A Comparison of Two Diabetes Self-Management Education Programs for the Reduction of Participant A1c Levels.

PURPOSE: Compare the effectiveness of two educational teaching methods for diabetic patients. DESIGN: Quasi-experimental study comparing two interventions using a pretest/post-test design. SETTING: Three clinics within a western U.S. regional health system. SUBJECTS: 818 adult diabetic participants (60.5 mean age, 52% female) attended one to four sessions between 2013-2017, and had A1c tests within 180 days of first attended session and 30 to 365 days after last attended session. INTERVENTION: A group-based, highly interactive learning experience (n = 561) and a traditional, lecture-style class (n = 257). MEASURES: Pre and post measures of A1c. ANALYSIS: Paired t-tests measured change within each group pre-post intervention. Two-sample t-tests measured mean change pre-post intervention between the two groups. Multivariable linear regression measured mean change in A1c between groups, adjusted for pre-test scores and controlling for demographic variables. RESULTS: Both interactive and traditional teaching interventions were effective at significantly reducing patient A1c levels by 1.3 (p < 0.001) and 1.0 (p < 0.001) points respectively. The between groups difference in A1c was not significant, t(512) = 1.66, p = 0.0985, but when controlling for age, pre-A1c and days post-A1c, the interactive intervention was significantly (p < 0.05) more effective reducing patient A1c levels by 0.19 points than the traditional intervention. CONCLUSION: Group-based, interactive diabetes self-management education programs may be an effective model for reducing patient A1c levels.

Does Time of Wound Complication after Cesarean Delivery Differ by Type of Skin Closure?

OBJECTIVE: A high proportion of postcesarean wound complications occur after patients have been discharged from the hospital, increasing personal and health care costs. We undertook this study to evaluate the association between skin closure methods (suture vs. staple) following a cesarean delivery and the frequency of wound complications occurring after hospital discharge. STUDY DESIGN: This is a secondary analysis of data from a randomized trial in which women undergoing cesarean delivery at ≥24 weeks' gestation were randomized to receive metallic staples or subcuticular suture for skin closure after surgery. Staples were removed at the time of hospital discharge on postoperative days 3 to 4 for Pfannenstiel incisions or days 7 to 10 for vertical. The primary outcome for this analysis was any wound complication occurring after hospital discharge. Wound complications were infections or any wound disruption without infection (including seromas and hematomas). Associations were examined using chi-square and Fisher's exact tests, as appropriate, and multivariable logistic regression. RESULTS: A total of 350 patients with follow-up through 4 to 6 weeks postpartum were included in the analysis: n = 171 received suture closure and n = 179 received staples. In the primary trial, wound complications occurred in 14.5% (n = 26) of individuals with staples and 5.9% (n = 10) with sutures (p = 0.008). Twenty-one (58.3%) of the 36 wound complications occurred after hospital discharge. The incidence of wound complications occurring after hospital discharge was 6.7% (n = 12) of patients receiving staples and 5.3% (n = 9) of those receiving sutures; p = 0.57; relative risk [95% confidence interval]: 1.27 [0.55-2.95]). After multivariable adjustment, type of skin closure method was not associated with wound complication after discharge from the hospital (odds ratio: 1.29; 0.52-3.17). CONCLUSION: Although suture closure compared with staples was associated with fewer wound complications after cesarean delivery, we found no significant differences between closure types in the frequency of wound complications occurring after hospital discharge.

The relationship between emergency department wait times and inpatient satisfaction.

This study examines patient perceptions of emergency department wait times and inpatient experiences. For many hospitals across the United States, the emergency department (ED) is now the "front door"; therefore, understanding the impact of ED experience on the inpatient experience is critical for leaders managing these complex settings today. Results showed statistically significant relationships between a very good ED experience and a very good inpatient experience. Perceived wait times in the ED, more so than actual ED wait times, served as a predictor of a very good ED rating as well as a very good rating of the inpatient experience.

Combined Tolterodine and Vaginal Estradiol Cream for Overactive Bladder Symptoms After Randomized Single-Therapy Treatment.

OBJECTIVES: The aims of this study were to compare 12-week outcomes of single-therapy tolterodine (Detrol LA) extended release to intravaginal estrogen (Estrace) for overactive bladder (OAB) symptoms and characterize 24- and 52-week outcomes in women undergoing combined therapy. METHODS: A single-site randomized, open-label trial in women with urinary frequency, urgency, nocturia, and/or urgency urinary incontinence symptoms was performed. Fifty-eight participants were randomized to oral tolterodine extended release daily or intravaginal estradiol cream nightly for 6 weeks then twice per week. The primary outcome was change in Overactive Bladder Questionnaire (OAB-q) symptom bother score at 12 weeks. Secondary outcomes included the Health-Related Quality of Life Questionnaire (HRQL) of the OAB-q and a 3-day bladder diary. At 12 weeks, subjects were offered addition of the alternative therapy with follow-up at 24 and 52 weeks. RESULTS: There was no difference in symptom bother score improvement between the tolterodine and intravaginal estradiol groups baseline to 12 weeks (20.6 ± 21.7, -15.8 ± 23.3, respectively, P = 0.45). There was a significant within-group decrease in symptom bother score from baseline to 12 weeks (tolterodine, P < 0.0001, and intravaginal estradiol, P = 0.002). Secondary outcome improvement within groups was noted in the HRQL total, urinary incontinence episodes, and median voiding frequency (all P ≤ 0.03) in the tolterodine group and in the HRQL total score (P = 0.03) in the intravaginal estradiol group, with no differences between groups. Combined therapy outcomes at 24 and 52 weeks compared with single therapy at 12 weeks revealed significant improvement in symptom bother score in the intravaginal estradiol + tolterodine group at 24 and 52 weeks (20.0 ± 23.9, P = 0.008; -16.7 ± 23.3, P = 0.02, respectively). CONCLUSIONS: Significant within-group improvement in OAB-q symptom bother was noted in both the intravaginal estradiol and tolterodine groups for OAB symptoms, with no difference between groups. Greater improvement from 12-week single therapy to 24 and 52 weeks of combined therapy was noted in the group originally assigned to intravaginal estradiol. The role of combined medical therapy for OAB symptoms needs further investigation.

Higher-dose oxytocin to prevent obstetric hemorrhage at vaginal delivery-does duration of infusion matter?

OBJECTIVE: Postpartum higher-dose oxytocin (80 U) compared with lower dose (10 U) given in 500 mL over 1 hour does not decrease postpartum hemorrhage (PPH) requiring treatment, but reduces the risk of hematocrit decline ≥ 6% among women delivering vaginally. Our objective was to evaluate whether the duration of administration of oxytocin influences outcomes. STUDY DESIGN: We compared a cohort receiving a postpartum oxytocin infusion of 80 U/500 mL over 1 hour to a concurrent cohort of women receiving 80 U/500 mL over 8 hours. The primary outcome was any treatment of PPH (uterotonics, blood transfusion, tamponade, and surgery). Secondary outcomes included pre- to postdelivery median hematocrit change and hematocrit decline ≥ 6%. RESULTS: There were 653 and 676 women identified in the 1- and 8-hour cohorts, respectively. There was no difference in PPH requiring any treatment between the 1- and 8-hour cohorts (6 vs. 6%, p = 0.70). There were no differences in individual treatment components including blood transfusion (p = 0.75). Median hematocrit decline (p = 0.02) was lower in the 8-hour cohort, but there was no difference in frequency of hematocrit decline ≥ 6% (p = 0.15). Results were unchanged by multivariable adjustments. CONCLUSIONS: Postpartum higher-dose oxytocin administered over 1 hour compared with 8 hours was not associated with an increased treatment of PPH or frequency of hematocrit decline ≥ 6%.

Economic impacts of the Pueblo Smoke-Free Air Act.

BACKGROUND: On July 1, 2003, the city of Pueblo CO enacted a smokefree ordinance (Pueblo Smoke-Free Air Act [PSFAA]) that prohibited smoking in public places and workplaces, including taverns and restaurants. Opponents to this ordinance argued that it would have a negative impact on tavern and restaurant sales. PURPOSE: The purpose of this study was to determine whether the PSFAA had a negative economic impact on tavern and restaurant sales tax revenues. METHODS: With data gathered in 2007, this study implemented an interrupted time-series model in 2008, using 42 months of pre- and post-intervention sales tax revenue data for Pueblo to determine whether implementation of this ordinance had an effect on tavern and restaurant sales tax revenues. Ratios of tavern and restaurant openings to closings were also computed for the pre- and post-intervention periods. RESULTS: Pre-post sales tax revenue data showed slight losses in sales tax revenue for taverns, and gains for restaurants, which more than offset the tavern losses. After adjusting for the consumer price index, the city of Pueblo experienced a 20.3% gain in combined tavern and restaurant sales tax revenues from the pre-ordinance period to the post-ordinance period. The ratio of tavern openings to closings improved from 1:1 pre-period to 3.3:1 post-period and the restaurant ratio remained unchanged at approximately 1.78:1 from pre- to post-period. CONCLUSIONS: There is no evidence that the PSFAA had a negative economic impact on consumer price index-adjusted tavern and restaurant sales tax revenues. From a fiscal policy perspective, this ordinance may have contributed to a net increase in sales tax revenues for the city of Pueblo. The business openings/closings data suggest that the confidence Pueblo's business sector had in the local hospitality industry was not negatively influenced by the PSFAA.