The Montana Postural Care Project: A pilot study implementing posture care management in a rural, low-resource region.

Background: Mobility impairment limits control of posture and body alignment. This leads to altered body shapes, co-occurring problems with pain and sleep, cardiopulmonary concerns, digestive health issues, and emergent health outcomes, which further complicate functions of daily living. 24-hour posture care management was developed to remedy these challenges by restoring body symmetry. Objective: To determine the feasibility of introducing posture care management to a rural-based, medically complex patient population, evaluate response of body symmetry, and examine its impact on pain and sleep quality. Methods: This pilot study employed a longitudinal, quasi-experimental study design from March 2016 to September 2018. The posture care management intervention introduced positioning support for use when lying down, a personalized training workshop for caregiver teams, and in-home initial and follow-up assessments to provide materials and collaboratively develop a personalized care plan. Participants were followed pre-post for 6-9 months. Results: A total of 73 participants enrolled in the study; 55 (75 %) completed. The majority were male (55 %) with a median age of 11. Most caregivers were immediate family members, and most participants had 1+ diagnosis characterized as a neurodevelopmental disorder. A majority of participants improved body symmetry (56-76 %), and 53 % with comparable information saw improvement in body symmetry with no worsening of pain or sleep quality. Conclusion: This study established the feasibility of administering posture care management in North America. These findings provide preliminary evidence of improvements in body symmetry and address concerns that posture care management can interfere with pain and sleep. Future research should consider levels of caregiver engagement and explore remote-monitored options of a posture care management intervention.

The Use of Holographic Memory Resolution® to Improve the Physical and Biopsychosocial Symptoms of Chronic Pain: A Feasibility, Mixed Methods Study.

Objective: Holographic Memory Resolution® (HMR®), a mind-based therapy, has been used for decades as a nonpharmacologic intervention for trauma imprinting to alleviate depression, anxiety, pain, and post-traumatic stress disorder (PTSD). No clinical studies were found examining the use of HMR®. This study examined the feasibility and preliminary efficacy of administering HMR® to individuals experiencing chronic pain and related biopsychosocial symptoms. Methods: A feasibility, mixed-methods study was conducted between October 2021 and July 2022 and included four HMR® sessions over 1-12 weeks. A convenience sample was comprised of 60 adults suffering from chronic physical or emotional pain of 4+ (0-10 scale) over 6+ months at two clinics in the U.S. Baseline and subsequent surveys after sessions 2, 3, and 4 assessed symptom response. Symptoms were longitudinally measured via self-report of depression, anxiety, somatic symptom burden, PTSD, and vitality. Results: 73% completed all four sessions, demonstrating feasibility. Ages ranged from 19 to 80 years, 85% were female, and 87% were Caucasian. 52% reported high risk for toxic stress. Four symptoms decreased significantly: depression (p = 0.05), anxiety (p = 0.03), symptom burden (p < 0.01) and PTSD symptoms (p = 0.01); vitality improved. Conclusions: HMR® may be a feasible intervention to address chronic pain and accompanying biopsychosocial symptoms; a randomized controlled trial is the next step to measure efficacy. Unlike other mind-based therapies, HMR® participants use their own internal language for identification and resolution of the pain. The trauma imprinting can then be gently addressed, and the memory-based components of pain resolved or reduced, which empowers participants to improve their well-being. Trial registration: ClinicalTrials.gov Identifier: NCT05001399.

Therapeutic positioning to address neuromuscular scoliosis on an adolescent child with Aicardi syndrome: a case study.

Among persons with neuromuscular mobility limitations, therapeutic positioning has been implemented to improve body function, avoid secondary complications such as contractures and body shape distortions, and optimize body energy through restorative sleep. This case study describes the application of a 24-hour posture care management intervention for a preadolescent girl with Aicardi syndrome. The intervention was administered by adding therapeutic bed positioning to use of a custom molded wheelchair seating system. Over the 6-year intervention period overlapping with the subject's adolescent years (age 11-17), marked improvement was observed in thoracic shape and symmetry. Moreover, the subject's mother reported regular full-nights of uninterrupted sleep, relaxed muscle tone upon waking, a stronger cough with less audible congestion, more efficient swallowing and zero hospitalizations. The 24-hour posture care management intervention offers an alternative option for families and caregivers of persons with neuromuscular mobility impairments who wish to use a low-risk, noninvasive, locally available approach to improve body symmetry, increase hours of restorative sleep, and ease caregiving routines. Further research in 24-hour posture care management, including positioning for sleep and rest, should be explored in individuals with complex movement limiting disabilities who are at risk of developing neuromuscular scoliosis.

A qualitative study of rural healthcare providers' views of social, cultural, and programmatic barriers to healthcare access.

BACKGROUND: Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient's acceptance of services that they are to receive and ensuring appropriate fit between services and a patient's specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution. METHODS: We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients' treatment plans. Semi-structured interviews and content analysis were used to explore barriers-appropriateness and acceptability-to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings. RESULTS: Five key themes emerged from analysis: 1) a friction exists between aspects of patients' rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. CONCLUSIONS: Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems' ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study.

BACKGROUND: Having sufficient healthcare access helps individuals proactively manage their health challenges, leading to positive long-term health outcomes. In the U.S., healthcare access is a public health issue as many Americans lack the physical or financial resources to receive the healthcare services they need. Mental healthcare is especially difficult due to lingering social stigmas and scarcity of services. Subsequently, those with mental health impairment tend to be complex patients, which may convolute delivery of services. OBJECTIVE: To quantify the prevalence of barriers to healthcare access among U.S. adults with and without mental health challenges (MHC) and evaluate the relationship between MHC and no usual source of care (NUSC). METHODS: A cross-sectional study was conducted with data from the 2017-2018 National Health Interview Survey. MHC was categorized into three levels: no (NPD), moderate (MPD) and severe (SPD) psychological distress. Eight barriers were quantified; one was used as the primary outcome: NUSC. Multivariable logistic regression was used to quantify associations between these characteristics. RESULTS: The sample included 50,103 adults. Most reported at least one barrier to healthcare access (95.6%) while 13.3% reported NUSC. For each barrier, rates were highest among those with SPD and lowest for those with NPD. However, in the multivariable model, SPD and MPD were not associated with NUSC (OR, 0.92; 95% CI, 0.83-1.01; 0.88; 0.73-1.07). Male sex (1.92; 1.78-2.06), Hispanic race/ethnicity (1.59; 1.42-1.77), and worry to afford emergent (1.38; 1.26-150) or normal (1.60; 1.46-1.76) healthcare were associated with NUSC. Having a current partner (0.88; 0.80-0.96), dependent(s) (0.77; 0.70-0.85) and paid sick leave (0.60; 0.56-0.65) were protective. CONCLUSIONS: The most prevalent barriers to healthcare access link to issues with affordability, and MHC exist more often when any barrier is reported. More work is needed to understand the acuity of burden as other social and environmental factors may hold effect.

Bilateral Total Knee Arthroplasty: Predictors of Discharge Disposition.

BACKGROUND: Total knee arthroplasty is on the rise. Some patients choose to undergo simultaneous bilateral total knee arthroplasty (simultaneous BTKA). No studies were found that examined which patients may be better candidates to successfully undergo this procedure. PURPOSE: The purpose of this study was to determine personal and comorbid characteristics of patients undergoing simultaneous BTKA that are predictive of length of stay (LOS) and discharge to a skilled nursing facility (SNF). METHODS: A retrospective database study of 125 patients post-simultaneous BTKA was conducted. Binary and multiple linear regression models identified personal and clinical predictors of LOS and SNF discharge. RESULTS: Body mass index (BMI) (p < .001) and SNF discharge (p = .025) were significant predictors of increased LOS and explained 18% of the variance. Older age, female sex, and presence of cardiopulmonary disease predicted SNF admission; 21% of the variance for SNF discharge was explained by the model. CONCLUSION: Patients with a high BMI should be carefully screened before undergoing simultaneous BTKA; older patients, women, and those with cardiopulmonary disease may benefit from early discharge planning for SNF transfer, thereby decreasing LOS and hospital utilization.

Evaluating the Impact of Treatment Care Planning on Quality Measures.

PURPOSE: The Center for Medicare & Medicaid Innovation Oncology Care Model (OCM) requires documentation of a 13-point Institute of Medicine care management plan for Medicare patients. In addition, OCM includes evaluation of quality using key performance measures that align with the ASCO Quality Oncology Practice Initiative (QOPI). Both efforts are designed to improve patient-centered care and foster patients' engagement in their care plan. METHODS: A multicenter quality improvement project was conducted to develop a strategy to meet the OCM treatment planning (TP) requirement (Plan), pilot clinician education coupled with use of electronic TP in early-stage breast cancer (Do), evaluate the impact of TP on QOPI measures (Study), and develop recommendations for future implementation (Act). RESULTS: Thirty-three clinical providers and 171 women with breast cancer were included. Improved performance on several QOPI measures was observed for the intervention group compared with the historical control group. CONCLUSION: Meeting the OCM TP requirement through incorporating a technology solution provided an opportunity for quality improvement and preparation for full-scale TP within the OCM. TP delivery was associated with improved performance on select ASCO QOPI measures, which is likely to correspond with improved performance on quality measures within OCM.

Prospective, Open Trial of Adjunctive Triple Chronotherapy for the Acute Treatment of Depression in Adolescent Inpatients.

OBJECTIVE: The aim of this pilot study was to explore the feasibility and proof of concept of triple chronotherapy (TCT) as a nonpharmacological adjunctive treatment in the acute management of depression in the adolescent population. METHODS: Thirty-one adolescents with nonpsychotic moderate-to-severe depression were included in the study. The 4-day TCT intervention comprised one night of sleep deprivation followed by 3 days of sleep phase advancement and daily bright light therapy. Primary outcomes were feasibility and depression, as measured by the Hamilton Depression Scale-17 (HAMD-17). Secondary outcomes included severity of illness, anxiety, self-harm, insomnia, and suicidality. RESULTS: Twenty-nine (94%) adolescents completed the 4-day TCT intervention. Twenty-six (84%) of the 31 enrolled patients experienced a reduction in depressive symptoms of at least 50% from baseline; 24 (77%) achieved remission, defined as a HAMD-17 score less than 8. The mean depression score was severe before the start of the intervention ( \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 21.8 ± 3.8) and dropped below the remission threshold by day 4 ( \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 4.4 ± 5.1; p < 0.001); the mean depression score was mild at 1 week (n = 17; \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 9.3 ± 5.2; p < 0.001) and 1 month (n = 10, \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\overline X$$ \end{document} = 7.8 ± 5.2; p < 0.001). Severity of illness scores according to the Clinical Global Impressions severity subscale improved from a mean of 5.3 at baseline to 3.1 following the TCT intervention (p < 0.0001); the effect was sustained through the 1-week postdischarge and the 1-month follow-up. Secondary outcomes showed significant improvement following the 4-day TCT intervention; improvement was sustained through the 1-week and 1-month follow-up periods. CONCLUSIONS: This pilot study determined TCT to be a feasible, safe, rapid, and potentially effective adjunctive treatment for depression in the adolescent population.

Predictors of oversedation in hospitalized patients.

PURPOSE: Results of a study to determine demographic and clinical characteristics predictive of oversedation and potential opioid-induced respiratory depression (OIRD) in hospitalized patients are reported. METHODS: In a retrospective case-controlled study, an incident reporting database was searched to identify cases of in-hospital oversedation; to form the control group, patients who did not experience an oversedation event while hospitalized were sampled in reverse chronological order until the desired total sample size (n = 225) was obtained. An allocation ratio of 2:1 was specified to adjust for case variability. Binary logistic regression was employed to identify factors predictive of oversedation. RESULTS: Female sex (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.05-5.50), comorbid renal disease (OR, 4.22; 95% CI, 1.66-10.70), untreated sleep apnea (OR, 32.32; 95% CI, 2.72-384.72), receipt of long-acting oxycodone (OR, 4.76; 95% CI, 1.70-13.33), and as-needed use of hydromorphone (OR, 2.73; 95% CI, 1.19-6.27) were significant predictors of oversedation; as-needed analgesia administered by the oral route (OR, 0.16; 95% CI, 0.07-0.36) or i.v. route (OR, 0.33; 95% CI, 0.14-0.80) had a significant protective effect. The final prediction model explained 47.8% of variance in oversedation risk and was found to have strong discriminatory performance. CONCLUSION: The identified risk factors for oversedation and potential OIRD in hospitalized patients can form the basis of quality-improvement initiatives to prevent oversedation through improved prescribing and patient monitoring.

Intent-to-treat analysis of a simultaneous multisite telehealth diabetes prevention program.

OBJECTIVE: Determine the effectiveness of a 16-week modified diabetes prevention program (DPP) administered simultaneously to multiple rural communities from a single urban site, as compared with a similar face-to-face intervention. A 12-week intervention was evaluated to consider minimization of staff costs in communities where resources are limited. RESEARCH DESIGN AND METHODS: A prospective cohort study compared DPP interventions implemented in rural (via telehealth technology) and urban (face-to-face) communities using an intent-to-treat analysis. Primary outcome measures included 5% and 7% body weight loss. Logistic regression analyses were used to determine predictors of intervention success and included a variable for treatment effect. RESULTS: Between 2010 and 2015, up to 667 participants were enrolled in the study representing one urban and 15 rural communities across Montana. The 16-week urban and rural interventions were comparable; 33.5% and 34.6% of participants lost 7% body weight, respectively; 50% and 47% lost 5% (p=0.22). Participants who were male (OR=2.41; 95% CI 1.32 to 4.40), had lower baseline body mass index (OR=1.03; 95% CI 1.01 to 1.07), attended more sessions (OR=1.33; 95% CI 1.11 to 1.58), and more frequently reported (OR=3.84; 95% CI 1.05 to 14.13) and met daily fat gram (OR=4.26; 95% CI 1.7 to 10.6) and weekly activity goals (OR=2.46; 95% CI 1.06 to 5.71) were more likely to meet their 7% weight loss goal. Predictors of meeting weight loss goals were similar for participants enrolled in the 12-week intervention. CONCLUSIONS: Using telehealth technology to administer a modified DPP to multiple rural communities simultaneously demonstrated weight loss results comparable to those in a face-to-face intervention. Given the limitation of resources, linking rural areas to urban centers using telemedicine may increase access to much needed services to prevent or delay progression to diabetes.

Improving Blood Pressure Control Using Smart Technology.

BACKGROUND: The authors sought to determine if wireless oscillometric home blood pressure monitoring (HBPM) that integrates with smartphone technology improves blood pressure (BP) control among patients with new or existing uncontrolled hypertension (HTN). METHODS: A prospective observational cohort study monitored BP control before and after an educational intervention and introduction to HBPM. Patients in the intervention group were instructed to track their BP using a smartphone device three to seven times per week. Cases were matched to controls at a 1:3 allocation ratio on several clinical characteristics over the same period and received usual care. The proportion of patients with controlled BP was compared between groups at pre- and postintervention, ∼9 months later. Results and Materials: The total study population included 484 patients with mean age 60 years (range 23-102 years), 47.7% female, and 84.6% Caucasian. Mean preintervention BP was 137.8 mm Hg systolic and 81.4 mm Hg diastolic. Mean BP control rates improved for patients who received HBPM from 42% to 67% compared with matched control patients who improved from 59% to 67% (p < 0.01). CONCLUSION: HBPM with smartphone technology has the potential to improve HTN management among patients with uncontrolled or newly diagnosed HTN. Technology needs to be easy to use and operate and would work best when integrated into local electronic health record systems. In systems without this capability, medical assistants or other personnel may be trained to facilitate the process. Nurse navigator involvement was instrumental in bridging communication between the patients and provider.

Nurses' Knowledge and Attitudes about Pain: Personal and Professional Characteristics and Patient Reported Pain Satisfaction.

Pain is a nursing sensitive indicator and yet pain is often not well managed in both hospital and ambulatory settings. Improving nurse knowledge and attitudes about pain may translate to improved patient outcomes. The objective of this study was to investigate knowledge and attitudes about pain (KAP) in nurses who work in diverse settings, professional and personal characteristics that predict KAP, and whether KAP correlated with patient satisfaction according to Hospital Consumer Assessment of Healthcare Providers (HCAHPS). Descriptive, cross-sectional, correlational study. A large integrated health care facility in the northwest. A total of 217 registered nurses working in acute, ambulatory, and long-term care. A Pain Knowledge and Attitudes Survey was administered to registered nurses in diverse settings. Scores were examined for personal and professional predictors of KAP and correlated with HCAHPS patient satisfaction surveys. Nurses scored an average of 72%; nurses in long-term care scored the highest. Having more than 5 years of nursing experience, being a certified nurse, and receiving pain education in the last year were predictive of a higher score on the KAP survey, which explained only 9.8% of the variance. Unit mean KAP scores were highly correlated with unit-based HCAHPS scores (r = 0.917, p = .01). Certified nurses scored higher on the KAP survey, consistent with other studies. This study suggests that having more knowledge and better attitudes about pain may improve patient satisfaction of pain. Further studies are needed that link knowledge and attitudes about pain to patient outcomes.