Medical Care最新文献

Background: The Accelerating Data Value Across a National Community Health Center Network (ADVANCE) collaborative is 1 of 8 clinical research networks participating in PCORnet®, the National Patient-Centered Clinical Research Network. Providing data, engagement, and regulatory infrastructure, ADVANCE facilitates the inclusion of people who receive primary care in community-based health centers (CHC) across over 90 patient-centered research studies. Centrally coordinated by OCHIN, in partnership with Fenway Health, Health Choice Network, Oregon Health & Science University, and the University of Washington, ADVANCE comprises the nation's most comprehensive network for health care and outcomes research in community-based primary care and hospital-based settings.

Objective: This manuscript discusses ADVANCE's unique past, present, and future approaches to strengthen infrastructure and capacity to enhance research in community-based primary care settings.

Main arguments: As community-based primary care organizations, CHCs have relationships, trust, and expertise with the communities they serve. ADVANCE provides critical data and engagement resources for including CHCs and their patients in research to improve patient-centered care and outcomes. Despite past investment, there is a recognized need for additional engagement, investment, capacity building, and research infrastructure to realize the full potential of CHC partnerships in clinical research and PCORnet® studies. By partnering with CHCs and tertiary hospitals, ADVANCE and the PCORnet infrastructure can provide enhanced access to clinical research opportunities that further support patient-centered, high-quality care delivery, and positive health outcomes while meeting CHCs' priorities and goals, progressing their own research capacity and infrastructure, and contributing to scalable research readiness models.

Background: PCORnet is a large, federated "network of networks" that facilitates innovative patient-centered comparative clinical effectiveness research (CER) and other health research at a national scale. As a flagship infrastructure program funded by the Patient-Centered Outcomes Research Institute® (PCORI®), an independent, nonprofit research organization, PCORnet is unique among national clincial research networks given the scale of the network. With linkages to more than 47 million unique patients, strong governance, research expertise, and commitment to keeping the patient at the center of all activities, PCORnet can be used to conduct a range of study types, from pragmatic trials to observational studies. Since 2015, PCORnet has been used to conduct more than 250 studies, ranging from observational research to pragmatic trials.

Objective: The main objective of this commentary is to provide PCORI's perspective on the importance of clinical research infrastructure, the unique contributions of the PCORnet infrastructure to patient-centered research, and PCORI's approach to continuous evaluation and evolution of PCORnet.

Relevance to the special issue: This commentary aims to be useful to readers in understanding PCORI's vision for PCORnet and approach to monitoring progress and measuring success.

Background/objective: Evidence about the patient benefits of alternative primary care delivery models for high-cost/high needs patients is mixed. We conducted a follow-up study of a program designed to improve outcomes of seriously ill adult patients in an integrated delivery system.

Methods: Using a quasi-experimental design, we examined the 180-day mortality of patients empaneled to a complex care program (CCP, n=1445) compared with that of eligible but unempaneled patients who continued to receive usual primary care (UPC, n=6409) for January 2019 through June 2021. Patients in the CCP and UPC were propensity score-matched on demographics, comorbidities, and frailty. In the propensity score matched samples (n=1440 in each group), the hazard of mortality was estimated using Cox proportional hazards regression.

Results: The CCP continued to empanel eligible adults with more comorbidities and greater frailty compared with the eligible patient population in UPC. In the matched samples, CCP patients had a significantly lower hazard of 180-day mortality compared with UPC in this replication cohort (0.71, 95% CI: 0.61-0.82). This was higher than the hazard ratio in the prior inception cohort (0.58, 95% CI: 0.47-0.70).

Conclusions: A reduced hazard of death was reproduced within a second incident cohort of among seriously ill adult patients who were empaneled to a CCP in an integrated health care system compared with matched, but unempaneled patients whose care remained within UPC.

PCORnet® is a large, complex network that may appear intimidating for new investigators and funders, posing a perceived barrier to expanding the use of this powerful resource for research. In this commentary, I highlight the importance of mentorship, immersion, and didactic training to build the future cadre of investigators leveraging the PCORnet infrastructure and expand the impact of PCORnet® Studies, while sharing personal experience navigating the opportunities and challenges offered by this network.

Background: The Congenital Heart Initiative-Redefining Outcomes and Navigation to Adult-Centered Care (CHI-RON) study is a unique collaboration between the PCORnet and Congenital Heart Initiative (CHI), the first patient powered registry for adult congenital heart disease (ACHD) patients. The CHI-RON study examines the effects of gaps in recommended care in ACHD.

Objective: Recruitment of racially diverse, younger, out-of-care, and male participants has been challenging in ACHD studies. Our goal was to design patient engagement and recruitment strategies to improve representation.

Research design: Launched in December 2020, patients from any location can self-enroll in the CHI registry, while the CHI-RON study (5/2022 - 10/2023) recruited ACHD patients at 12 sites participating in PCORnet. CHI-RON Recruitment methodology included a patient partner engagement toolkit and a recruitment algorithm using the PCORnet® Common Data Model designed specifically to improve diversity and reduce self-enrollment biases in comparison to the CHI registry.

Subjects: ACHD patients, age 18 years or older, with the ability to complete PROs independently.

Measures: Demographic/Recruitment Statistics for study participants and Patient Engagement in Research Scale (PEIRS-22) for the study team partners.

Results: As of October 2023, a total of 2652 participants were recruited through CHI-RON recruitment methodology while 1326 were self-enrolled in the CHI. CHI-RON recruitment methodologies have increased representation when compared with self-enrolled CHI participants in terms of ethnicity (10.9% vs. 7.4% Hispanic, P<0.001), race (5.4% vs. 2.6%, Black/African American, P<0.001), sex (41% vs. 28% male, P<0.001), younger age (35.5 +/-12.8 y vs. 43.5±14.5 y, P<0.001), and education (33.4% vs. 24% high school equivalent or less, P<0.001).Most study team patient partners (n=12, 86%) reported a very to extremely high degree of engagement (PEIRS-22 average score 101.6), especially in the subdomains of contributions, support, feeling valued, and benefits.

Conclusions: Patient engagement and novel recruitment strategies are critical to improving the inclusion of under-represented populations in clinical research and ensuring alignment with the needs of ACHD patients.

Importance: Anesthesia care is delivered by Certified Registered Nurse Anesthetists (CRNAs) working independently, physician anesthesiologists working alone, and anesthesia care teams with CRNAs supervised by physician anesthesiologists. The impact of these models and CRNA supervision on patient satisfaction remains unclear.

Objective: To identify associations between anesthesia care team credentials, CRNA supervision, and patient satisfaction with care access, provider ratings, and overall satisfaction.

Design: We linked survey data on patient satisfaction with administrative data from the Veterans Health Administration (VHA) to gather veteran demographics, staffing, and clinical features of each surgical case.

Participants: Our sample included 45,757 veterans who responded to the Survey of Healthcare Experiences of Patients following an invasive surgical procedure performed in a VHA operating room between 2016 and 2023.

Main measures: Satisfaction was assessed using 4 outpatient survey items: overall VHA satisfaction, provider ratings, whether the provider listened carefully, and whether the provider showed respect. Inpatient measures included hospital ratings, doctors' courtesy and respect, doctors' attentiveness, willingness to recommend the VHA, and preference for VHA over free care elsewhere.

Results: Anesthesia care models and supervision ratios were not significantly associated with veterans' overall satisfaction, provider or hospital ratings, or likelihood of recommending the VHA. Small positive effects of CRNA involvement were observed on provider attentiveness and respect. Satisfaction was high across all provider types, and findings were robust to exclusion of COVID-19 data and lower-complexity cases.

Conclusions: Veterans' overall satisfaction with anesthesia care reflects a consistently high standard across models and credentials, with subtle benefits from CRNA involvement in patient-provider communication.

Background: Descriptive studies have documented high hospital nurse burnout and turnover but there are few, if any, large-scale evaluations of organizational interventions to improve clinician retention. The Magnet model is an organizational hospital intervention associated with better clinician and patient outcomes but there is insufficient evidence as to whether the Magnet model based on structural empowerment of clinicians results in better outcomes or rewards hospitals with good work environments, and whether the Magnet model can be implemented at scale outside the United States.

Objective: To evaluate whether Magnet4Europe-a multiyear organizational intervention of European hospitals-could be implemented and would result in improvements in nurse well-being, care quality, and patient safety.

Design: Quasi-experimental longitudinal evaluation of 56 European intervention hospitals in 6 countries. Hospital-level implementation of the intervention measured by changes (from baseline to follow-up) in 77 Magnet model intervention targets. Outcome measures (eg, nurse burnout, intent to leave, quality of care, patient safety) were derived from surveys of nurses (4546 nurses at baseline; 3171 at follow-up).

Findings: Hospitals that implemented intervention targets during the study period observed reductions in nurse burnout, nurses' intentions to leave their jobs, and unfavorable care quality. Each 10-percentage-point increase in intervention target implementation was associated with 2.7%-point reduction in nurses who intend to leave (β -2.66; 95% CI: -4.74, -0.58, P <0.05). Hospitals which implemented more than 25% of intervention targets observed 6.3%-point reduction in nurse burnout, 7.6%-point reduction in intent to leave, 6.4%-point reduction in unfavorable care quality, and 3.7%-point reduction in unfavorable patient safety. Improvements in hospital percentages of nurses reporting staffing adequacy were associated with reductions in burnout, intentions to leave, unfavorable care quality, and patient safety.

Conclusion: Successful implementation of Magnet4Europe demonstrates promise for international adoption at scale of Magnet as an organizational intervention for improving clinician well-being, care quality, and patient safety.

This study analyzed COVID-19 disease severity distributions among different age, racial, and ethnic groups for pre-Omicron and Omicron variant periods from May 2020 to October 2022. Disease severity categories were defined by ICD-10-CM diagnostic codes recorded in the electronic health record in the 7 days preceding and 13 days following the SARS-CoV-2 positive laboratory record (index date) and were grouped into 4 mutually exclusive categories: severe complications, high, moderate, and low disease severity. Low severity was defined as the absence of codes for any of the other categories. Among 1,613,706 included patients, there was a lower prevalence of disease severity during the Omicron variant period across all race and ethnicity groups (P<0.001) compared with the pre-Omicron variant period; however, the Omicron period had a higher prevalence of severe complications (P<0.05). Relative to White patients with high disease severity, Black patients and patients of other races had 37.1% and 52.4% (Pt<0.0001) greater risk of having high disease severity, respectively, in the pre-Omicron period, but high disease severity was similar across racial groups during the Omicron period. During pre-Omicron, mean monthly relative differences among Hispanic patients with high disease severity and severe complications compared with non-Hispanic patients were -5.17% and -39.4%, respectively, which shifted to 24.4% and 44.1% in the Omicron period (Pt<0.0001). These findings provide valuable insight into patterns of COVID-19 disease severity, especially for marginalized populations, and highlight the need for targeted public health strategies as variant-specific trends evolve over time.

Background: Scientific advances and cost efficiencies in genetics and genomics are expanding clinical application for prevention, diagnosis, and treatment.

Objective: PCORnet®, a research network that includes participation from 78 health systems nationally and is linked to more than 47 million unique patients with at least one encounter annually, can help (1) understand the ability of genetics/genomics to predict health outcomes, (2) identify diseases impacted by genetic/genomic factors, (3) evaluate pharmacogenomics' role in medication optimization, (4) evaluate emerging gene therapies, and (5) compare clinical genetic or genomic strategies within learning health systems to improve outcomes, while (6) facilitating patient and other partner engagement across these areas.

Main arguments: The breadth of data accessible via PCORnet represents a unique opportunity to study relationships among genetic markers and clinical and exposome-based disease risk factors, particularly as more genomic data become available. The network's experience developing computable phenotypes for identifying specific diseases can be leveraged to evaluate the role of genetics/genomics in health. The PCORnet infrastructure can be used to identify patients with particular conditions for predictive modeling or comparative clinical effectiveness research using electronic health record data. The network can also recruit patients for observational cohorts or pragmatic clinical trials on pharmacogenomics or the return of genetic results, evaluation of emerging gene therapies, or embedded research into learning health systems to compare clinical genetics/genomics implementation approaches in health care. The partner engagement focus of the PCORnet® Network Partners can enrich research and improve health care delivery and outcomes. The rise of clinical genetics and genomics will profoundly impact health care in the next decade, and the PCORnet® Network Partners are primed to make a leading contribution in this area.