Quality Improvement Intervention associated with Improved Lung Protective Ventilation Settings in an Emergency Department.

INTRODUCTION: Patients requiring endotracheal intubation and mechanical ventilation in the emergency department (ED) are critically ill, and their ventilator management is crucial for their subsequent clinical outcomes. Lung-protective ventilation (LPV) setting strategies are key considerations for this care. The objectives of this 2019-2020 community-based quality improvement project were to: a) identify patients at greater risk of not receiving LPV, and b) evaluate the effectiveness of a series of brief quality improvement educational sessions to improve LPV setting protocol adherence rates. METHODS: A 15-month retrospective chart review of ventilator settings and subject characteristics (N = 200) was conducted before and after a series of 10-15-minute educational sessions were delivered to improve LPV adherence. This information was presented at a series of four educational sessions for 25 attending physicians (n = two sessions) and 27 residents at conferences (n = two sessions). Two additional materials (e.g., LPV reference charts, tape measures to gauge patients' heights) were also posted in three ED resuscitation rooms and on cabinets containing emergency airway equipment. The pre and post-intervention occurrence rates of LPV setting orders were inferentially compared before and after educational sessions. RESULTS: Patients ventilated using LPV increased from 70% to 82% after the educational sessions (p = 0.04). All patients who were 67 inches or greater in height were ventilated appropriately before and after sessions. For patients under 65 inches in height, post-session LPV adherence increased from 13% to 53% (p = 0.01). CONCLUSIONS: Based on these results, a brief ED provider educational intervention can significantly improve the utilization of LPV guideline-based settings. Patients under 65 inches in height may also be especially at risk of receiving non-LPV ventilator setting orders.

Common Problematic Scholarly Activity Project Planning Expectations of Project Novices.

INTRODUCTION: Scholarly Activity (SA) projects, whether using methods more traditionally associated with research and or "quality improvement" projects, have been shown to confer value to resident physicians and other project novices in multiple ways. The inclusion of community and university-based residents and faculty in spearheading SA projects has led to improved understanding of medical literature and enhanced clinical practices, arguably producing more "well-rounded" physicians. PURPOSE OF PAPER: The primary purpose of this paper is to provide a summary of problematic expectations frequently assumed by project novices when developing and conducting SA projects. RESULTS: The authors will discuss a total of 26 problematic project-related novice expectations during five typical project phase categories. CONCLUSIONS: Learning to navigate the complexities of training to become a practicing physician, while also planning high quality SA project designs has been and will continue to be a complex challenge. The authors hope that this article can be used by supervising faculty and other graduate medical education mentors to assist the SA project novice (SAPN) plan SA projects. By establishing realistic expectations during project planning phases, the SAPN can avoid potential missteps that typically impede SA project completion.

Implementation of a Rapid Post-Code Debrief Quality Improvement Project in a Community Emergency Department Setting.

CONTEXT: Regular debriefing has been associated with improved resource utilization and measurable improvements in team performance in crisis situations. While Emergency Department (ED) staff have often stated that they would like to be provided a formal debriefing model after "code blue" and similar events, few EDs have such protocols in place. METHODS: The study consisted of two data collection processes: (1) completion of a 7-item survey distributed pre-intervention, 6-months post-intervention, and 1-year post-intervention, and (2) completion of a Rapid Post-Code Debriefing form. Overall responses were measured on a possible 0-10 scale and individual responses were tracked. The debrief process was triggered by one of four criteria and followed a standard format using a readily available form. RESULTS: A total of 178 pre- and post-debriefing protocol implementation survey responses were collected throughout the duration of the study. Of those, 79 (44.4%) were pre-protocol response surveys. The post-protocol responses were comprised of 51 (51.5%) six month and 48 (48.5%) 12-month surveys. The average overall satisfaction with code-response performance increased significantly following the implementation of the debriefing protocol, from M=6.661, SD=2.028 to M=7.90, SD=1.359 (independent t-test = 5.069, p<0.001). There was a statistically significant decrease regarding how respondents felt emotionally supported after a code by their staff, (Pearson Chi Square 14.977, df 4, p = 0.005). CONCLUSION: During this study, implementation of a post-code debriefing resulted in increased overall satisfaction with how codes had been conducted and there was a significant change in how staff felt in regards to code team leaders and an expectation of "returning to work." However, there a noted overall decrease in perceptions of feeling supported by other staff involved during the code. Further studies in both community and academic-based ED settings are needed to further explore these complex relationships.

Cardiovascular Risk Factors and Benign Paroxysmal Positional Vertigo in Community Otolaryngology-Head and Neck Surgery.

OBJECTIVE: Cardiovascular risk factors have been associated with benign paroxysmal positional vertigo (BPPV), possibly causing degeneration of the utricular epithelium and subepithelium, but supportive evidence is mixed. This is the first study to examine the association between cardiovascular risk factors and BPPV as they present in the community practice of comprehensive otolaryngology-head and neck surgery. STUDY DESIGN: Cross-sectional case-matched case-control series. SETTING: A community practice of otolaryngology-head and neck surgery with 3 clinical offices and a socioeconomically diverse patient population. SUBJECTS AND METHODS: Clinical data were collected retrospectively from the electronic health records of a continuous 4-year series of 628 patients with BPPV and age- and sex-matched controls. RESULTS: There were no statistically significant associations found between BPPV and diabetes, hypertension, dyslipidemia, or body mass index in the study population in pairwise comparisons or multivariable modeling. CONCLUSION: This study suggests that BPPV as encountered in a community ear, nose, and throat practice is not generally associated with cardiovascular risk factors. The possibility that these or other cardiovascular risk factors may be causative in some cases cannot be excluded, though most cases of BPPV appear to be caused primarily by shedding of otoconia from the utricle that is idiopathic or at least in part by unconfirmed noncardiovascular factors.

Ancillary Findings on CT Pulmonary Angiograms that are Negative for Pulmonary Embolism.

CONTEXT: One advantage of computed tomographic pulmonary angiograms (CTPA) is that they often show pathology in patients in whom pulmonary embolism (PE) has been excluded. In this investigation, we identified the ancillary findings on CTPAs that were negative for PE to obtain an impression of the type of findings shown. METHODS: This was a retrospective analysis of findings on CTPAs that were negative for PE obtained in nine emergency departments between January 2016 - February 2018. Ancillary findings were assessed by review of the radiographic reports. RESULTS: Ancillary findings were identified in N=338 (40.9%) of 825 patients with CTPAs that were negative for PE. Most ancillary findings, 254 (75.1%) of 338 were pulmonary or pleural abnormalities. Liver, gall bladder, kidney, or pancreatic abnormalities were shown in 26 (7.7%) cases, and abnormalities of the heart or great vessels were shown in 23 (6.8%) of cases. Abnormalities of the esophagus or intestine were shown in 12 (3.6%), abnormalities of the thyroid in 10 (3.0%) and abnormalities of bone or soft tissue lesions were shown in three (0.9%) cases. Inferential statistical procedures demonstrated that the occurrence of ancillary findings in patients with negative CTPAs was proportionately greater in patients who were 50 years and older (p < 0.001), although not between genders (p = 0.145). CONCLUSIONS: Ancillary findings on CTPAs that were negative for PE were frequently reported. Future studies might focus of the extent to which ancillary findings on CTPA assisted physicians in management of the patient.

Comparative Evaluation of Two Obstetrical/Gynecology Resident "Boot Camps" of Different Lengths: Equivalent Practice Skills Confidence and Knowledge Levels.

CONTEXT: Since the earlier time of master-apprentice type GME relationships, more residency program educators have developed various forms of boot camps to ease incoming learners into their new specialty roles as first-year residents. Such boot camps have ranged from informal informational sessions with faculty using simulation activities, to more formal workshops entailing pre- and post-event skills assessments with simulation exercises, formative feedback and debriefing sessions. The purpose of this pilot project was to examine for relative pre- and post-boot camp changes in Obstetrics/Gynecology (OB/GYN) practice skills confidence and knowledge levels in two consecutive cohorts (2014 and 2015) of first-year residents. METHODS: Boot camps were of two different lengths: a five-day 2014 camp (n = 32 residents) and shortened three-day 2015 boot camp (n = 29 residents). Respondents from both boot camp cohorts were invited to complete the same 25-item OB/GYN practice skills confidence and knowledge survey. The first three authors developed this survey prior to the initial boot camp (2014). Revisions/adjustments were then made to content after the 2014 to pare down from the initial five days' worth of content for the 2014 boot camp to three days for the 2015 boot camp. RESULTS: Each of 45 sample resident respondents who provided complete pre-and post-boot camp data demonstrated improvements in self-rated practice confidence and knowledge levels. Mean per resident pre-post-boot camp survey rating levels for individual items in the shorter 2015 boot camp cohort increased by 1.096 (SD = 0.5487), over a two-fold increase for most individual items in the 2014 residents. Mean cohort differences represented a non¬-significant equivalent increase in pre-post practice confidence and knowledge levels for individual ratings items between the 2014 and 2015 cohorts (p = 0.241). CONCLUSIONS: Based on these preliminary results, the authors conclude that it may be possible to adjust their OB/GYN boot camp from five days to three and still achieve comparable learner outcomes while delivering the same basic content.

Predictors of 2010-2011 Michigan Medicaid Beneficiary Adverse E-Code Health Care Encounters.

To inform Medicaid medication management and public health policymaking, the authors analyzed the major predictive factors influencing program-approved therapeutic use or poisoning E-coded encounters leading to emergency department visits and hospital admission for the totality of Michigan Medicaid beneficiaries during a 12-month 2010-2011 period. The analytic cohort was composed of 26,134 approved E-code encounters submitted for 19,865 discrete Michigan Medicaid beneficiaries.More than 1% of all beneficiaries experienced at least one adverse medication/agent-related E-code encounter during the period. More such encounters and costlier approved encounters were recorded female subjects, African Americans, dually eligible adults, urban elderly, those with fee-for-service Medicaid coverage, and those residing in urban-density counties.Especially notably for patient safety policymakers, more than 9% of total E-coded encounters for children and adults were primarily attributed by providers to likely preventable poisoning causes such as exposure to household cleaning agents/gases, cosmetic products, illicit drug/alcohol, or secondary tobacco smoke. Encounter costs for the total sample totaled $37 million but ranged considerably up to more than a quarter million dollars.In view of the future expanding Medicaid-covered beneficiary cohorts, the authors propose several key patient safety/public health policy implications for researchers and policymakers striving to serve lower-income health care consumer groups.

Effectiveness of a Faculty Development Course on Delivering Learner-Centered Feedback Utilizing the Flipped Training Model.

CONTEXT: Effective feedback is an important step in the acquisition of residents' clinical skills and a key component of most adult learning strategies. Faculty-resident feedback discussions can facilitate resident self-assessment and reflection on their performance and motivate them to study and ask questions in areas where their knowledge may be evaluated as deficient. The flipped training model approach, a type of blended learning that reverses the traditional learning environment by delivering instructional content outside of the classroom, has garnered increased support within both graduate medical education (GME) and other healthcare disciplines. METHODS: The overall purpose of this exploratory pilot project was to examine the pre-post impact of a faculty feedback flipped training model course provided to a convenience sample of community-based faculty learners. After receiving campus IRB approval, the authors developed a set of five primary course goals and objectives. A convenience sample of n = 17 community-based faculty who had completed the entire course were administered a pair of pre and post-course surveys regarding their overall feedback satisfaction and comfort levels for supervising residents. RESULTS: In summary, five of the 13 total survey items increased at statistically significant levels from pre-course levels. The majority of qualitative faculty comments also positively evaluated the flipped training model approach. CONCLUSIONS: These promising pilot findings suggest that a flipped GME faculty feedback skills training model can help improve faculty learners' satisfaction and confidence as they supervise residents and/or medical students. The impact of these types of flipped training models for GME faculty needs to be more rigorously examined in project settings with larger samples to identify what specific types of curricular activities might prove to be most effective for diverse faculty learners in GME programs across the nation.

Medical Marijuana and the Treatment of Post Traumatic Stress Disorder: A Survey of Michigan Psychiatrists' Opinions.

CONTEXT: Although recent studies have indicated a potential mechanism of action through which medical marijuana (MM) and its derivatives may treat Posttraumatic Stress Disorder (PTSD) symptoms, definitive evidence is still lacking. Few studies concerning physician attitudes regarding MM and/or marijuana-derived medications for PTSD are found in the psychiatric literature. METHODS: A non-probability convenience sample of psychiatric physicians in Michigan was surveyed during 2016. The 12-item survey questionnaire asked respondents a series of questions about their personal characteristics, prior experiences of treating PTSD and opinions concerning the use/potential use of MM for treatment of PTSD. RESULTS: A total of 83 psychiatrists (11.7% of total invited) responded to the survey. Several statistically significant correlations between respondent characteristics and other key measures (e.g., Age Category, Gender, Years of Psychiatric Practice, Psychiatric Practice Role (i.e., resident vs. attending), Number of Psychiatric Subspecialties, and Number of PTSD Patients Diagnosed and/or Treated to date) were found. A composite summary score was also formulated from questions related to opinion regarding the use of MM for PTSD and categorized into three comparison groups. The final stepwise multinomial logistic model demonstrated three statistically significant factors influencing what response category respondents fell into regarding MM use for PTSD: a) how often respondents had been exposed to recommendations concerning the use of MM for PTSD (p < 0.001), b) Age Category (p = 0.001) and how frequently respondents had recommended MM for treatment of PTSD (p < 0.001). CONCLUSIONS: The results from this smaller sample indicate that the majority of psychiatrist respondents did not support MM for the treatment of PTSD. Judging from these results, Michigan psychiatrists may be extremely conservative regard the prospective use of MM for PTSD. Few sample respondents indicated that they had been exposed to professional literature detailing MM and derivatives as a treatment for PTSD. Most respondents also indicated that they were Unsure/There is Not Enough Research concerning the scientific evidence for the use of MM for PTSD. Based on these findings from a smaller sample, the use of MM and its derivatives for treatment of PTSD may not currently be supported by the majority of Michigan psychiatrists.

Development of a Quality Improvement/Patient Safety Curriculum to Increase Emergency Medicine Resident Scholarly Activity.

CONTEXT: There currently is no standard method for teaching Quality Improvement/Patient Safety (QIPS) content to prepare resident physicians planning QIPS projects. As part of the 2015-2016 MSU Statewide Campus System Teach for Quality (Te4Q) learner cohort, the first two authors from the McLaren Oakland Hospital Emergency Medicine (EM) residency program developed a structured multi-phase QIPS curriculum. The curriculum was developed to help a cohort of seven second-year EM residents feel more confident to design and conduct their own QIPS projects. METHODS: After institutional review board project approval was obtained, the first two authors evaluated both the pre and post-curriculum confidence survey scores of enrolled EM residents during May, 2016 as part of their Te4Q program participation. RESULTS: Residents completed a 15-item QIPS confidence survey before and after completing the QIPS curriculum. The mean pre-curriculum score was 3.00 (SD 1.53) on a scale from 0 to 10, indicating that the average sample respondent felt a lower level of comfort concerning their ability to design and conduct a prospective QIPS project. The mean post-curriculum confidence score from residents increased to 6.71 (SD 1.25) on a 0 to 10 scale, over double an increase from the pre-workshop score on this item. Using a series of non-parametric Wilcoxon Matched Pairs Signed Rank Test procedures suitable for smaller samples, statistically significant increases in pre- to post-curriculum differences were shown for composite confidence scores (Z = 2.207, p = 0.027), as well as for five of the 12 individual confidence items (p-values ranged from 0.023 to 0.046). CONCLUSIONS: These initial results certainly indicate that a structured ongoing QIPS curriculum may have the potential to improve EM residents' confidence levels to design and implement QIPS projects with faculty. The impact of these types of curricula for EM and other types of residents needs to be more rigorously examined in more tightly controlled GME settings with larger samples to gauge what types of resident learners will more likely benefit from such educational offerings across the nation.

Billing Implications of Emergency Medicine Resident Physicians' Laceration Length Estimates.

CONTEXT: Lacerations are a common occurrence in urgent care and emergency room settings. The types of lacerations repaired in these settings range from superficial and linear to deep and stellate. Healthcare professionals are required to describe these wounds in documentation and part of that description is length. In a busy clinical setting, many providers use a visual estimation of wound length for documentation. The purpose of this exploratory pilot study was to systematically examine the factors (e.g., sex, residency year, prior laceration training) associated with overall accuracy of five laceration length estimates made on a series of five identically-marked linear dummy torso sutured lacerations by a convenience sample of Emergency Medicine (EM) resident physicians. Before the study, the authors hypothesized that laceration estimates from later-year residents and/or those with more prior laceration training would be more accurate. METHODS: The EM residents who attended a statewide educational session were encouraged to participate in the study by independently entering information concerning their a) personal characteristics, and b) five laceration length estimates from five dummy torso sutured lacerations onto hard copy forms during break and lunch periods of the daylong conference. The use of any types of measurement devices was prohibited. RESULTS: A total non-probability convenience sample of 107 participants (93 EM resident physicians and 14 medical student attendees) from 14 different Michigan-based EM residency programs completed a 10-item survey during the educational conference. Results for both composite and individual actual-to-estimated (AE) laceration differences varied widely within the sample, with up to 58.9% of laceration over estimates hypothetically having resulted in overbilling of payers for the laceration repair. CONCLUSIONS: The considerable range in laceration estimates obtained from these EM clinicians indicate the complexity of attempting to estimate lacerations without measuring devices, as well as the potential for over-billing under such conditions. Larger resident samples recording laceration length estimates, with testing of potential interaction effects on AE patterns, are needed in the future to provide additional evidence concerning this aspect of EM billing.

Examination of Resident Physician Quality Improvement/Patient Safety Project Confidence Levels from Multiple Programs.

CONTEXT: It is now increasingly recognized that physicians should be engaged in quality improvement/patient safety (QIPS) activities to make their patient care systems perform more reliably and safely. In order to ensure that our nation's physicians embed this aspect of practice into their work, there also is a growing expectation for effective integration of QIPS training into graduate medical education. This exploratory pilot study was conducted to identify how residents' personal and residency program characteristics might be related to their perceived confidence to develop and conduct prospective QIPS projects. METHODS: A total non-probability convenience sample of 43 DO resident physicians from five residency programs (Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, and Psychiatry) at Authority Health were surveyed from 09/28/2015 to 01/06/2016 using online Survey Monkey software. A 38-item survey asked residents about their personal and residency program characteristics, as well as their current overall perceived confidence to develop and conduct QIPS projects. RESULTS: Two model terms that proved non-significant during analyses were residents' age category and year in residency training. In the final stepwise multinomial regression model, however, three covariates including: a) sex (p=0.045), b) being in a primary care residency program (p=0.038) and c) having had prior QIPS project experience (p=0.049) were each found to be statistically significant predictors of respondents' perceived comfort level categories. Male residents and those who were in a primary care residency program (i.e., Family Medicine, Internal Medicine or Pediatrics), and/or reported having had prior QIPS project experience, reported significantly higher confidence levels. CONCLUSIONS: Somewhat similar to earlier studies, these results suggest the need to incorporate QIPS education for resident trainees across the nation. Ideally, the findings from larger resident studies will enable GME leaders to develop and deliver evidence-based QIPS curricula that are better oriented to resident physicians' personal characteristics and preferences.

Is quality improvement sustainable? Findings of the American College of Cardiology's Guidelines Applied in Practice.

OBJECTIVE: (i) To examine the sustainability of an in-hospital quality improvement (QI) intervention, the American College of Cardiology's Guideline Applied to Practice (GAP) in acute myocardial infarction (AMI). (ii) To determine the predictors of physician adherence to AMI guidelines-recommended medication prescribing. DESIGN: Prospective observational study. SETTING: Five mid-Michigan community hospitals. PARTICIPANTS: 516 AMI patients admitted consecutively 1 year after the GAP intervention. These patients were compared with 499 post-GAP patients. MAIN OUTCOME MEASURES: The main outcome was adherence to medication use guidelines. Predictors of medication use were determined using multivariable logistic regression analysis. RESULTS: 1 year after GAP implementation, adherence to most medications remained high. We found a significant increase in beta-blocker (BB) use in-hospital (87.9 vs. 72.1%, P < 0.001) whereas cholesterol assessment within 24 h (79.5 vs. 83.6%, P > 0.225) did not change significantly. However, discharge aspirin (83 vs. 90%, P < 0.018) and BB prescriptions (84 vs. 92%, P < 0.016) dropped to preintervention rates. Discharge angiotensin-converting enzyme inhibitor and treatment of patients with low-density lipoprotein of ≥ 100 were unchanged. Predictors of receiving appropriate medications were male gender (for aspirin and BBs) and treatment with percutaneous coronary intervention compared with coronary artery bypass graft. Notably, prescription rates for discharge medications differed significantly by hospital. CONCLUSIONS: Early benefits of the Mid-Michigan GAP intervention on guideline use were only partially sustained at 1 year. Differences in guideline adherence by treatment modality and hospital demonstrate challenges for follow-up phases of GAP. Additional strategies to improve sustainability of QI efforts are urgently needed.

Increasing comorbidity with diabetes in the community: diabetes research challenges.

BACKGROUND: The purpose of this paper is to discuss the ongoing definitional, measurement and analytic challenges imposed on community-based diabetes researchers examining the experiences and outcomes of home-dwelling adults surviving longer with diabetes and additional comorbid health conditions. When selecting from the still limited number of standard hospital-oriented comorbidity methods, researchers across the world will need to consider a frequently complex series of methodological decisions from their enrolling such adults with increased comorbidity into study samples. CONCLUSIONS: Three categories of methodological implications from increasing forms of comorbid diabetes are discussed for diabetes researchers. Six sequenced research design strategies with specific examples are offered regarding how to most rigorously incorporate elements of comorbidity into prospective diabetes study designs.

Do self-report and medical record comorbidity data predict longitudinal functional capacity and quality of life health outcomes similarly?

BACKGROUND: The search for a reliable, valid and cost-effective comorbidity risk adjustment method for outcomes research continues to be a challenge. The most widely used tool, the Charlson Comorbidity Index (CCI) is limited due to frequent missing data in medical records and administrative data. Patient self-report data has the potential to be more complete but has not been widely used. The purpose of this study was to evaluate the performance of the Self-Administered Comorbidity Questionnaire (SCQ) to predict functional capacity, quality of life (QOL) health outcomes compared to CCI medical records data. METHOD: An SCQ-score was generated from patient interview, and the CCI score was generated by medical record review for 525 patients hospitalized for Acute Coronary Syndrome (ACS) at baseline, three months and eight months post-discharge. Linear regression models assessed the extent to which there were differences in the ability of comorbidity measures to predict functional capacity (Activity Status Index [ASI] scores) and quality of life (EuroQOL 5D [EQ5D] scores). RESULTS: The CCI (R2 = 0.245; p = 0.132) did not predict quality of life scores while the SCQ self-report method (R2 = 0.265; p < 0.0005) predicted the EQ5D scores. However, the CCI was almost as good as the SCQ for predicting the ASI scores at three and six months and performed slightly better in predicting ASI at eight-month follow up (R2 = 0.370; p < 0.0005 vs. R2 = 0.358; p < 0.0005) respectively. Only age, gender, family income and Center for Epidemiologic Studies-Depression (CESD) scores showed significant association with both measures in predicting QOL and functional capacity. CONCLUSIONS: Although our model R-squares were fairly low, these results show that the self-report SCQ index is a good alternative method to predict QOL health outcomes when compared to a CCI medical record score. Both measures predicted physical functioning similarly. This suggests that patient self-reported comorbidity data can be used for predicting physical functional capacity and QOL and can serve as a reliable risk adjustment measure. Self-report comorbidity data may provide a cost-effective alternative method for risk adjustment in clinical research, health policy and organizational improvement analyses. TRIAL REGISTRATION: Clinical Trials.gov NCT00416026.

Posthospital heart-healthy behaviors in adults with comorbid diabetes.

The purpose of these secondary analyses was to examine relationships between patient factors and patient-provider decision-making style (PDM) on heart-healthy behavior changes in 142 adults with diabetes after hospitalization for an acute coronary syndrome (ACS). A clinical trial randomized adults to either control or a telephone coaching intervention. Generalized estimating equations were used to analyze the relationship between patient factors and PDM style on longitudinal postdischarge changes in three heart-healthy behaviors, avoiding high fat foods, weight loss, and increased physical activity. Neither PDM style nor telephone coaching intervention affected heart-healthy behaviors in this population. Although adults with diabetes preferred collaborative patient-provider decision-making, present levels of provider engagement were not sufficient to support behavior change. Results suggest the need for sustained and tailored nursing interventions to facilitate heart-healthy behavior changes in adults with diabetes after ACS hospitalization.

Increasing primary care comorbidity: a conceptual research and practice framework.

PURPOSE: To present a "contrasting perspectives" conceptual framework reflecting the typically strained experiences of many comorbid adults now interacting with primary care clinicians across the world. BACKGROUND: More comorbidity-related needs are presented to primary care clinicians during typically shorter office-based health care encounters. The overall perceptual differences between many comorbid consumers and health care clinicians and systems in many countries are likely to worsen. CONCLUSIONS: Conceptual implications are discussed for primary care researchers testing interventions and attempting to influence the outcomes of increasingly comorbid primary care adults. Implications for Nursing Research and Practice: Three strategies are offered for researchers and clinicians considering how to include elements of comorbidity into their prospective primary care study interventions and care delivery processes.

Hopelessness and its effect on cardiac rehabilitation exercise participation following hospitalization for acute coronary syndrome.

PURPOSE: Hopelessness has been associated with a higher risk of fatal and nonfatal coronary heart disease, yet very few studies have examined hopelessness after a cardiac event. This investigation examined hopelessness as an independent predictor of participation in a hospital-based cardiac rehabilitation exercise program. METHODS: A total of 207 patients with acute coronary syndrome were interviewed at 3 and 8 months after hospital discharge. Measures included 1 factor of the Beck Hopelessness Scale, the Center for Epidemiological Studies Depression Scale, the Activity Status Index, the Charlson Comorbidity Index, a sociodemographic variables tool, and a cardiac rehabilitation exercise participation questionnaire. RESULTS: Random-effects logistic regression analysis revealed that hopelessness persisted over time and was an independent predictor of lower exercise participation. In contrast, depression showed no significant influence on exercise participation. CONCLUSIONS: Study findings suggest the importance of assessing hopelessness in patients with acute coronary syndrome and identifying approaches to exercise recommendations that directly address hopelessness. Interventions focused on the prevention and treatment of hopelessness symptoms may contribute to improved recovery of patient with acute coronary syndrome.

Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome?

BACKGROUND: Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care. OBJECTIVE: To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge. DESIGN: Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus). DATA: medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization). ANALYSIS: pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis. PARTICIPANTS: Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys. MEASUREMENTS: We measured secondary prevention behaviors, physical functioning, and quality of life. RESULTS: QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months. CONCLUSIONS: Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.

The perceptions of older veterans concerning their postdischarge outcome experiences.

This study investigated the perceptions of a sample of older veterans regarding their outcome experiences after hospital discharge. Qualitative data from 165 participants were analyzed for major conceptual themes that best fit the structure of comments regarding participants' postdischarge experiences. Most responses were brief and suggested that few participants had considered their outcomes as being influenced by prior discharge planning interventions. Few participants described having actively worked to address their new health needs or feeling equipped to work through the system to do so. Practice implications are discussed for clinicians who help prepare patients during more rapid discharges.