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1.
ACS Omega ; 9(19): 21187-21203, 2024 May 14.
Article in English | MEDLINE | ID: mdl-38764625

ABSTRACT

This study reports the fabrication and characterization of poly(vinyl alcohol) (PVA) and gelatin (Gel)-based nanofiber membranes cross-linked with citric acid (CA) by a green electrospinning method in which nano 45S5 bioglass (BG) and urea were incorporated. Various combinations of PVA, gelatin, and BG were prepared, and nanofiber membranes with average fiber diameters between 238 and 595 nm were fabricated. Morphological, chemical, and mechanical properties, porosity, swelling, water retention, and water vapor transmission rate of the fabricated membranes were evaluated. PVA:Gel (90:10), 15% CA, and 3% BG were determined as the optimum blend for nanofiber membrane fabrication via electrospinning. The membrane obtained using this blend was further functionalized with 10% w/w polymer urea coating by the electrospray method following the cross-linking. In vitro biocompatibility tests revealed that the fabricated membranes were all biocompatible except for the one that functionalized with urea. In vivo macroscopic and histopathological analysis results of PVA/Gel/BG and PVA/Gel/BG/Urea treated wounds indicated increased collagenization and vascularization and had an anti-inflammatory effect. Furthermore, careful examination of the in vivo macroscopic results of the PVA/Gel/BG/Urea membrane indicated its potential to decrease uneven scar formation. In conclusion, developed PVA/Gel/BG and PVA/Gel/BG/Urea electrospun membranes with multifunctional and biomimetic features may have the potential to be used as beneficial wound dressings.

2.
J Ment Health Policy Econ ; 27(1): 3-12, 2024 Mar 01.
Article in English | MEDLINE | ID: mdl-38634393

ABSTRACT

BACKGROUND: Consensus-guidelines for prescribing antidepressants recommend that clinicians should be vigilant to match antidepressants to patient's medical history but provide no specific advice on which antidepressant is best for a given medical history. AIMS OF THE STUDY: For patients with major depression who are in psychotherapy, this study provides an empirically derived guideline for prescribing antidepressant medications that fit patients' medical history. METHODS: This retrospective, observational, cohort study analyzed a large insurance database of 3,678,082 patients. Data was obtained from healthcare providers in the U.S. between January 1, 2001, and December 31, 2018. These patients had 10,221,145 episodes of antidepressant treatments. This study reports the remission rates for the 14 most commonly prescribed single antidepressants (amitriptyline, bupropion, citalopram, desvenlafaxine, doxepin, duloxetine, escitalopram, fluoxetine, mirtazapine, nortriptyline, paroxetine, sertraline, trazodone, and venlafaxine) and a category named "Other" (other antidepressants/combination of antidepressants). The study used robust LASSO regressions to identify factors that affected remission rate and clinicians' selection of antidepressants. The selection bias in observational data was removed through stratification. We organized the data into 16,770 subgroups, of at least 100 cases, using the combination of the largest factors that affected remission and selection bias. This paper reports on 2,467 subgroups of patients who had received psychotherapy. RESULTS: We found large, and statistically significant, differences in remission rates within subgroups of patients. Remission rates for sertraline ranged from 4.5% to 77.86%, for fluoxetine from 2.86% to 77.78%, for venlafaxine from 5.07% to 76.44%, for bupropion from 0.5% to 64.63%, for desvenlafaxine from 1.59% to 75%, for duloxetine from 3.77% to 75%, for paroxetine from 6.48% to 68.79%, for escitalopram from 1.85% to 65%, and for citalopram from 4.67% to 76.23%. Clearly these medications are ideal for patients in some subgroups but not others. If patients are matched to the subgroups, clinicians can prescribe the medication that works best in the subgroup. Some medications (amitriptyline, doxepin, nortriptyline, and trazodone) always had remission rates below 11% and therefore were not suitable as single antidepressant therapy for any of the subgroups. DISCUSSIONS: This study provides an opportunity for clinicians to identify an optimal antidepressant for their patients, before they engage in repeated trials of antidepressants. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: To facilitate the matching of patients to the most effective antidepressants, this study provides access to a free, non-commercial, decision aid at http://MeAgainMeds.com. IMPLICATIONS FOR HEALTH POLICIES:  Policymakers should evaluate how study findings can be made available through fragmented electronic health records at point-of-care. Alternatively, policymakers can put in place an AI system that recommends antidepressants to patients online, at home, and encourages them to bring the recommendation to their clinicians at their next visit. IMPLICATIONS FOR FURTHER RESEARCH:  Future research could investigate (i) the effectiveness of our recommendations in changing clinical practice, (ii) increasing remission of depression symptoms, and (iii) reducing cost of care. These studies need to be prospective but pragmatic. It is unlikely random clinical trials can address the large number of factors that affect remission.


Subject(s)
Citalopram , Trazodone , Humans , Citalopram/therapeutic use , Fluoxetine/therapeutic use , Paroxetine/therapeutic use , Sertraline/therapeutic use , Bupropion/therapeutic use , Nortriptyline/therapeutic use , Amitriptyline , Duloxetine Hydrochloride , Venlafaxine Hydrochloride , Desvenlafaxine Succinate , Escitalopram , Doxepin , Prospective Studies , Cohort Studies , Retrospective Studies , Antidepressive Agents/therapeutic use , Psychotherapy
3.
J Gen Intern Med ; 2023 Nov 27.
Article in English | MEDLINE | ID: mdl-38010463

ABSTRACT

BACKGROUND: Clinician burnout has become a major issue in the USA, contributing to increased mental health challenges and problems with quality of care, productivity, and retention. OBJECTIVE: The objective of this study was to understand primary care clinicians' perspectives on burnout during the COVID-19 pandemic as well as their perspectives on the causes of burnout and strategies to improve clinician well-being. APPROACH: This qualitative research involved in-depth interviews with 27 primary care clinicians practicing in a range of settings across the USA. Semi-structured interviews lasted between 60 and 90 min and were conducted using Zoom video conferencing software between July 2021 and February 2023. Transcripts were analyzed in NVivo software using multiple cycles of coding. KEY RESULTS: Clinicians shared their experiences with burnout and mental health challenges during the COVID-19 pandemic. Contributors to burnout included high levels of documentation, inefficiencies of electronic health record (EHR) systems, high patient volume, staffing shortages, and expectations for responding to patient emails and telephone calls. The majority of participants described the need to work after clinic hours to complete documentation. Many clinicians also discussed the need for health system leaders to make sincere efforts to enhance work-life balance and create a culture of health and well-being for health professionals. Suggested strategies to address these issues included supportive leadership, accessible mental health services, and additional administrative time to complete documentation. CONCLUSIONS: The results of this study provide an in-depth view of participating primary care clinicians' experiences and perceptions of burnout and other mental health challenges. These viewpoints can improve awareness of the issues and strategies to improve the health and well-being of our clinician workforce. Strategies include aligning payment models with the best approaches for delivering quality patient care, reducing administrative burden related to documentation, and redesigning EHR systems with a human factors approach.

4.
J Holist Nurs ; : 8980101231200352, 2023 Sep 29.
Article in English | MEDLINE | ID: mdl-37774689

ABSTRACT

Purpose of Study: Nurses around the world have faced challenges during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the association between depression and anxiety and trait energy and trait fatigue, and baseline health status and work characteristics. Design of Study: A cross-sectional study. Methods: A survey was conducted to collect self-reported data from nurses involved in patient care in Northern Virginia. Depression and anxiety were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) depression and anxiety scales. To measure trait energy and trait fatigue, the Mental and Physical State and Trait Energy and Fatigue Scale (MPSTEFS) was used. Findings: There was a significant association between depression and energy (b=-0.46, t = -1.78, p < .001) and loneliness (b=1.38, t = 4.00, p < .001) and increased alcohol use (b=2.11, t = 2.04, p = .045). We also found that nurses with depression were significantly more likely to seek mental health counseling (b=-2.91, t = 2.54, p = 0.013), which was also the case for anxiety (b=3.13, t = 2.14, p = .036). Conclusions: Our study highlights the mental health burden among nurses who worked in the early phase of the COVID-19 pandemic and its association with increased alcohol use and loneliness. The findings may help healthcare leaders identify early signals of deterioration in nurses' well-being.

5.
Inquiry ; 58: 46958021996518, 2021.
Article in English | MEDLINE | ID: mdl-33645303

ABSTRACT

The recent decade brought major changes to primary care practices. Previous research on change has focused on change processes, and change implementations rather than studying employee's feelings, perceptions, and attitudes toward change. The objective of this cross-sectional study was to examine the relationship between healthcare professionals' behavioral responses to change and practice characteristics. Our study, which builds upon Conner's theory, addresses an extensive coverage of individual behaviors, feelings, and attitudes toward change. We analyzed survey responses of healthcare professionals (n = 1279) from 154 primary care practices in Virginia. Healthcare professionals included physicians, advanced practice clinicians, clinical support staff, and administrative staff. The Change Diagnostic Index© (CDI) was used to measure behavioral responses in 7 domains: anxiety, frustration, delayed development, rejection of environment, refusal to participate, withdrawal, and global reaction. We used descriptive statistics and multivariate regression analysis. Our findings indicate that professionals had a significantly lower aptitude for change if they work in larger practices (≥16 clinicians) compared to solo practices (P < .05) and at hospital-owned practices compared to independent practices (P < .05). Being part of an accountable care organization was associated with significantly lower anxiety (P < .05). Understanding healthcare professionals' responses to change can help healthcare leaders design and implement successful change management strategies for future transformation.


Subject(s)
Health Personnel , Physicians , Attitude of Health Personnel , Cross-Sectional Studies , Delivery of Health Care , Humans , Primary Health Care
6.
J Am Board Fam Med ; 34(1): 40-48, 2021.
Article in English | MEDLINE | ID: mdl-33452081

ABSTRACT

BACKGROUND: Engaging primary care practices in quality improvement (QI) efforts has been challenging. Literature provides little guidance on the engagement of small to medium-sized practices in QI. This study examined the association between practice readiness and practice characteristics and engagement during a targeted QI effort. METHODS: The study analyzed cross-sectional data collected by the Heart of Virginia Health care, a cardiovascular disease QI intervention study with 195 practices. Data sources include 1) coach-assessed practice engagement in 7 domains (outcome), 2) surveys of readiness completed by 2529 clinicians and staff, a response rate of 86%, and 3) surveys of practice characteristics completed by a physician leader or practice manager. We used descriptive statistics and ordered logit regression for the analysis. RESULTS: Associations between readiness and engagement were statistically significant for clinician engagement (odds ratio [OR] = 5,74; 95% CI, 1.79-18.42; P = .003) and leadership engagement (OR = 3.19; 95% CI, 1.10-9.24; P = .032). Adjusting for covariates, being a hospital-owned practice was associated with a lower level of clinician engagement (OR = 0.35; 95% CI, 0.16-0.76; P = .009) relative to independent practices. DISCUSSION: Our study highlights the importance of clinician and leadership engagement as drivers of practice readiness to change in a QI effort. Lack of clinician engagement in hospital-owned practices could be driven by other factors such as burnout that need to be explored in future studies. CONCLUSIONS: Clinicians and leadership involvement in QI efforts is critical. The findings suggest that QI plans should involve clinicians and leaders early in the process to foster commitment, establish practice readiness, and sustain improvement efforts.


Subject(s)
Primary Health Care , Quality Improvement , Cross-Sectional Studies , Delivery of Health Care , Humans , Leadership
7.
J Gen Intern Med ; 36(5): 1222-1228, 2021 05.
Article in English | MEDLINE | ID: mdl-33420562

ABSTRACT

BACKGROUND: Workplace burnout among healthcare professionals is a critical public health concern. Few studies have examined organizational and individual factors associated with burnout across healthcare professional groups. OBJECTIVE: The purpose of this study was to examine the association between practice adaptive reserve (PAR) and individual behavioural response to change and burnout among healthcare professionals in primary care. DESIGN: This cross-sectional study used survey data from 154 primary care practices participating in the EvidenceNOW Heart of Virginia Healthcare initiative. PARTICIPANTS: We analysed data from 1279 healthcare professionals in Virginia. Our sample included physicians, advanced practice clinicians, clinical support staff and administrative staff. MAIN MEASURES: We used the PAR instrument to measure organizational capacity for change and the Change Diagnostic Index© (CDI) to measure individual behavioural response, which achieved a 76% response rate. Logistic regression analysis was used to estimate the effects of PAR and CDI on burnout. KEY RESULTS: As organizational capacity for change increased, burnout in healthcare professionals decreased by 51% (OR: 0.49; 95% CI, 0.33, 0.73). As healthcare professionals showed improved response toward change, burnout decreased by 84% (OR: 0.16; 95% CI, 0.11, 0.23). Analysis by healthcare professional type revealed a significant association between high organizational capacity for change, positive response to change and low burnout among administrative staff (OR: 2.92; 95% CI, 1.37, 6.24). Increased hours of work per week was associated with higher odds of burnout (OR: 1.07; 95% CI, 1.05, 1.10) across healthcare professional groups. CONCLUSION: As transformation efforts in primary care continue, it is critical to understand the influence of these initiatives on healthcare professionals' well-being. Efforts to reduce burnout among healthcare professionals are needed at both a system and organizational level. Building organizational capacity for change, supporting providers and staff during major change and consideration of individual workload may reduce levels of burnout.


Subject(s)
Burnout, Professional , Burnout, Professional/epidemiology , Cross-Sectional Studies , Health Personnel , Humans , Primary Health Care , Virginia/epidemiology
8.
J Am Board Fam Med ; 33(6): 942-952, 2020.
Article in English | MEDLINE | ID: mdl-33219073

ABSTRACT

BACKGROUND: Despite major efforts to transition to a new physician payment system under the Medicare Access and CHIP Reauthorization Act (MACRA), little is known about how well practices are prepared. This study aimed to understand how small and medium-sized primary care practices in the Heart of Virginia Healthcare (https://www.vahealthinnovation.org/hvh/) perceive their quality incentives under MACRA. METHODS: This study analyzed data from 16 focus-groups (70 participants), which yielded a range of physician, advanced practice clinician, office manager, and staff perspectives. Focus-groups were audio-recorded and transcribed, then imported into NVivo for coding and analysis of themes. A multidisciplinary research team reviewed the transcripts to maximize coding insights and to improve validity. RESULTS: The main findings from the focus-groups are: 1) MACRA awareness is relatively higher in independent practices, 2) steps taken toward MACRA differ by practice ownership, and 3) practices have mixed perceptions about the expected impact of MACRA. Two additional themes emerged from data: 1) practices that joined accountable care organizations are taking proactive approaches to MACRA, and 2) independent practices face ongoing challenges. CONCLUSIONS: This study highlights a dilemma in which independent practices are proactively attempting to prepare for MACRA's requirements, yet they continue to have major challenges. Practices are under extreme pressure to comply with reimbursement regulations, which may force some practices joining a health system or merging with another practice or completely closing the practices. Policy makers should assess the unintended consequences of payment reform policies on independent practices and provide support in transitioning to a new payment system.


Subject(s)
Accountable Care Organizations , Physicians , Aged , Humans , Medicare , Primary Health Care , United States , Virginia
9.
J Gen Intern Med ; 35(10): 2882-2888, 2020 10.
Article in English | MEDLINE | ID: mdl-32779136

ABSTRACT

BACKGROUND: Little is known about what determines strategy implementation around quality improvement (QI) in small- and medium-sized practices. Key questions are whether QI strategies are associated with practice readiness and practice characteristics. OBJECTIVE: Grounded in organizational readiness theory, we examined how readiness and practice characteristics affect QI strategy implementation. The study was a component of a larger practice-level intervention, Heart of Virginia Healthcare, which sought to transform primary care while improving cardiovascular care. DESIGN: This observational study analyzed practice correlates of QI strategy implementation in primary care at 3 and 12 months. Data were derived from surveys completed by clinicians and staff and from assessments by practice coaches. PARTICIPANTS: A total of 175 small- and medium-sized primary care practices were included. MAIN MEASURES: Outcome was QI strategy implementation in three domains: (1) aspirin, blood pressure, cholesterol, and smoking cessation (ABCS); (2) care coordination; and (3) organizational-level improvement. Coaches assessed implementation at 3 and 12 months. Readiness was measured by baseline member surveys, 1831 responses from 175 practices, a response rate of 73%. Practice survey assessed practice characteristics, a response rate of 93%. We used multivariate regression. KEY RESULTS: QI strategy implementation increased from 3 to 12 months: the mean for ABCS from 1.20 to 1.59, care coordination from 2.15 to 2.75, organizational improvement from 1.37 to 1.78 (95% CI). There was no statistically significant association between readiness and QI strategy implementation across domains. Independent practice implementation was statistically significantly higher than hospital-owned practices at 3 months for ABCS (95% CI, P = 0.01) and care coordination (95% CI, P = 0.03), and at 12 months for care coordination (95% CI, P = 0.04). CONCLUSION: QI strategy implementation varies by practice ownership. Independent practices focus on patient care-related activities. FQHCs may need additional time to adopt and implement QI activities. Practice readiness may require more structural and organizational changes before starting a QI effort.


Subject(s)
Primary Health Care , Quality Improvement , Delivery of Health Care , Humans , Organizational Innovation , Virginia
10.
J Am Board Fam Med ; 33(3): 378-385, 2020.
Article in English | MEDLINE | ID: mdl-32430369

ABSTRACT

BACKGROUND: The rising prevalence of burnout among physicians and other healthcare professionals has become a major concern in the United States. Identifying indicators of burnout could help reduce negative consequences such as turnover, loss of productivity, and adverse health behaviors. The goal of this study was to examine whether individual behaviors and attitudes towards major disruptive change has an effect on workplace burnout. METHODS: This study analyzed survey responses from 1273 healthcare professionals from 154 small to medium-sized primary care practices participating in the EvidenceNOW initiative in Virginia. Healthcare professionals' behaviors and attitudes, such as anxiety and withdrawal, were assessed to determine associations with workplace burnout. Results were examined by professional role. RESULTS: Workplace burnout was reported by 31.6% of the physicians, 17.2% of advanced practice clinicians, 18.9% of clinical support staff, and 17.5% of administrative staff. Regardless of burnout status, results show all healthcare professional groups had high levels of anxiety. Providers had significantly higher scores for anxiety than all other healthcare professionals. Providers who experienced higher levels of anxiety and withdrawal were more than three times as likely to report burnout compared to those who experienced low levels in these domains. CONCLUSIONS: Understanding individual behaviors and attitudes towards disruptive change may help practice leaders and policymakers develop strategies to reduce burnout among healthcare professionals. Programs should focus on strengthening the work environment of small to medium-sized practices to improve organizational capacity for change and address high levels of anxiety experienced by physicians, advanced practice clinicians and staff.


Subject(s)
Burnout, Professional , Physicians , Primary Health Care , Burnout, Professional/epidemiology , Humans , Job Satisfaction , Prevalence , Primary Health Care/organization & administration , Surveys and Questionnaires , United States/epidemiology , Virginia , Workplace
11.
J Public Health Res ; 7(1): 1280, 2018 Feb 05.
Article in English | MEDLINE | ID: mdl-29780766

ABSTRACT

BACKGROUND: Surveillance of disparities in healthcare insurance, services and quality of care among children are critical for properly serving the medical/healthcare needs of underserved populations. The purpose of this study was to assess racial/ethnic differences in children's (0 to 17 years old) health insurance adequacy and consistency (child has insurance coverage for the last 12 months). DESIGN AND METHODS: We used data from the 2011/2012 National Survey of Children's Health (n=79,474). Descriptive statistics and logistic regression analyses were conducted to examine the distribution and influence of several sociodemographic/family related factors on insurance adequacy and consistency across different racial/ethnic groups. RESULTS: Stratified analyses by race/ethnicity revealed that white and black children living in households at or below 299% of the Federal Poverty Level (FPL) were approximately 29 to 42% less likely to have adequate insurance compared to children living in families of higher income levels. Regardless of race/ethnicity, we found that children with public health insurance were more likely to have adequate insurance than their privately insured counterparts, while adolescents were at greater risk of inadequate coverage. Hispanic and black children were more likely to lack consistent insurance coverage. CONCLUSIONS: This study provides evidence that racial/ethnic differences in adequate and consistent health insurance exists with both white and minority children being affected adversely by poverty. Establishing outreach programs for low income families, and cross-cultural education for healthcare providers may help increase health insurance adequacy and consistency within certain underserved populations.

12.
Med Hypotheses ; 77(2): 263-5, 2011 Aug.
Article in English | MEDLINE | ID: mdl-21601369

ABSTRACT

Trabeculectomy is commonly conducted when medical therapy fails to control intraocular pressure (IOP). The success of trabeculectomy for the treatment of glaucoma depends on the wound-healing response at the subconjunctival filtering bleb site. Postoperative scar formation is a serious problem in this surgery. Current strategies to counteract scarring include local antimetabolite treatment, which is associated with severe side effects, limiting its application. Therefore, additional means to safely modulate wound healing are desirable. In ophthalmic surgery, fibrin glue is used mainly for sealing and hemostatics purpose. Fibrin glue coating of tenon face of conjunctiva, scleral surface, reverse face of scleral flap and scleral bed with insoluble fibrin glue can halt both ooze bleeding and vascular leakage. By retarding the first step of wound healing, less postoperative inflammation may occur. Additionally aqueous humor flows through a fibrin glue coated interface. Therefore, we hypothesize that fibrin glue coating of the surgical surfaces in trabeculectomy surgery may yield less subconjunctival fibrosis and more successful bleb. To the best of our knowledge, no basic research has yet been performed regarding fibrin glue coating for halting the vascular leakage and easing the aqueous drainage into subconjunctival space in glaucoma surgery.


Subject(s)
Cicatrix/prevention & control , Fibrin Tissue Adhesive/therapeutic use , Trabeculectomy/methods , Wound Healing/physiology , Blister , Humans , Postoperative Period , Trabeculectomy/instrumentation
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