. The current study evaluated an intervention in which lay navigators were utilized to provide patient education and practical support for helping patients overcome barriers to CT participation and related clinical care. A patient barrier checklist was utilized to record patient barriers to CT participation and care, actions taken by navigators to assist patients with these barriers, and whether or not these barriers could be overcome. Forty patients received patient navigation services. The most common barriers faced by navigated patients were fear (n=9), issues communicating with medical personnel (n=9), insurance issues (n=8), transportation difficulties (n=6) and perceptions about providers and treatment (n=4). The most common activities undertaken by navigators were making referrals and contacts on behalf of patients (e.g., support services, family, clinicians; n=25). Navigators also made arrangement for transportation, financial, medication and equipment services for patients (n=11) and proactively navigated patients (n=8). Barriers that were not overcome for two or more patients included insurance issues, lack of temporary housing resources for patients in treatment and assistance with household bills. The wide array of patient barriers to CT participation and navigator assistance documented in this study supports the CT navigator role in facilitating quality care.

Factors Influencing Oral Intake Improvement and Feeding Tube Dependency in Patients with Poststroke Dysphagia.

OBJECTIVE: To assess ischemic stroke patients regarding the relationship between lesion locations, swallowing impairment, medical and demographic factors and (1) oral intake improvement and (2) feeding tube dependency at discharge from their acute hospital stay. METHODS: We conducted an exploratory, retrospective observational longitudinal cohort study of acute, first-ever, ischemic stroke patients. Patients who had an initial nonoral feeding recommendation from a speech and language pathologist and who underwent a modified barium swallow study within their hospital stay were included. Oral intake status was measured with the Functional Oral Intake Scale (FOIS) as the change in FOIS during the hospital stay and as feeding tube dependency at hospital discharge. Associations were assessed with multiple linear regression modeling controlling for age, comorbidities, and hospital length of stay. RESULTS: We included 44 stroke patients. At hospital discharge, 93% of patients had oral intake restrictions and 30% were feeding tube dependent. Following multiple linear regression modeling, age, damage to the left superior frontal gyrus, dorsal anterior cingulate gyrus, hypothalamus, and nucleus accumbens were significant predictors for FOIS change. Feeding tube dependency showed no significant associations with any prognostic variables when controlling for confounders. CONCLUSIONS: The vast majority of patients with an initial nonoral feeding recommendation are discharged with oral intake restrictions indicating a continued need for swallowing assessments and treatment after discharge. Lesion locations associated with motivation, reward, and drive to consume food as well as swallowing impairment, higher age, and more comorbidities were related to less oral intake improvement.

Mapping acute lesion locations to physiological swallow impairments after stroke.

Dysphagia is a common deficit after a stroke, and it is frequently associated with pneumonia, malnutrition, dehydration, and poor quality of life. It is not yet fully clear which brain regions are directly related to swallowing, and how lesions affect swallow physiology. This study aimed to assess the statistical relationship between acute stroke lesion locations and impairment of specific aspects of swallow physiology. We performed lesion symptom mapping with 68 retrospectively recruited, acute, first-ever ischemic stroke patients. Lesions were determined on diffusion weighted MRI scans. Post-stroke swallow physiology was determined using the Modified Barium Swallow Study Impairment Profile (MBSImP©™). The relationship between brain lesion location and 17 physiological aspects of swallowing were tested using voxel-based and region-based statistical associations corrected for multiple comparisons using permutation thresholding. We found that laryngeal elevation, anterior hyoid excursion, laryngeal vestibular closure, and pharyngeal residue were associated with lesioned voxels or regions of interests. All components showed distinct and overlapping lesion locations, mostly in the right hemisphere, and including cortical regions (inferior frontal gyrus, pre- and postcentral gyrus, supramarginal gyrus, angular gyrus, superior temporal gyrus, insula), subcortical regions (thalamus, amygdala) and white matter tracts (superior longitudinal fasciculus, corona radiata, internal capsule, external capsule, ansa lenticularis, lenticular fasciculus). Our findings indicate that different aspects of post-stroke swallow physiology are associated with distinct lesion locations, primarily in the right hemisphere, and primarily including sensory-motor integration areas and their corresponding white matter tracts. Future studies are needed to expand on our findings and thus, support the development of a neuroanatomical model of post-stroke swallow physiology and treatment approaches targeting the neurophysiological underpinnings of swallowing post stroke.

Differences in swallow physiology in patients with left and right hemispheric strokes.

BACKGROUND: We sought to determine the impact of lesion lateralization and lesion volume on swallow impairment on group-level by comparing patients with left and right hemisphere strokes and on patient-level by analyzing patients individually. METHODS: We performed a retrospective, observational, cross-sectional study of 46 patients with unilateral (22 left, 24 right), acute, first-ever, ischemic strokes who received a diffusion weighted MRI (DW-MRI) and modified barium swallow study (MBSS) during their acute hospital stay. We determined lesion side on the DW-MRI and measured swallow physiology using the Modified Barium Swallow Impairment Profile (MBSImP™©), Penetration-Aspiration Scale (PAS), swallow timing, distance, area, and speed measures. We performed Pearson's Chi-Square and Wilcoxon Rank-Sum tests to compare patients with left and right hemisphere strokes, and Pearson or Spearman correlation, simple logistic regression, linear, and logistic multivariable regression modeling to assess the relationship between variables. RESULTS: At the group-level, there were no differences in MBSImP oral swallow impairment scores between patients with left and right hemisphere stroke. In adjusted analyses, patients with right hemisphere strokes showed significantly worse MBSImP pharyngeal total scores (p = 0.02), worse MBSImP component specific scores for laryngeal vestibular closure (Bonferroni adjusted alpha p ≤ 0.0029), and worse PAS scores (p = 0.03). Patients with right hemisphere strokes showed worse timing, distance, area, and speed measures. Lesion volume was significantly associated with MBSImP pharyngeal residue (p = 0.03) and pharyngeal total scores (p = 0.04). At the patient-level, 24% of patients (4 left, 7 right) showed opposite patterns of MBSImP oral and pharyngeal swallow impairment than seen at group-level. CONCLUSION: Our study showed differences in swallow physiology between patients with right and left unilateral strokes with patients with right hemisphere strokes showing worse pharyngeal impairment. Lesion lateralization seems to be a valuable marker for the severity of swallowing impairment at the group-level but less informative at the patient-level.

Impact of Gastrostomy Feeding Tube Placement on the 1-Year Trajectory of Care in Patients After Stroke.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) feeding tubes are commonly placed in acute stroke patients with a need for enteral nutrition. However, PEG tubes are associated with medical complications and a decrease in quality of life. We compared the 1-year care trajectory of stroke patients with and without PEG tube placement to enhance knowledge about the long-term impact of PEG tube placement. METHODS: We conducted a retrospective analysis of commercially insured stroke patients included in the Truven Health MarketScan Research Databases of 2011. We analyzed their index hospital stay and conducted 1-month, 3-months, 6-months, and 1-year follow-ups. We compared admissions to inpatient rehabilitation facilities, acute hospitals, skilled nursing facilities, outpatient hospital visits, and home visits for stroke patients with and without PEG tube placement using unadjusted and adjusted modelling. RESULTS: Of the 8911 included stroke patients, 148 patients (1.7%) had a PEG tube placed during their index hospital stay. After controlling for age, gender, stroke severity, comorbidities, and stroke type, PEG tube placement was an independent predictor for admissions to inpatient rehabilitation facilities and skilled nursing facilities. Furthermore, PEG tube placement was an independent predictor for all-cause, unplanned hospital readmissions in a multivariable logistic model (area under the receiver operating characteristic curve was .84). CONCLUSION: Stroke patients who receive a PEG tube can expect a significantly different care trajectory after being discharged from the acute hospital. Our findings can aide in predicting recovery and planning resources and identifying gaps and points for improvement in stroke care for patients with PEG tube placement.

FIM-Minimum Data Set Motor Item Bank: Short Forms Development and Precision Comparison in Veterans.

OBJECTIVE: To improve the practical use of the short forms (SFs) developed from the item bank, we compared the measurement precision of the 4- and 8-item SFs generated from a motor item bank composed of the FIM and the Minimum Data Set (MDS). DESIGN: The FIM-MDS motor item bank allowed scores generated from different instruments to be co-calibrated. The 4- and 8-item SFs were developed based on Rasch analysis procedures. This article compared person strata, ceiling/floor effects, and test SE plots for each administration form and examined 95% confidence interval error bands of anchored person measures with the corresponding SFs. We used 0.3 SE as a criterion to reflect a reliability level of .90. SETTING: Veterans' inpatient rehabilitation facilities and community living centers. PARTICIPANTS: Veterans (N=2500) who had both FIM and the MDS data within 6 days during 2008 through 2010. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Four- and 8-item SFs of FIM, MDS, and FIM-MDS motor item bank. RESULTS: Six SFs were generated with 4 and 8 items across a range of difficulty levels from the FIM-MDS motor item bank. The three 8-item SFs all had higher correlations with the item bank (r=.82-.95), higher person strata, and less test error than the corresponding 4-item SFs (r=.80-.90). The three 4-item SFs did not meet the criteria of SE <0.3 for any theta values. CONCLUSIONS: Eight-item SFs could improve clinical use of the item bank composed of existing instruments across the continuum of care in veterans. We also found that the number of items, not test specificity, determines the precision of the instrument.

Linking Existing Instruments to Develop an Activity of Daily Living Item Bank.

This study examined dimensionality and item-level psychometric properties of an item bank measuring activities of daily living (ADL) across inpatient rehabilitation facilities and community living centers. Common person equating method was used in the retrospective veterans data set. This study examined dimensionality, model fit, local independence, and monotonicity using factor analyses and fit statistics, principal component analysis (PCA), and differential item functioning (DIF) using Rasch analysis. Following the elimination of invalid data, 371 veterans who completed both the Functional Independence Measure (FIM) and minimum data set (MDS) within 6 days were retained. The FIM-MDS item bank demonstrated good internal consistency (Cronbach's α = .98) and met three rating scale diagnostic criteria and three of the four model fit statistics (comparative fit index/Tucker-Lewis index = 0.98, root mean square error of approximation = 0.14, and standardized root mean residual = 0.07). PCA of Rasch residuals showed the item bank explained 94.2% variance. The item bank covered the range of θ from -1.50 to 1.26 (item), -3.57 to 4.21 (person) with person strata of 6.3. The findings indicated the ADL physical function item bank constructed from FIM and MDS measured a single latent trait with overall acceptable item-level psychometric properties, suggesting that it is an appropriate source for developing efficient test forms such as short forms and computerized adaptive tests.

Stroke Administrative Severity Index: using administrative data for 30-day poststroke outcomes prediction.

AIM: Current stroke severity scales cannot be used for archival data. We develop and validate a measure of stroke severity at hospital discharge (Stroke Administrative Severity Index [SASI]) for use in billing data. METHODS: We used the NIH Stroke Scale (NIHSS) as the theoretical framework and identified 285 relevant International Classification of Diseases, 9th Revision diagnosis and procedure codes, grouping them into 23 indicator variables using cluster analysis. A 60% sample of stroke patients in Medicare data were used for modeling risk of 30-day postdischarge mortality or discharge to hospice, with validation performed on the remaining 40% and on data with NIHSS scores. RESULTS: Model fit was good (p > 0.05) and concordance was strong (C-statistic = 0.76-0.83). The SASI predicted NIHSS at discharge (C = 0.83). CONCLUSION: The SASI model and score provide important tools to control for stroke severity at time of hospital discharge. It can be used as a risk-adjustment variable in administrative data analyses to measure postdischarge outcomes.

Linking existing instruments to develop a continuum of care measure: accuracy comparison using function-related group classification.

PURPOSES: To compare measurement accuracy of test forms with varied number of items (13, 8, and 4 items) generated from the self-care physical function item bank composed of Functional Independence Measure (FIM™) and the Minimum Data Set (MDS). METHODS: Retrospective data analysis of 2499 Veterans who completed both FIM and MDS within 6 days. We compared measurement accuracy between the converted FIM (FIMc) motor score generated from the MDS and the original FIM (FIMa) motor score (13 items) at: (a) individual-level using point differences, and (b) group-level using function-related group (FRG). RESULTS: The differences of mean FIMa and FIMc scores were between 0.05 and 1.07 points for all test forms. Over 81% of FIMc from MDS_13 were within 15 points of the FIMa. 81-90% of FRGs generated by the FIM short forms was identical to those generated by the FIMa for stroke, lower limb amputation, knee and hip replacement; and 59.9-90.5% by all MDS test forms. All MDS test forms had above 74% agreement with same or adjacent FMGs (ICC 0.65-0.91). CONCLUSIONS: The accuracy is dependent on the comparison level (i.e., individual or group), length of the test and which FRG is used. Our results partially support using existing instruments-without decreasing the number of the items-to generate a continuum of care measurement.

Factors Associated With Gastrostomy Tube Removal in Patients With Dysphagia After Stroke: A Review of the Literature.

Gastrostomy feeding tubes are commonly placed in patients with dysphagia after stroke. The subsequent removal of the tube is a primary goal during rehabilitation. The purpose of our review was to identify predictors and factors associated with gastrostomy tube removal in patients with dysphagia after stroke. We conducted a literature review following the PRISMA statement and included the search databases PubMed, Scopus, Web of Science, and CINAHL. Articles were included in the final analysis per predefined inclusion and exclusion criteria. Our search retrieved a total of 853 results consisting of 416 articles (after eliminating duplicates). Six articles met our final eligibility criteria. The following factors were identified in at least 1 article as being significantly associated with gastrostomy tube removal: reduced age, decreased number of comorbidities, prolonged inpatient rehabilitation stay, absence of bilateral stroke, nonhemorrhagic stroke, reduced dysphagia severity, absence of aspiration, absence of premature bolus loss, and timely initiation of pharyngeal swallow. Aspiration was the only factor that was investigated by 2 studies-both using multiple regression and both showing stable results, with absence of aspiration increasing the chances for tube removal. In conclusion, little is known about factors associated with gastrostomy tube removal in patients with dysphagia after stroke. Most of the identified factors are associated with stroke or disease severity; however, the role of the individual factors remains unclear. The strongest predictor appears to be absence of aspiration on modified barium swallow studies emphasizing the importance of instrumental swallow studies in this patient population.

Psychometric properties of upper extremity outcome measures validated by Rasch analysis: a systematic review.

The aim of this study was to provide a systematic review of psychometric studies of upper extremity (UE) outcome measures validated by Rasch analysis and assess the extent to which their measurement areas cover the domains of the International Classification of Functioning, Disability and Health model. A literature search from 1966 to 2014 was performed using PubMed, CINAHL, Scopus, PsycINFO, Ovid/MEDLINE, ERIC, and Cochrane library. Fourteen keywords indicating 'upper extremity', 'psychometric properties', and 'outcome measures' were used. From a total of 1039 studies, 17 UE impairment outcome measures that fulfilled the inclusion criteria were selected and reviewed. The instruments targeted adults with various neurological or orthopedic conditions (i.e. stroke, upper and lower extremity impairments, and back pain). Twelve instruments targeted the body structure/function domain and 11 instruments targeted the activity domain of the International Classification of Functioning, Disability and Health model. Only two instruments targeted the participation domain. All outcome measures showed reasonably sound psychometric properties, including construct validity (good fit statistic), moderate to high reliability (r=0.86-0.99), and sound dimensionality (unidimensional). The reviewed psychometric properties of UE outcome measures are useful for clinicians in deciding which measures to use to assess patients' UE impairments.

Factors Associated With Gastrostomy Tube Removal in Patients With Dysphagia After Stroke.

Gastrostomy feeding tubes are commonly placed in patients with dysphagia after stroke. The subsequent removal of the tube is a primary goal during rehabilitation. The purpose of our review was to identify predictors and factors associated with gastrostomy tube removal in patients with dysphagia after stroke. We conducted a literature review following the PRISMA statement and included the search databases PubMed, Scopus, Web of Science, and CINAHL. Articles were included in the final analysis per predefined inclusion and exclusion criteria. Our search retrieved a total of 853 results consisting of 416 articles (after eliminating duplicates). Six articles met our final eligibility criteria. The following factors were identified in at least 1 article as being significantly associated with gastrostomy tube removal: reduced age, decreased number of comorbidities, prolonged inpatient rehabilitation stay, absence of bilateral stroke, nonhemorrhagic stroke, reduced dysphagia severity, absence of aspiration, absence of premature bolus loss, and timely initiation of pharyngeal swallow. Aspiration was the only factor that was investigated by 2 studies-both using multiple regression and both showing stable results, with absence of aspiration increasing the chances for tube removal. In conclusion, little is known about factors associated with gastrostomy tube removal in patients with dysphagia after stroke. Most of the identified factors are associated with stroke or disease severity; however, the role of the individual factors remains unclear. The strongest predictor appears to be absence of aspiration on modified barium swallow studies emphasizing the importance of instrumental swallow studies in this patient population.

Patient participation in cancer clinical trials: A pilot test of lay navigation.

BACKGROUND: Clinical trials (CT) represent an important treatment option for cancer patients. Unfortunately, patients face challenges to enrolling in CTs, such as logistical barriers, poor CT understanding and complex clinical regimens. Patient navigation is a strategy that may help to improve the delivery of CT education and support services. We examined the feasibility and initial effect of one navigation strategy, use of lay navigators. METHODS: A lay CT navigation intervention was evaluated in a prospective cohort study among 40 lung and esophageal cancer patients. The intervention was delivered by a trained lay navigator who viewed a 17-minute CT educational video with each patient, assessed and answered their questions about CT participation and addressed reported barriers to care and trial participation. RESULTS: During this 12-month pilot project, 85% (95% CI: 72%-93%) of patients eligible for a therapeutic CT consented to participate in the CT navigation intervention. Among navigated patients, CT understanding improved between pre- and post-test (means 3.54 and 4.40, respectively; p-value 0.004), and 95% (95% CI: 82%-98%) of navigated patients consented to participate in a CT. Navigated patients reported being satisfied with patient navigation services and CT participation. CONCLUSIONS: In this formative single-arm pilot project, initial evidence was found for the potential effect of a lay navigation intervention on CT understanding and enrollment. A randomized controlled trial is needed to examine the efficacy of the intervention for improving CT education and enrollment.

Practice Patterns of Percutaneous Endoscopic Gastrostomy Tube Placement in Acute Stroke: Are the Guidelines Achievable?

OBJECTIVES: Our objectives were to evaluate trends in percutaneous endoscopic gastrostomy (PEG) tube placement rate and timing in acute stroke patients. We hypothesized that noncompliance with clinical practice guidelines for timing of tube placement and an increase in placement occurred because of a decrease in length of hospital stay. METHODS: We conducted a retrospective observational study of archival hospital billing data from the Florida state inpatient healthcare cost and utilization project database from 2001 to 2012 for patients with a primary diagnosis of stroke. Outcome measures were timing of PEG tube placements by year (2006-2012), rate of placements by year (2001-2012), and length of hospital stay. Univariate analyses and simple and multivariable logistic regression analyses were conducted. RESULTS: The timing of gastrostomy tube placement remained stable with a median of 7 days post admission from 2006 through 2012. The proportion of tubes that were placed at or after 14 days and thereby met the guideline recommendations varied from 14.09% in 2006 to 13.41% in 2012. The rate of tube placement in stroke patients during the acute hospital stay decreased significantly by 25% from 6.94% in 2001 to 5.22% in 2012 (P < .0001). The length of hospital stay for all stroke patients decreased over the study period (P < .0001). CONCLUSIONS: The vast majority of PEG tube placements happen earlier than clinical practice guidelines recommend. Over the study period, the rate of tubes placed in stroke patients decreased during the acute hospital stay despite an overall reduced length of stay.