Integrated Genomic and Social Network Analyses of SARS-CoV-2 Transmission in the Healthcare Setting.

BACKGROUND: Infection prevention (IP) measures are designed to mitigate the transmission of pathogens in healthcare. Using large-scale viral genomic and social network analyses, we determined if IP measures used during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic were adequate in protecting healthcare workers (HCWs) and patients from acquiring SARS-CoV-2. METHODS: We performed retrospective cross-sectional analyses of viral genomics from all available SARS-CoV-2 viral samples collected at UC San Diego Health and social network analysis using the electronic medical record to derive temporospatial overlap of infections among related viromes and supplemented with contact tracing data. The outcome measure was any instance of healthcare transmission, defined as cases with closely related viral genomes and epidemiological connection within the healthcare setting during the infection window. Between November 2020 through January 2022, 12 933 viral genomes were obtained from 35 666 patients and HCWs. RESULTS: Among 5112 SARS-CoV-2 viral samples sequenced from the second and third waves of SARS-CoV-2 (pre-Omicron), 291 pairs were derived from persons with a plausible healthcare overlap. Of these, 34 pairs (12%) were phylogenetically linked: 19 attributable to household and 14 to healthcare transmission. During the Omicron wave, 2106 contact pairs among 7821 sequences resulted in 120 (6%) related pairs among 32 clusters, of which 10 were consistent with healthcare transmission. Transmission was more likely to occur in shared spaces in the older hospital compared with the newer hospital (2.54 vs 0.63 transmission events per 1000 admissions, P < .001). CONCLUSIONS: IP strategies were effective at identifying and preventing healthcare SARS-CoV-2 transmission.

Exercise capacity following SARS-CoV-2 infection is related to changes in cardiovascular and lung function in military personnel.

BACKGROUND: Since the COVID-19 pandemic, post-COVID syndrome (persistent symptoms/complications lasting >12 weeks) continues to pose medical and economic challenges. In military personnel, where optimal fitness is crucial, prolonged limitations affecting their ability to perform duties has occupational and psychological implications, impacting deployability and retention. Research investigating post-COVID syndrome exercise capacity and cardiopulmonary effects in military personnel is limited. METHODS: UK military personnel were recruited from the Defence Medical Services COVID-19 Recovery Service. Participants were separated into healthy controls without prior SARS-CoV-2 infection (group one), and participants with prolonged symptoms (>12 weeks) after mild-moderate (community-treated) and severe (hospitalised) COVID-19 illness (group 2 and 3, respectively). Participants underwent cardiac magnetic resonance imaging (CMR) and spectroscopy, echocardiography, pulmonary function testing and cardiopulmonary exercise testing (CPET). RESULTS: 113 participants were recruited. When compared in ordered groups (one to three), CPET showed stepwise decreases in peak work, work at VT1 and VO2 max (all p < 0.01). There were stepwise decreases in FVC (p = 0.002), FEV1 (p = 0.005), TLC (p = 0.002), VA (p < 0.001), and DLCO (p < 0.002), and a stepwise increase in A-a gradient (p < 0.001). CMR showed stepwise decreases in LV/RV volumes, stroke volumes and LV mass (LVEDVi/RVEDVi p < 0.001; LVSV p = 0.003; RVSV p = 0.001; LV mass index p = 0.049). CONCLUSION: In an active military population, post-COVID syndrome is linked to subclinical changes in maximal exercise capacity. Alongside disease specific changes, many of these findings share the phenotype of deconditioning following prolonged illness or bedrest. Partitioning of the relative contribution of pathological changes from COVID-19 and deconditioning is challenging in post-COVID syndrome recovery.

Associations Between Mental and Physical Illness Comorbidity and Hospital Utilization.

OBJECTIVE: Characterize the prevalence of chronic physical illness types and mental illness and their comorbidity among adolescents and young adults (AYA) and assess the association of comorbidity on hospital utilization. METHODS: This study features a population-level sample of 61 339 insurance-eligible AYA with an analytic sample of 49 089 AYA (aged 12-21) in Vermont's 2018 all-payer database. We used multiple logistic regressions to examine the associations between physical illness types and comorbid mental illness and emergency department (ED) use and inpatient hospitalization. RESULTS: The analytic sample was 50% female, 63% Medicaid, and 43% had ≥1 chronic illness. Mental illness was common (31%) and highly comorbid with multiple physical illnesses. Among AYA with pulmonary illness, those with comorbid mental illness had 1.74-times greater odds (95% confidence interval [CI]: 1.49-2.05, P ≤.0005) of ED use and 2.9-times greater odds (95% CI: 2.05-4.00, P ≤.0005) of hospitalization than those without mental illness. Similarly, comorbid endocrine and mental illness had 1.84-times greater odds of ED use (95% CI: 1.39-2.44, P ≤.0005) and 2.1-times greater odds of hospitalization (95% CI: 1.28-3.46, P = .003), comorbid neurologic and mental illness had 1.36-times greater odds of ED use (95% CI: 1.18-1.56, P ≤.0005) and 2.4-times greater odds of hospitalization (95% CI: 1.73-3.29, P ≤.0005), and comorbid musculoskeletal and mental illness had 1.38-times greater odds of ED use (95% CI: 1.02-1.86, P = .04) and 2.1-times greater odds of hospitalization (95% CI: 1.20-3.52, P = .01). CONCLUSIONS: Comorbid physical and mental illness was common. Having a comorbid mental illness was associated with greater ED and inpatient hospital utilization across multiple physical illness types.

The length of hospital stay following bariatric surgery in Australia: the impact of patient, procedure, system and surgeon.

BACKGROUND: The length of a patient's stay (LOS) in a hospital is one metric used to compare the quality of care, as a longer LOS may flag higher complication rates or less efficient processes. A meaningful comparison of LOS can only occur if the expected average length of stay (ALOS) is defined first. This study aimed to define the expected ALOS of primary and conversion bariatric surgery in Australia and to quantify the effect of patient, procedure, system, and surgeon factors on ALOS. METHODS: This was a retrospective observational study of prospectively maintained data from the Bariatric Surgery Registry of 63 604 bariatric procedures performed in Australia. The primary outcome measure was the expected ALOS for primary and conversion bariatric procedures. The secondary outcome measures quantified the change in ALOS for bariatric surgery resulting from patient, procedure, hospital, and surgeon factors. RESULTS: Uncomplicated primary bariatric surgery had an ALOS (SD) of 2.30 (1.31) days, whereas conversion procedures had an ALOS (SD) of 2.71 (2.75) days yielding a mean difference (SEM) in ALOS of 0.41 (0.05) days, P < 0.001. The occurrence of any defined adverse event extended the ALOS of primary and conversion procedures by 1.14 days (CI 95% 1.04-1.25), P < 0.001 and 2.33 days (CI 95% 1.54-3.11), P < 0.001, respectively. Older age, diabetes, rural home address, surgeon operating volume and hospital case volume increased the ALOS following bariatric surgery. CONCLUSIONS: Our findings have defined Australia's expected ALOS following bariatric surgery. Increased patient age, diabetes, rural living, procedural complications and surgeon and hospital case volume exerted a small but significant increase in ALOS. STUDY TYPE: Retrospective observational study of prospectively collected data.

Bariatric Surgery Efficiency, Safety and Health Outcomes in Government Versus Privately Funded Hospitals.

PURPOSE: This study aims to determine if the hospital efficiency, safety and health outcomes are equal in patients who receive bariatric surgery in government-funded hospitals (GFH) versus privately funded hospitals (PFH). MATERIALS AND METHODS: This is a retrospective observational study of prospectively maintained data from the Australia and New Zealand Bariatric Surgery Registry of 14,862 procedures (2134 GFH and 12,728 PFH) from 33 hospitals (8 GFH and 25 PFH) performed in Victoria, Australia, between January 1st, 2015, and December 31st, 2020. Outcome measures included the difference in efficacy (weight loss, diabetes remission), safety (defined adverse event and complications) and efficiency (hospital length of stay) between the two health systems. RESULTS: GFH treated a higher risk patient group who were older by a mean (SD) 2.4 years (0.27), P < 0.001; had a mean 9.0 kg (0.6) greater weight at time of surgery, P < 0.001; and a higher prevalence of diabetes at day of surgery OR = 2.57 (CI95%2.29-2.89), P < 0.001. Despite these baseline differences, both GFH and PFH yielded near identical remission of diabetes which was stable up to 4 years post-operatively (57%). There was no statistically significant difference in defined adverse events between the GFH and PFH (OR = 1.24 (CI95% 0.93-1.67), P = 0.14). Both healthcare settings demonstrated that similar covariates affect length of stay (LOS) (diabetes, conversion bariatric procedures and defined adverse event); however, these covariates had a greater effect on LOS in GFH compared to PFH. CONCLUSIONS: Bariatric surgery performed in GFH and PFH yields comparable health outcomes (metabolic and weight loss) and safety. There was a small but statistically significant increased LOS following bariatric surgery in GFH.

The SYMPTOM-upper gastrointestinal study: A mixed methods study exploring symptom appraisal and help-seeking in Australian upper gastrointestinal cancer patients.

OBJECTIVE: There is limited evidence on the development of pancreatic and oesophagogastric cancer, how patients decide to seek help and the factors impacting help-seeking. Our study, the first in Australia, aimed to explore symptom appraisal and diagnostic pathways in these patients. A secondary aim was to examine the potential to recruit cancer patients through a cancer quality registry. METHODS: Patients diagnosed with pancreatic or oesophagogastric cancer were recruited through Monash University's Upper-Gastrointestinal Cancer Registry. Data collected through general practitioners (GP) and patient questionnaires included symptoms and their onset, whereas patient interviews focused on the patient's decision-making in seeking help from healthcare pracitioners. Data collection and analysis was informed by the Aarhus statement. Coding was inductive, and themes were mapped onto the Model of Pathways to Treatment. RESULTS: Between November 2018 and March 2020, 27 patient questionnaires and 13 phone interviews were completed. Prior to diagnosis, patients lacked awareness of pancreatic and oesophagogastric cancer symptoms, leading to the normalisation, dismissal and misattribution of the symptoms. Patients initially self-managed symptoms, but worsening of symptoms and jaundice triggered help-seeking. Competing priorities, beliefs about illnesses and difficulties accessing healthcare delayed help-seeking. CONCLUSION: Increased awareness of insidious pancreatic and oesophagogastric cancer symptoms in patients and general practitioners may prompt more urgent investigations and lead to earlier diagnosis.

Coronary artery calcium scoring vs. coronary CT angiography for the assessment of occupationally significant coronary artery disease.

BACKGROUND: Existing pathways for investigating coronary artery disease (CAD) in individuals undertaking high-hazard employment are currently guided by coronary artery calcium scoring (CACS) or coronary CT angiography (CTA). The optimal pathway has not been established. AIM: To compare the diagnostic outcome and occupational recommendations from two differing investigative pathways for the investigation of CAD in a cohort of high-hazard employees. METHODS: We collected CACS and coronary CTA data from three clinics across two Hospitals on 200 consecutive individuals employed in high-hazard occupations to confirm/exclude occupationally significant CAD. High-hazard occupations were grouped into civil/military pilots and aircraft controllers (n â€‹= â€‹106); non-pilot aircrew (NPA) (n â€‹= â€‹26); and ground-based (military) personnel (GBP) (n â€‹= â€‹52). Demographics, referral indications and recommended occupational outcomes between pathways were compared between groups. RESULTS: The CACS pathway led to more than double the number of individuals being returned to partial or full employment, compared with the coronary CTA pathway (OR 2.10, [95%CI 1.54-2.85], P â€‹< â€‹0.001). This effect was seen in all sub-groups. Of the 177 subjects that would have been returned to full employment using CACS, 21 (11.9%) would have been occupationally restricted on the basis of significant non-calcified plaque disease using coronary CTA (11.4% pilots/controllers; 19.2% non-pilot aircrew, and 7.7% ground-based personnel). CONCLUSION: Using CACS to determine the presence of occupational CAD risks returning individuals to roles with occupationally significant CAD that may lead to an unacceptably high likelihood of an incapacitating/distracting acute coronary event. Coronary CTA appears to be a more reliable, non-invasive imaging modality for confirming or excluding occupationally significant CAD in high-hazard employees.

Assessing the Relationship Between Well-Care Visit and Emergency Department Utilization Among Adolescents and Young Adults.

PURPOSE: To investigate the association between adolescent and young adult (AYA) well-care visits and emergency department (ED) utilization. METHODS: Vermont's all-payer claims data were used to evaluate visits for 49,089 AYAs (aged 12-21 years) with a health-care claim from January 1 through December 31, 2018. We performed multiple logistic regression analyses to determine the association between well-care visits and ED utilization, investigating potential moderating effects of age, insurance type, and medical complexity. RESULTS: Nearly half (49%) of AYAs who engaged with the health-care system did not attend a well-care visit in 2018. AYAs who did not attend a well-care visit had 24% greater odds (95% confidence interval [CI]: 1.19-1.30) of going to the ED at least once in 2018, controlling for age, sex, insurance type, and medical complexity. Older age, female sex, Medicaid insurance, and greater medical complexity independently predicted greater ED utilization in the adjusted model. In stratified analyses, late adolescents and young adults (aged 18-21 years) who did not attend a well-care visit had 47% greater odds (95% CI: 1.37 - 1.58) of ED visits, middle adolescents (aged 15-17 years) had 9% greater odds (95% CI: 1.01-1.18), and early adolescents (aged 12-14 years) had 16% greater odds (95% CI: 1.06 - 1.26). CONCLUSIONS: Not attending well-care visits is associated with greater ED utilization among AYAs engaged in health care. Focus on key quality performance metrics such as well-care visit attendance, especially for 18- to 21-year-olds during their transition to adult health care, may help reduce ED utilization.

The association between quality care and outcomes for a real-world population of Australian patients diagnosed with pancreatic cancer.

BACKGROUND: This study: (i) assessed compliance with a consensus set of quality indicators (QIs) in pancreatic cancer (PC); and (ii) evaluated the association between compliance with these QIs and survival. METHODS: Four years of data were collected for patients diagnosed with PC. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). A multivariable analysis tested the relationship between significant patient and hospital characteristics, patient cluster effects within hospitals and survival. RESULTS: 1061 patients were eligible for this study. Significant association with improved survival were: (i) in the potentially resectable group having adjuvant chemotherapy administered following surgery or a reason documented (HR, 0.29; 95 CI, 0.19-0.46); (ii) in the locally advanced group included having chemotherapy ± chemoradiation, or a reason documented for not undergoing treatment (HR, 0.38; 95 CI, 0.25-0.58); and (iii) in the metastatic disease group included having documented performance status at presentation (HR, 0.65; 95 CI, 0.47-0.89), being seen by an oncologist in the absence of treatment (HR, 0.48; 95 CI, 0.31-0.77), and disease management discussed at a multidisciplinary team meeting (HR, 0.79; 95 CI, 0.64-0.96). CONCLUSION: Capture of a concise data set has enabled quality of care to be assessed.

Assessment of well-being in the clinic: Using the state version of the short Scale of General Well-Being as a clinical outcome measure.

OBJECTIVE: Interest in the concept of well-being within clinical and applied psychology settings has increased, highlighting a need to develop appropriate measures. The aim was to adapt and test the validity of the 14-item Scale of General Well-Being (14-SGWB) originally developed by Longo et al. (2018), as a clinical outcome measure. METHOD: Study 1 is a psychometric study with 543 nonclinical participants, the wording of the 14-SGWB was adapted, and tested for reliability and convergent validity. Study 2 investigated the adapted version with 125 clients over 10 therapy sessions, examining sensitivity, and reliable change cut-off. RESULTS: The final 14-SGWB-clinical tool has a single component structure, good convergent validity, and can assess reliable and clinically significant change. CONCLUSION: Measures that assess positive psychological change are important for the future development of clinical and applied psychology. The 14-SGWB-ct offers researchers a measure to extend evaluations of interventions to the effects on well-being.

Partnership transitions among the children of immigrants in Norway: The role of partner choice.

The family life courses of immigrants and their descendants have been widely studied as indicators of societal integration. But largely absent are investigations into the role of cohabitation in the family lives of these subpopulations. Using Norwegian register data on individuals who were either native born or who immigrated before age 18, we analyse the formation of first cohabiting and marital unions. Next, we compare associations between endogamous or exogamous partner choice and transitions from these first unions. Results showed that the children of immigrants were less likely to cohabit endogamously, but overall more likely to cohabit exogamously and to marry than Norwegians without a migration background. Endogamous migrant-background cohabiting unions were least likely to dissolve, whereas cohabiting couples involving one or two majority partners were less marriage prone than endogamous migrant-background couples. Similarly, among those married, endogamous migrant-background couples were less likely to divorce than their exogamous counterparts.

A Path to Clinical Quality Integration Through a Clinically Integrated Network: The Experience of an Academic Health System and Its Community Affiliates.

INTRODUCTION: Academic medical centers (AMCs) and community physicians seeking to establish a clinically integrated network (CIN) may benefit from a road map to navigate the opportunities and challenges of such an organizational structure. Creating and participating in a CIN requires careful consideration, investment of time, financial resources, alignment of a new quality infrastructure, shared governance, and vision. POTENTIAL BENEFITS, CHALLENGES, AND REGULATORY CONSIDERATIONS: Potential AMC benefits include geographic clinical expansion, the ability to provide care for a broader population of patients, a mechanism to collaborate with regional physician graduates, and an expansion of available teaching sites for trainees. Potential benefits to community practices include propagation of high-value care, enhanced access to evidence-based protocols and priority measures, preparation for value-based reimbursement structures, and connection to an institution that produces future health care practitioners. Challenges to CIN creation include goal alignment, trust between AMC and community partners, acceptance of common quality measures and benchmarks, access to shared data, and local adoption of quality improvement activities. QUALITY AND INFORMATION TECHNOLOGY CONSIDERATIONS: At inception the mission was to create an innovative academic-community alliance delivering high-quality, high-value, personalized care. Defining the clinical quality goals, measurement, governance, and improvement strategy, as well as information technology structure and decision making, are described. FUTURE DIRECTIONS: The network continues to grow and now includes more than 350 physicians, in 16 different specialties across 50 different independent medical practices throughout Southern California. We believe this builds a firm foundation for value-based health care.

The Upper Gastrointestinal Cancer Registry (UGICR): a clinical quality registry to monitor and improve care in upper gastrointestinal cancers.

PURPOSE: The Upper Gastrointestinal Cancer Registry (UGICR) was developed to monitor and improve the quality of care provided to patients with upper gastrointestinal cancers in Australia. PARTICIPANTS: It supports four cancer modules: pancreatic, oesophagogastric, biliary and primary liver cancer. The pancreatic cancer (PC) module was the first module to be implemented, with others being established in a staged approach. Individuals are recruited to the registry if they are aged 18 years or older, have received care for their cancer at a participating public/private hospital or private clinic in Australia and do not opt out of participation. FINDINGS TO DATE: The UGICR is governed by a multidisciplinary steering committee that provides clinical governance and oversees clinical working parties. The role of the working parties is to develop quality indicators based on best practice for each registry module, develop the minimum datasets and provide guidance in analysing and reporting of results. Data are captured from existing data sources (population-based cancer incidence registries, pathology databases and hospital-coded data) and manually from clinical records. Data collectors directly enter information into a secure web-based Research Electronic Data Capture (REDCap) data collection platform. The PC module began with a pilot phase, and subsequently, we used a formal modified Delphi consensus process to establish a core set of quality indicators for PC. The second module developed was the oesophagogastric cancer (OGC) module. Results of the 1 year pilot phases for PC and OGC modules are included in this cohort profile. FUTURE PLANS: The UGICR will provide regular reports of risk-adjusted, benchmarked performance on a range of quality indicators that will highlight variations in care and clinical outcomes at a health service level. The registry has also been developed with the view to collect patient-reported outcomes (PROs), which will further add to our understanding of the care of patients with these cancers.

Young carers in England: Findings from the 2018 BBC survey on the prevalence and nature of caring among young people.

BACKGROUND: Many young people are involved in caring for parents, siblings, or other relatives who have an illness or disability. The aim of this study was to estimate the prevalence of caring by young people in England. METHOD: A national survey of 925 English young people was conducted using the 18-item survey version of the Multidimensional Assessment of Caring Activities Checklist for Young Carers. RESULTS: Around 7% of young people were identified as doing at least a high amount of caring activity and 3% a very high amount. Most frequently, caring by a young person is for a mother or a sibling, with a physical disability. Caring activity consisted mostly of domestic activities, household management, and emotional care. CONCLUSION: This study provides the most up to date and methodologically sophisticated survey data on the prevalence of young caring in England, with implications for policy and practice.

Medical referrals: introducing a GP-priority clerking shift to ensure equitable patient care.

The Society of Acute Medicine (SAM) guidelines indicate that all medical patients should be assessed within 4 hours of referral. Our initial audit cycle revealed that in our institution, significantly less patients referred via their GP were seen within recommended time, when compared with patients referred via the Emergency Department (ED). We undertook a targeted educational intervention, improved the communication process for referrals and modified the senior house officer (SHO) clerking rota, and re-audited the service to determine the effect of these changes. Subsequently, the proportion of GP-referred patients reviewed within recommended time significantly improved for both initial clerking (from 60% to 95.5%, p=0.011) and consultant review (from 50% to 90.5%, p=0.009), with no detrimental effect on waiting times for ED-referred patients. This is likely to be clinically important, impacting on best practice and patient safety.

Readability of Human Subjects Training Materials for Research.

Institutions are required to ensure that persons involved in human subjects research receive appropriate human subjects protections training and education. Several organizations use the Collaborative Institutional Training Initiative (CITI) program to fulfill training requirements. Most researchers find the CITI program too complex for community members who collaborate with researchers. This study aimed to determine the readability of CITI modules most frequently used in community-based participatory research (CBPR). The mean readability level of the CITI modules is 14.8 grade; CBPR readability levels ranged from 11.6 to 12.0 grade (sixth- to eighth-grade reading level is recommended). With a baseline objective measure, modifications can be made to improve the plain language quality and understandability of human subjects training modules for community members.