Evidence-Based Antibiotic Prophylaxis in Clean Hand Surgeries: An Educational Intervention to Decrease Use.

PURPOSE: Evidence for the use of prophylactic antibiotics in clean hand surgery is limited, yet surgeons continue to administer antibiotics to prevent postoperative infections. We sought to assess the effect of a program directed at reducing the use of antibiotic prophylaxis in carpal tunnel release surgery and elicit reasons for continued use. METHODS: A surgeon leader implemented a program between September 1, 2018 and September 30, 2019 to reduce antibiotic prophylaxis in clean hand surgeries in a hospital system of 10 medical centers. It consisted of (1) an evidence-based educational session for all participating orthopedic and hand surgeons during which the elimination of the use of antibiotics in clean hand surgeries was requested and (2) a year-long, monthly antibiotic use audit and feedback cycle using carpal tunnel release (CTR) as a proxy for clean hand surgery. The rate of antibiotic use in the year of the intervention was compared to the rate prior to the intervention. Multivariable regression was used to determine patient-related risk factors for receiving antibiotics. Participating surgeons completed a survey to elucidate factors that contributed to continued use. RESULTS: Antibiotic prophylaxis decreased from 1223/2379 (51%) in 2017-2018 to 531/2550 (21%) in 2018-2019. During the last month of evaluation, the rate decreased to 28/208 (14%). Logistic regression revealed a higher rate of antibiotic use during the period after the intervention among patients who had diabetes mellitus or who were operated upon by an older surgeon. The follow-up surgeon survey revealed a strong positive correlation between surgeon willingness to administer antibiotics and patient hemoglobin A1c and body mass index. CONCLUSIONS: The rate of antibiotic use in carpal tunnel release decreased from 51% the year prior to 14% the final month of implementing a surgeon-led program to reduce antibiotic prophylaxis. Multiple barriers to the implementation of evidence-based practice were identified. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Recommendations for Systematizing Transplant Education Within a Care Delivery System for Patients With Chronic Kidney Disease Stages 3 to 5.

CONTEXT: Early tailored transplant education could help patients make informed transplant choices. OBJECTIVE: We interviewed 40 patients with chronic kidney disease (CKD) stages 3 to 5, 13 support persons, and 10 providers at Kaiser Permanente Southern California to understand: (1) barriers to transplant education and (2) transplant educational preferences and recommendations based on CKD stage and primary language spoken. DESIGN: A grounded theory analysis identified central themes related to transplant education barriers, preferences, and recommendations. RESULTS: Barriers included confusion about diagnosis and when transplant may be necessary, concerns about transplant risks, families' lack of transplant knowledge, financial burdens, transportation and scheduling, and the emotional overload of chronic illness. Hispanic and Spanish-speaking participants reported difficulty in understanding transplant education and medical mistrust. Recommendations included providing general education, earlier introduction to transplant, wait-listing information, transplant education for support persons, living donation education for patients and potential donors, opportunities to meet living donors and kidney recipients, information on the benefits of transplant, recovery, and available financial resources, flexible class scheduling, online and print resources, and more provider follow-up. Spanish-speaking and Hispanic participants recommended using bilingual educators, print, video, and online resources in Spanish, and culturally responsive education. Patients with CKD stages 3 to 4 wanted information on slowing disease progression and avoiding transplant. CONCLUSION: Increasing access to culturally responsive transplant education in multiple languages, pairing appropriate content to the disease stage, and increasing system-wide follow-up as the disease progresses might help patients make more informed choices about transplant.

E-SCOPE: A Strategic Approach to Identify and Accelerate Implementation of Evidence-based Best Practices.

BACKGROUND: More than 50,000 randomized controlled trials and 8000 systematic reviews are anticipated to be published annually in the coming years. This huge volume of published findings makes it challenging for health care delivery systems to review new evidence, prioritize health care practices that warrant implementation, and implement best practices. OBJECTIVE: The objective of this study was to describe the Kaiser Permanente Southern California E-SCOPE (Evidence Scanning for Clinical, Operational, and Practice Efficiencies) program, a systematic method to accelerate the implementation of evidence-based practices in clinical care settings. METHODS: E-SCOPE uses a strategic evidence search algorithm to conduct proactive literature searches to identify high-quality studies of interventions that yield improved health outcomes, quality and/or efficiency of care delivery, or cost savings. Each quarterly search yields 500-1000 abstracts; about 5%-10% of studies are selected each quarter for consideration for implementation. These studies are presented to clinical and operational leaders and other stakeholders to make the final determination regarding the implementation of the practice; E-SCOPE staff work closely with stakeholders to develop an implementation plan, identify practice owners, and ensure sustainability. RESULTS: The time from study publication to implementation using the E-SCOPE process ranges from 4 to 36 months, with an average of ∼16 months. Four examples of E-SCOPE implementation efforts, including new deployment, scale-up/spread, deimplementation, and operational efforts, are described. CONCLUSION: A single, centralized program for the proactive identification of the most up-to-date, evidence-based best practices and facilitated implementation can efficiently and effectively promote continuous learning and implementation in a learning health care system.

A randomized controlled trial of Explore Transplant at Home to improve transplant knowledge and decision-making for CKD 3-5 patients at Kaiser Permanente Southern California.

BACKGROUND: Five-year survival on dialysis is only 40%, compared to 74% with a deceased donor kidney transplant (DDKT) and 87% with a living donor kidney transplant (LDKT). An American Society of Transplantation (AST) Consensus Conference recommended that patients with chronic kidney disease (CKD) Stages 3-5 have the opportunity to learn about and decide which treatment option is right for them, particularly about LDKT. However, early education about LDKT and DDKT outside of transplant centers is inconsistent and often poor, with patients in CKD 3 and 4 and ethnic/racial minorities even less likely to receive it. A new randomized control trial (RCT), in partnership with Kaiser Permanente Southern California (KPSC), will assess knowledge gaps and the effectiveness of a supplementary video-guided, print and technology-based education intervention for English- and Spanish-speaking patients in CKD Stages 3, 4, and 5 to increase LDKT knowledge and decision-making. To date, no published LDKT educational interventions have studied such a large and diverse CKD population. METHODS: In this RCT, 1200 English and Spanish-speaking CKD Stage 3-5 patients will be randomly assigned to one of two education conditions: ET@Home or KPSC standard of care education. Randomization will be stratified by CKD stage and primary language spoken. Those in the ET@Home condition will receive brochures, postcards, DVDs, and text messages delivering educational content in modules over a six-month period. Baseline data collection will measure demographics, transplant derailers, and the amount of previous CKD and transplant education they have received. Changes in CKD and transplant knowledge, ability to make an informed decision about transplant, and self-efficacy to pursue LDKT will be captured with surveys administered at baseline and at six months. DISCUSSION: At the conclusion of the study, investigators will understand key knowledge gaps for patients along the CKD continuum and between patients who speak different languages and have assessed the effectiveness of both English- and Spanish-language supplementary education in increasing KPSC patients' knowledge about the opportunities for and risks and benefits of LDKT. We hope this program will reduce disparities in access to transplant. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03389932; date registered: 12/26/2017.

Correction to: Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters.

In the original publication, age stratified mortality rates were incorrectly added in Fig. 2. The correct Fig. 2 is given below.

Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters.

PURPOSE: The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS: A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS: Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION: Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making.

The effect of the interdialytic interval on cognitive function in patients on haemodialysis.

BACKGROUND: Cognitive deficits are common among individuals on haemodialysis (HD). The degree of dysfunction may shift over the course of the interdialytic interval. OBJECTIVES: To use ecological momentary assessment (EMA) to examine the relationship between the length of the interdialytic interval and reports of cognitive dysfunction. DESIGN: A quantitative study whereby each patient's cognitive functioning was measured during both short and long interdialytic intervals. PARTICIPANTS: Adults maintained on HD (Female n = 15, Male n = 11; MAge = 42.7 ± 15.8 years) were drawn from a standalone HD unit within a large university medical centre. MEASUREMENTS: Tests of baseline neurocognitive functioning were undertaken (Mini-Mental Status Examination, Digit Span, California Verbal Learning Test, Benton Visual Retention Test, Trail-Making Test) and smartphone-based electronic diary reports of cognitive impairment were made around six times each day for one week. RESULTS: Cognitive function and aptitude in this sample, although low, did not reflect clinically-significant impairment, with a mean Mini-Mental Status Exam score of 25.7 ± 3.0. Diary reports of cognitive impairment were also minimal, with an overall mean rating of .22 out of 5. Contrary to expectations, cognitive impairment was significantly greater on the one-day interdialytic days than on Day 2 of the two-day interdialytic interval (ß = .094, p = .017). CONCLUSIONS: Although cognitive impairment appears to be mild in stable, young patients with end stage renal disease, volumetric disruptions caused by HD may exacerbate such dysfunction.

Patient perspectives on the optimal start of renal replacement therapy.

BACKGROUND: Healthcare systems and providers are encouraged to prepare their patients with advanced chronic kidney disease (CKD) for a planned start to renal replacement therapies (RRT). Less well understood are the socioemotional experiences surrounding the optimal start of RRT versus suboptimal haemodialysis (HD) starts with a central catheter. OBJECTIVES: To characterise the experiences of patients beginning RRT. DESIGN: Qualitative, semi-structured phone interviews. PARTICIPANTS: A total of 168 patients with stage 5 CKD initiating RRT in an integrated, capitated learning healthcare system. APPROACH: Qualitative data from patients were collected as part of a quality improvement initiative to better understand patient-reported themes concerning preparation for RRT, patients' perceptions of their transition to dialysis and why sub-optimal starts for RRT occur within our healthcare system. Dual review and verification was used to identify key phrases and themes within and across each domain, using both deductive a priori codes generated by the interview guide and grounded discovery of emergent themes. RESULTS: From the patient perspective, preparing for RRT is an experience rooted in deep feelings of fear. In addition, a number of key factors contributed to patients' preparation (or failure to prepare) for RRT. While the education provided by our system was viewed as adequate overall, patients often felt that their emotional and psychosocial needs went unmet, regardless of whether or not, they experienced an optimal dialysis start. CONCLUSIONS: Future efforts should incorporate additional strategies for helping patients with advanced CKD achieve emotional and psychological safety while preparing for RRT.

The Online Personal Action Plan: A Tool to Transform Patient-Enabled Preventive and Chronic Care.

INTRODUCTION: Patient-facing online tools for managing preventive and chronic care can be a resource-effective way to increase patient agency in health promotion. Recently, Kaiser Permanente Southern California added the Online Personal Action Plan (oPAP) to the member web portal to better enable members to access information about prevention, health promotion, and care gaps. This study described Kaiser Permanente Southern California members who use oPAP, as well as how members use oPAP to close five different care gaps: hemoglobin A1c testing, pneumonia vaccination, and three cancer screenings. METHODS: Care gap closure rates between oPAP users and members not registered on the online patient portal between December 2014 and March 2015 were compared. Data were analyzed in 2015. A total of 838,638 cases (48.9% women; mean age, 49.5 years; 40.4% oPAP users) were examined. RESULTS: Adjusting for demographics, BMI, smoking status, health and insurance status, and number of open care gaps, oPAP access was associated with a somewhat greater likelihood of care gap closure within 90 days for select care gap types, particularly hemoglobin A1c testing and breast, cervical, and colorectal cancer screening among eligible members. The effect of oPAP access on care gap closure differed by certain ethnic minority groups. CONCLUSIONS: Although healthcare organizations have developed approaches to managing and closing preventive care gaps, these efforts are resource intensive. Users of oPAP are more likely than non-registered members to close gaps, especially cancer screening tests. The oPAP appears to be an effective tool at improving patient engagement in preventive health care.

Patient-Reported Factors Associated With Poor Phosphorus Control in a Maintenance Hemodialysis Population.

OBJECTIVE: The purpose of this study was to determine the influence of patient-reported medication adherence and phosphorus-related knowledge on phosphorus control and pharmacy-reported adherence to phosphorus binding medication among patients on maintenance hemodialysis. DESIGN: Retrospective, cross-sectional cohort study. SUBJECTS: Seventy-nine hemodialysis patients (mean age 64.2 years, SD = 14 years; 46.8% female) in a stand-alone hemodialysis unit within an integrated learning healthcare system. Ten percent (10%) of subjects were Caucasian, 42% Latino, 19% African American, and 29% Asian. Forty-eight percent had diabetes; 72% had BMI ≥ 30. Inclusion criteria included the provision of survey data and having medication refill data available in the pharmacy system. 77.2% had mean phosphorus levels ≤ 5.5 mg/dL; 22.8% had mean phosphorus levels > 5.5 mg/dL. INTERVENTION: Subjects were administered the 8-item Morisky Medication Adherence Scale (MMAS-8) and also reported on their phosphorus-related knowledge. MAIN OUTCOME MEASURE: Phosphorus levels within an adequate range. RESULTS: The mean serum phosphorus level was 4.96 mg/dL (SD = 1.21). In the well-controlled group, mean phosphorus was 4.44 mg/dL (SD = 0.76). In the poorly controlled group, mean phosphorus was 6.69 mg/dL (SD = 0.74). A total of 61% of patients reported at least some unintentional medication nonadherence, and 48% reported intentional medication nonadherence. Phosphorus-specific knowledge was low, with just under half of patients reporting that they could not name two high-phosphorus foods or identify a phosphorus-related health risk. Phosphorus binder-related nonadherence was substantially higher in the uncontrolled than the controlled group. Adjusting for age, individuals with poorer self-reported binder adherence were less likely to have controlled phosphorus levels (odds ratio = 0.71, P = .06). CONCLUSION: Phosphorus-related non-adherence, but not low phosphorus-specific knowledge, was associated with poorer phosphorus control. Such findings provide important information for the development of evidence-based strategies for improving phosphorus control among patients on dialysis.

Negative emotions and risk for type 2 diabetes among Korean immigrants.

PURPOSE: The purpose of this study is to examine the relationship between negative emotions and bio-behavioral risk factors among Korean immigrants at risk for type 2 diabetes (T2DM). METHODS: Data were collected from 148 Korean immigrant adults who are "at risk" for T2DM as defined by having family history of T2DM in first-degree relatives, body mass index greater than 23, or history of gestational diabetes in women. Participants completed questionnaires and underwent biological measures. Negative emotions included feeling nervous, hopeless, restless, anxious, and stressed as well as depressive symptoms. RESULTS: High percentages of participants had T2DM risk factors including overweight, greater than normal waist to hip ratio, and blood glucose readings that are indicative of T2DM. Feeling stressed was the most commonly reported negative emotion (66%), followed by feeling anxious (51%), restless (38%), nervous (30%), and hopeless (13%). Experience of negative emotions was significantly related to behavioral risk factors; higher levels of experiencing negative emotions were related to increased soda intake and a decreased likelihood of doing at least 10 minutes of moderate exercise. Stress and anxiety were each negatively related to moderate exercise, and depressive symptoms were negatively related to both moderate and vigorous exercise. No significant relationship was found between negative emotions and biological risk factors. CONCLUSIONS: Findings suggest that negative emotions, individually and taken together, may be related to T2DM risk behaviors in high-risk Korean immigrants. Behavioral interventions to prevent T2DM in this population should consider assessing and addressing negative emotions.

Spousal undermining of older diabetic patients' disease management.

Marriage can enhance health for individuals with a chronic disease, yet spouses may also undermine disease management. The current study investigated spousal undermining of dietary regimen in 129 patients with type 2 diabetes mellitus. A total of 40 patients reported that their spouses tempted them with forbidden foods, and 15 reported that their spouses conveyed disregard for their diabetic diet. Spousal tempting was associated with worse dietary adherence, and spousal disregard with worse nondietary adherence. Spousal undermining is relatively rare but is associated with patients' disease management and warrants further investigation to better understand how spouses influence partners' day-to-day management of chronic diseases.

I (should) need a cigarette: adolescent social anxiety and cigarette smoking.

BACKGROUND: Approximately half of high school students in the USA have used tobacco. Social anxiety can put adolescents at increased risk for smoking. PURPOSE: This study aims to determine whether adolescents high in trait social anxiety report more cigarette use and greater urge to smoke before, during, and after friend interactions than do teens low in trait social anxiety. METHODS: Four hundred two students who reported smoking more than once during high school were assessed approximately every 30 min during up to 84-day monitoring sessions. RESULTS: Controlling for momentary anxiety, high socially anxious teens were equally or less likely to smoke, but more likely to report urge to smoke, surrounding friend interactions than low socially anxious teens. CONCLUSIONS: Although high socially anxious adolescents do not smoke more than low socially anxious peers, they may believe that they should need a cigarette in anxiety-provoking situations. Such urges may later develop into smoking behaviors.