Modelling the impact of climate change on health

The main objective of this thesis is to develop a robust statistical model by accounting the non-linear relationships between hospital admissions due to lower respiratory (LR) disease and factors of climate and pollution, and their delayed effects on hospital admissions. This study also evaluates whether the model fits can be improved by considering the non-linearity of the data, delayed effect of the significant factors, and thus calculate threshold levels of the significant climate and pollution factors for emergency LR hospital admissions. For the first time three unique administrative datasets were merged: Hospital Episode Statistics, Met office observational data for climate factors, and data from London Air Quality Network. The results of the final GLM, showed that daily temperature, rain, wind speed, sun hours, relative humidity, and PM10 significantly affected the LR emergency hospital admissions. Then, we developed a Distributed lag non-linear model (DLNM) model considering the significant climate and pollution factors. Time and ‘day of the week’ was incorporated as linear terms in the final model. Higher temperatures around ≥270C a quicker effect of 0-2 days lag but lower temperatures (≤00C) had delayed effects of 5-25 days lag. Humidity showed a strong immediate effect (0-3 days) of the low relative humidity at around ≤40% and a moderate effect for higher humidity (≥80%) with lag period of 0-2 days. Higher PM10 around ≥70-μg/m3 has both shorter (0-3 days) and longer lag effects (15-20 days) but the latter one is stronger comparatively. A strong effect of wind speed around ≥25 knots showed longer lag period of 8-15 days. There is a moderate effect for a shorter lag period of 0-3 days for lower wind speed (approximately 2 knots). We also notice a stronger effect of sun hours around ≥14 hours having a longer lag period of 15-20 days and moderate effect between 1-2 hours of 5-12 days lag. Similarly, higher amount of rain (≥30mm) has stronger effects, especially for the shorter lag of 0-2 days and longer lag of 7- 10 days. So far, very little research has been carried out on DLNM model in such research area and setting. This PhD research will contribute to the quantitative assessment of delayed and non-linear lag effects of climate and pollutants for the Greater London region. The methodology could easily be replicated on other disease categories and regions and not limited to LR admissions. The findings may provide useful information for the development and implementation of public health policies to reduce and prevent the impact of climate change on health problems

Program: Graduate Research Achievement Day 2018

Full program for 2018 Graduate Research Achievement Day.https://digitalcommons.odu.edu/graduateschool_achievementday2017-18_programs/1000/thumbnail.jp

The Impact of Rural-Urban Residency on Colorectal Cancer Screening, Stage at Diagnosis and Treatment in the Privately Insured Population

Colorectal Cancer (CRC) is the third most common and leading cause of cancer death in the United States. Although CRC screening can prevent and detect CRC at an early stage, about 35% of Americans are not screened. Despite the recent increase in screening, people with lower SES and those who live in rural areas have lowest screening. In rural areas, a common obstacle for screening is the long trips for health services which is associated with advanced CRC. Moreover, surgery is a substantial part of CRC treatment since stages I-III and some metastatic CRC (mCRC) patients are treated with surgery. Up to 25% of patients who undergo surgery get readmitted to the hospital due to several factors which costs $300 million annually. Prior studies showed some variations in CRC treatment between rural and urban patients. The purpose of this study was to assess the association between rural-urban status and CRC screening, stage at diagnosis and the receipt of CRC surgery. There were three specific aims: 1) To assess the impact of rurality on CRC screening, 2) To assess the impact of travel time on the stage of CRC diagnosis, and 3) To evaluate rural-urban differences in healthcare utilization. We conducted analyses using data from Blue Cross Blue Shield of Nebraska (BCBSNE) between 2012 and 2016. For Aim 1, the study population included BCBSNE members aged 50-64 years with average-risk CRC. For Aim2, the study population included BCBSNE members aged 50-64 years with average-risk CRC. For Aim 3, the study population consisted of CRC patients between the ages of 19-65 years old who had CRC surgery during the study period. Claims data were used to ascertain the CRC screening, diagnosis, receipt of surgery and hospital readmission using ICD and CPT codes. Rural-urban status was based on the Rural-Urban Commuting Area Codes and travel time between the residence and the provider facility was calculated using Google Map. For Aim 1, prevalence rates for FOBT and colonoscopy were calculated and compared using X2-test. Univariate and multivariate logistic regression analyses were performed to assess the relationship between the independent variables and CRC screening test. For Aim 2, we used Wilcoxon rank-sum tests for continuous variables and X2-tests for categorical variables and we adjusted for covariates using logistic regression. For Aim 3, Readmission and surgery status were estimated using multivariate logistic regression. There was no significant difference between rural and rural residents in colonoscopy use. However, after adjustment, rural residents were 47% more likely to use FOBT. Patients who do not use preventive services were 2.80 more likely to present with mCRC and urban residents were 3.50 times more likely to receive mCRC. The fact that 12% of our population presents with mCRC suggests some non-compliance with screening guidelines. Therefore, we recommend removing barriers that prevent rural patients from receiving screening colonoscopy and thus increase early detection of CRC. Until these obstacles have been lessened, screening with more convenient tests is encouraged. The use of mailed FOBT test is easy and more accessible

Goal directed fluid therapy in colorectal surgery : strategies for the low risk patient

Morbidity and mortality following major surgery has considerable variation both nationally and globally, and hence considerable research has been focused on how post operative outcomes can be improved. In order to achieve improvement it is essential to be able to stratify a patient’s risk, and hence direct appropriate therapy and interventions to those who will benefit.Fluid therapy is used peri‐operatively to expand the circulating volume to optimise cardiac output, and hence increasing oxygen delivery to tissues, allowing the patient to meet the metabolic demands of surgery. There has been considerable debate on the optimal fluid regime for major surgery. Goal directed fluid therapy utilises cardiac output monitoring to optimise haemodynamic status on an individualised basis. Various protocols have shown improved post‐operative outcomes, and new non-invasive technologies are emerging which will allow uptake of targeted fluid therapy to be extended within the surgical population. The oesophageal Doppler is an established technology used to target fluid therapy, and various studies have shown reduced morbidity when it is used in patients undergoing major abdominal surgery. Plethysmograph variability index (PVI) is a non‐invasive technology, which evaluates variations in the plethysmographic waveform with the respiratory cycle indicating fluid responsiveness. However, currently there are no published outcome studies of its use for intra‐operative goal directed fluid therapy. The aim of this thesis is to examine the use of PVI in low-risk colorectal surgery patients, primarily investigating if similar volumes of fluids are administered when goal directed therapy is targeted using PVI or oesophageal Doppler. Fluid balance, post-operative morbidity and length of hospital stay are also compared to evaluate if PVI can be used as an alternative target for intra-operative goal-directed fluid therapy in this patient group

AND THE SURVEY SAYS ... A QUALITATIVE EXPLORATION OF STRUCTURATIONAL DIVERGENCE FROM THE PERSPECTIVES OF NURSE MANAGERS WHO ARE ACCOUNTABLE FOR PATIENT EXPERIENCE MEASURES

For more than a decade, hospital leaders have focused on boosting patient experience scores as part of the federal government’s value-based purchasing (VBP) program. Hospitals that receive federal financial assistance (such as Medicare) are mandated to participate in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a standardized survey that measures patients’ perceptions of their care. Results are publicly reported, and hospitals may be penalized on their reimbursements if they do not reach established benchmarks for patient experience. However, much debate has occurred about whether VBP has increased the quality of healthcare and whether the HCAHPS is an accurate measure of patient experience. Nurse managers on inpatient hospital units are, for their part, the ones held accountable for their units’ patient experience scores, which are scores that they often cannot control. This dissertation project is a qualitative exploration of how such accountability impacts nurse managers. With structurational divergence theory (SDT) as a framework, the study seeks to gain a deeper understanding about gridlock that exists and the resulting negative spirals of communication that occur when patient experience expectations by hospital leaders conflict with the needs of nurses on the frontline. Findings of this research suggest that the pressure to earn optimal patient experience scores is, by and large, a source of stress to inpatient nurse managers. Furthermore, findings reveal that opportunities exist within hospital organizations to enhance communication processes about patient experience, with the overarching finding being a need to better communicate to frontline staff the “why” behind the rationale for working toward patient experience goals. Also, findings indicate that expectations by hospital senior leaders to meet established patient experience goals can create conflict for nurse managers who are often caught in the middle between satisfying organizational goals and tending to the needs of frontline staff. Such conflict can spur a reactive work approach that is task- oriented and impedes the visualization of patient experience as a holistic concept. Several recommendations are offered to address issues from macro (policy), meso (organizational), and micro (nurse manager) levels. Additionally, this dissertation proposes an expansion to SDT. Ultimately, the research deduces that hospital organizations should work toward a more holistic consideration of patient experience, in lieu of an intense focus on patient experience metrics. This includes honing mutual understanding and embracing communication processes that will facilitate collaboration, rather than polarization, among organizational structures

Predicting risk and improving outcomes in high risk patients undergoing major non-cardiac surgery in the UK

Introduction: The research undertaken m this thesis was to inform OPTIMISE, a randomised controlled trial of goal directed haemodynamic therapy (GDHT) versus usual care in high-risk patients undergoing gastrointestinal surgery. The trial involved a complex intervention of cardiac output monitored administration of fluids and inotropic drugs during the perioperative period. Uncertainty exists regarding: 1. Whether the choice of fluid therapy could have influenced the outcome of the trial. 6% hydroxyl-ethyl starch (HES) has been associated with risk of death and acute kidney injury (AKI) in critically ill patients. 2. Whether he availability or provision of critical care beds is associated with improved surgical outcome and thus could have influenced the outcome of the trial. The trial intervention has traditionally been administered in a critical care setting, and this may have a bearing on outcome. 3. The trial intervention itself could have been associated with increased cardiac complications. Concerns remain regarding the administration of inotropic agents outwith traditional indications.Methods: 1. A meta-analysis was undertaken comparing perioperative use of 6% HES solutions to any comparator. 2. Surgical activity, population demographics and critical care provision in th e UK were examined using large administrative databases. 3. A UK-wide cohort of non-cardiac high-risk surgical patients admitted to intensive care was generated by combining data held by the Scottish Intensive Care Audit Group (SICSAG) and the Intensive Care National Research and Audit Centre (ICNARC) for the calendar year 2009. 4. Using this data, advanced statistical modelling techniques were used to test the association between critical care bed provision and outcome after high-risk surgery. 5. Measurement of postoperative 5th generation highly sensitive troponin (HST) release was undertaken in a subgroup of trial participants, in order to determine if the intervention was associated with increased myocardial necrosis. Logistic regression was undertaken to test if preoperative measurement of HST was associated with risk of death or major adverse cardiac events (MACE).Results: The principal findings of this thesis were: I. In a meta-analysis of 1567 patients from 19 clinical trials comparing perioperative administration of 6 % HES solutions versus any comparator no difference was observed in 30-day mortality arms (p=0.91, 12=0%; FEM: RD 0.00, 95% CI -0.02, 0.02) or AKI (p=0.62, 12=0%; FEM: RD -0.01, 95% CI -0.04, 0.02) was observed. 2. Significant variation exists in ICU bed provision within the UK. 3. In an epidemiological study of 16 I 47 patients admitted to ICU following surgery in the UK, significant variation in acute hospital mortality was observed (OR 1.42; 95% Cl : 1.29, 1.62). This did not appear to be accounted for by severity of illness, other patient-level factors or ICU bed provision. 4. Using HST we were unable to detect any difference in myocardial injury or infarction between GDHT and usual care groups. Preoperative HST measurement did not predict those at risk of perioperative death or MACE.Conclusion: Use of 6% HES in the trial intervention was unlikely to have affected trial outcome. Significant regional variation exists in outcome after surgery in the UK, which cannot be account for by patient level-factors or ICU bed provision. The trial intervention in OPTIMISE was unlikely to have caused increased incidence of myocardial infarction or necrosis. In this study preoperative measurement of 5th generation HST did not appear to predict those at risk of death at 30 or 180 days or MACE

Improving access to and uptake of early pulmonary rehabilitation following hospitalisation for acute exacerbations of COPD

Background: Substantial benefits are associated with early pulmonary rehabilitation (PR) following severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) requiring hospitalisation. However, referral for, and uptake of, early PR are poor. Methods and findings: In a prospective cohort study of 291 hospitalisations for AECOPD, COPD discharge bundles delivered by PR practitioners were associated with increased PR referral (60% vs 12%, p<0.001; adjusted odds ratio [OR]: 14.46, 95% confidence interval [CI]: 5.28 to 39.57) and uptake (40% vs 32%, p=0.001; adjusted OR: 8.60, 95% CI: 2.51 to 29.50) compared with non-PR practitioners. In a randomised controlled trial with convergent qualitative interviews, a co-designed education video delivered at hospital discharge did not improve post-hospitalisation PR uptake (41% usual care vs. 34% intervention group; p=0.37), referral, or completion. Six of fifteen interviewed participants from the intervention group did not recall receiving the video. Given the poor uptake of outpatient post-hospitalisation PR, a mixed methods systematic review was conducted to explore the feasibility, acceptability and clinical effectiveness of home-based models of PR in the post-AECOPD setting. Although home-based exercise training appeared to be feasible and acceptable to patients and healthcare professionals (HCPs), there were few trials and data was heterogenous regarding clinical effectiveness. A model of care integrating home-based exercise training and hospital at home care was co-designed by service users and HCPs. This was tested in a mixed methods feasibility study. The model of care was feasible and acceptable to patients, family carers and HCPs, and was not associated with adverse events, suggesting formal evaluation of clinical efficacy is warranted. Conclusions: Both referrer and patient factors contribute to poor referral and uptake rates for post-hospitalisation outpatient PR. Home-based PR is feasible and acceptable to patients, carers and HCPs; further research is needed to explore clinical efficacy and cost-effectiveness of post-hospitalisation home-based PR.Open Acces

Toward a Discourse Community for Telemedicine: A Domain Analytic View of Published Scholarship

In the past 20 years, the use of telemedicine has increased, with telemedicine programs increasingly being conducted through the Internet and ISDN technologies. The purpose of this dissertation is to examine the discourse community of telemedicine. This study examined the published literature on telemedicine as it pertains to quality of care, defined as correct diagnosis and treatment (Bynum and Irwin 2011). Content analysis and bibliometrics were conducted on the scholarly discourse, and the most prominent authors and journals were documented to paint and depict the epistemological map of the discourse community of telemedicine. A taxonomy based on grounded research of scholarly literature was developed and validated against other existing taxonomies. Telemedicine has been found to increase the quality and access of health care and decrease health care costs (Heinzelmann, Williams, Lugn and Kvedar 2005 and Wootton and Craig 1999). Patients in rural areas where there is no specialist or patients who find it difficult to get to a doctor’s office benefit from telemedicine. Little research thus far has examined scholarly journals in order to aggregate and analyze the prevalent issues in the discourse community of telemedicine. The purpose of this dissertation is to empiricallydocument the prominent topics and issues in telemedicine by examining the related published scholarly discourse of telemedicine during a snapshot in time. This study contributes to the field of telemedicine by offering a comprehensive taxonomy of the leading authors and journals in telemedicine, and informs clinicians, librarians and other stakeholders, including those who may want to implement telemedicine in their institution, about issues telemedicine