Leveling Up: A Review of Machine Learning Models in the Cardiac ICU.

Machine learning has emerged as a significant tool to augment the medical decision-making process. Studies have steadily accrued detailing algorithms and models designed using machine learning to predict and anticipate pathologic states. The cardiac intensive care unit is an area where anticipation is crucial in the division between life and death. In this paper, we aim to review important studies describing the utility of machine learning algorithms to describe the future of artificial intelligence in the cardiac intensive care unit, especially in regards to the prediction of successful ventilatory weaning, acute respiratory distress syndrome, arrhythmia, and acute kidney injury.

Preparing residents to practice integrated behavioral health care: Multi-site feasibility study of a competency-based curriculum.

OBJECTIVE: Workforce development is essential for the dissemination of team-based integrated behavioral healthcare. There is limited literature on training family medicine residents to function within an integrated behavioral health (IBH) system. The purpose of this pilot study was to assess the feasibility and value of an IBH competency-based curriculum for family medicine residents across multiple programs. METHODS: Residency programs were recruited using professional listservs and networks to test a competency-based, multi-modal curriculum for preparing residents to practice IBH in primary care. Faculty instructors who led the workshop were invited to complete semi-structured interviews to examine the feasibility and appropriateness of the curriculum. Interview data were analyzed using thematic analysis to identify, analyze, and report patterns. Residents completed a survey of perceived IBH skill and knowledge before and after training. A paired-sample t-test was used to determine significant differences pre- and post-training. RESULTS: All five instructors completed interviews. Results suggest IBH training is valuable. Instructors gave specific feedback on online modules, implementation flexibility, and adjusting faculty development to differing levels of experience. Nineteen of forty residents (48%) completed anonymous pre-, post-, and retrospective-training surveys. Residents reported an increase in competence after training. CONCLUSION: The results of this pilot suggest that IBH training implementation is feasible, desirable, timely, and may improve resident ability to work on an IBH team. Training should accommodate variations in program structure and faculty expertise.

Mechanisms of tyrosine kinase inhibitor resistance in renal cell carcinoma.

Renal cell carcinoma (RCC), the most prevalent type of kidney cancer, is a significant cause of cancer morbidity and mortality worldwide. Antiangiogenic tyrosine kinase inhibitors (TKIs), in combination with immune checkpoint inhibitors (ICIs), are among the first-line treatment options for patients with advanced RCC. These therapies target the vascular endothelial growth factor receptor (VEGFR) tyrosine kinase pathway and other kinases crucial to cancer proliferation, survival, and metastasis. TKIs have yielded substantial improvements in progression-free survival (PFS) and overall survival (OS) for patients with advanced RCC. However, nearly all patients eventually progress on these drugs as resistance develops. This review provides an overview of TKI resistance in RCC and explores different mechanisms of resistance, including upregulation of alternative proangiogenic pathways, epithelial-mesenchymal transition (EMT), decreased intracellular drug concentrations due to efflux pumps and lysosomal sequestration, alterations in the tumor microenvironment including bone marrow-derived cells (BMDCs) and tumor-associated fibroblasts (TAFs), and genetic factors such as single nucleotide polymorphisms (SNPs). A comprehensive understanding of these mechanisms opens the door to the development of innovative therapeutic approaches that can effectively overcome TKI resistance, thereby improving outcomes for patients with advanced RCC.

Value-Based Integrated Case Management at Payor Level: Implementation and Impact.

PURPOSE OF STUDY: Case management is an ideal service for patients with health complexity. However, most case management models do not integrate medical and behavioral health training and interventions, and there are little data evaluating these models in privately insured populations. The purpose of this study was to evaluate impact of an integrated case management (ICM) service at the payor level. PRIMARY PRACTICE SETTING: Health care insurance company. METHODOLOGY AND SAMPLE: A multimethod observational study was conducted at a health care insurance company in the Pacific Northwest of the United States. We conducted focus groups of case managers, leaders, and administrators and statistical analyses of outcomes data. Measures included care quality data (discharge follow-up appointment, cost per case, depression and anxiety measures, customer experience and satisfaction, and audit scores) of members receiving ICM services and employee focus group data (acceptability, adoption, feasibility, appropriateness, fidelity, and sustainability) related to the practice of ICM. RESULTS: Care quality data suggest ICM reduces mental health symptoms and increases discharge follow-up appointments for members. Implementation challenges include new employee orientation to ICM model, traditional views of case management, performance evaluation, documentation, and information technology. Facilitators of implementation include training, autonomy, and leadership support. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Organizations should be aware both of the benefits and challenges related to implementing ICM. Open communication between case managers and leadership and an improvement-focused culture appear to be important elements of implementation success. Future research should examine the perspective of members receiving ICM services and the implementation of ICM into health care delivery systems.

Patient screening for integrated behavioral health in adult primary care: A rapid review of effective procedures.

PURPOSE: Although many primary care clinics screen for behavioral health (BH) conditions using validated tools, it is not clear whether adult BH screening leads to better patient outcomes. Our objective was to determine the evidence base by reviewing effectiveness research for multiple strategies of BH screening in adult primary care identified in the Practice Integration Profile. METHOD: We conducted five rapid reviews of effectiveness research supporting BH screening strategies cited in the Practice Integration Profile. Each rapid review was conducted using an adapted REAL (Rapid Evidence Assessment of the Literature) methodology and a standardized search tailored for each screening strategy to identify evidence related to BH screening in primary care. RESULTS: The database search yielded 931 references. Following eligibility review and extraction, we evaluated data from 20 references examining five screening strategies. Results demonstrated limited support for all five strategies and high risk of bias within most studies. Outcomes associated with various BH screening strategies were rarely the focus of study. CONCLUSIONS: There is an absence of robust, well-structured evidence supporting many of the BH screening strategies advocated for in primary care. Stakeholders may wish to understand how to ensure value when developing a robust screening program that will improve patient health outcomes. Future research should advance the science of BH screen selection, timing, and implementation by answering new questions about screening strategies. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Understanding the Uptake and Challenges of Genetic Testing Guidelines for Prostate Cancer Patients.

BACKGROUND: Multiple studies have confirmed a high prevalence of prognostic germline mutations in prostate cancer. In recognition, the NCCN guidelines and recommendations for genetic counselling (GC) in prostate cancer patients were expanded. METHODS: Data on prostate cancer patients at a single tertiary cancer center from January 2019 - June 2019 were queried. The cohort of patients from the queried list were evaluated for their eligibility for genetic testing. From the patients that were eligible for testing, the rate of referrals was ascertained. A 10-item questionnaire was concurrently sent to providers to understand germline genetic testing patterns and potential barriers. RESULTS: Only 39% of the eligible prostate cancer patients were referred, with testing completed in 11% with indications. 30% of providers reported they would be comfortable completing genetic counseling themselves. The identified barriers to provide genetic testing themselves were lack of time and expertise (50%). Other barriers included: lack of genetic counselor workforce (70%), lack of knowledge of genetic testing and the inadequate co-ordination of referrals (60%). CONCLUSION: In this retrospective study, many patients met the criteria for GC, however, the referrals for this patient population are inconsistent, and only a handful of the eligible patients completed testing. Identified barriers were provider's knowledge and comfort with guidelines and testing, systemic bottlenecks such as limited capacity of genetic counsellors, and the creation of improved workflows.

Impact of Medicaid Expansion on Healthcare Access Among Individuals Living With Chronic Diseases.

INTRODUCTION: The Affordable Care Act's Medicaid expansion has been found to increase healthcare access among low-income individuals in the general population. Fewer studies have explored the impact of Medicaid expansion on healthcare access among those living with chronic diseases. It is also unclear whether the impact of Medicaid expansion varies across levels of educational attainment or poverty among this subgroup. This study investigates the impact of Medicaid expansion on healthcare access among adults aged 18-64 years living with chronic diseases, as well as its variations across educational attainment and federal poverty levels. METHODS: The 2011-2017 Behavioral Risk Factor Surveillance System data were used. Difference-in-difference analyses explored the impact of Medicaid expansion on healthcare access (health insurance coverage, routine checkup, having a personal doctor, and cost-related delayed care within the past 1 year) among individuals living with chronic diseases. Analyses were also stratified by levels of educational attainment and quartiles of the federal poverty level. Data were analyzed between February and November 2019. RESULTS: Medicaid expansion was associated with increased health insurance coverage (ß=0.27, 95% CI=0.16, 0.38), increased likelihood of having a routine checkup (ß=0.12, 95% CI=0.04, 0.22) within the past 1 year, increased likelihood of having a personal doctor (ß=0.08, 95% CI=0.01, 0.12), and decreased likelihood of reporting cost-related delayed care (ß=-0.10, 95% CI=-0.19, -0.02). Medicaid expansion was associated with increased health insurance coverage across all levels of educational attainment and federal poverty level quartiles. CONCLUSIONS: Medicaid expansion increased healthcare access for low-income individuals living with chronic diseases.