Organizational and Environmental Context for Including Advanced Practice Providers in UPMC Hospitalist Models

This study qualitatively examines the environmental and organizational context driving the implementation of advanced practice providers (APPs) in hospital medicine at UPMC. We utilized a comparison case study methodology, including field observation and semi-structured interviews at two hospital medicine programs. We identified three distinct models of APPs in hospital medicine, including the Team Approach, Divide and Conquer, and a Hybrid model, and linked the evolution of these models to contextual factors. Our findings present unique insight into the roles of APPs on UPMC hospital medicine teams. We show that environmental pressures, organizational initiatives, and clinician experience can influence APP roles

A united statement of the global chiropractic research community against the pseudoscientific claim that chiropractic care boosts immunity.

BACKGROUND: In the midst of the coronavirus pandemic, the International Chiropractors Association (ICA) posted reports claiming that chiropractic care can impact the immune system. These claims clash with recommendations from the World Health Organization and World Federation of Chiropractic. We discuss the scientific validity of the claims made in these ICA reports. MAIN BODY: We reviewed the two reports posted by the ICA on their website on March 20 and March 28, 2020. We explored the method used to develop the claim that chiropractic adjustments impact the immune system and discuss the scientific merit of that claim. We provide a response to the ICA reports and explain why this claim lacks scientific credibility and is dangerous to the public. More than 150 researchers from 11 countries reviewed and endorsed our response. CONCLUSION: In their reports, the ICA provided no valid clinical scientific evidence that chiropractic care can impact the immune system. We call on regulatory authorities and professional leaders to take robust political and regulatory action against those claiming that chiropractic adjustments have a clinical impact on the immune system

IDENTIFYING FACTORS ASSOCIATED WITH PHYSICAL THERAPISTS’ ADHERENCE TO LOW BACK PAIN GUIDELINES ACROSS THE DOMAINS OF THE CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH: A MIXED METHODS STUDY

In 2007 a regional physical therapy (PT) organization implemented low back pain (LBP) guidelines throughout its 50 outpatient clinical sites. Despite multiple improvement efforts since that time guideline adherence is suboptimal (38%). In this study the Consolidated Framework for Implementation Research (CFIR) guided an evaluation to identify determinants of adherence.\ud \ud A sequential, mixed methods design was used to identify determinants of adherence to LBP guidelines. We surveyed PTs using instruments pertinent to LBP management and implementation success to explore factors associated with guideline adherence across three CFIR domains: Individual, Innovation, and Inner Setting. Instruments included the Pain Attitudes and Beliefs Scale, Intolerance of Uncertainty Scale, Ottawa Acceptability of Decision Rules Instrument, and Alberta Context Tool. Survey responses, provider demographics and professional characteristics were merged with risk-adjusted measures of guideline adherence using data from the organization’s database. Generalized linear models (GLM) were first used to assess univariate associations, then main effects and 2x2 interactions were evaluated using GLM with forced, backward stepwise elimination. The sample was stratified by quartile using the risk-adjusted adherence measure. Purposive maximum variation sampling identified 15 high and 15 low performing providers for semi-structured telephonic interviews. \ud \ud One hundred and twelve survey completers (74%) had a risk-adjusted guideline adherence measure and were included in the study. There was no association between PT’s acceptability of individual guideline recommendations and adherence. There were significant interactions between Professional Certification (PC) and Uncertainty Paralysis (β=-0.06, p>0.05), PC and Time to Deliver Quality Care (β=0.26, p=0.03), and PC and Connections with Colleagues (β=0.36, p=0.01). Qualitative interviews identified barriers to adherence resulting from the complexity of the guidelines and limited skills required to carry out some of the recommendations. The interviews also revealed that perceived support for the initiative was stronger from senior management compared to front line supervisors.\ud \ud This study addresses three gaps in the dissemination and implementation literature: 1) it describes one method to identify determinants for tailoring interventions; 2) it quantifies interaction effects within and between CFIR domains; and 3) it assesses determinants of sustainability in a mature implementation initiative

Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial

Background: Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yoga\u27s effectiveness in underserved patients with more severe functional disability and pain. Objective: To determine whether yoga is noninferior to PT for cLBP. Design: 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927). Setting: Academic safety-net hospital and 7 affiliated community health centers. Participants: 320 predominantly low-income, racially diverse adults with nonspecific cLBP. Intervention: Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice. Measurements: Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life. Results: One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups. Limitations: Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up. Conclusion: A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain. Primary Funding Source: National Center for Complementary and Integrative Health of the National Institutes of Health

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care.

ImportanceAcute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.ObjectiveTo assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.Design, setting, and participantsThis inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.ExposuresSBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).Main outcomes and measuresTransition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.ResultsOverall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P Conclusions and relevanceIn this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care

The Art of Measuring Physical Parameters in Galaxies: A Critical Assessment of Spectral Energy Distribution Fitting Techniques

The study of galaxy evolution hinges on our ability to interpret multiwavelength galaxy observations in terms of their physical properties. To do this, we rely on spectral energy distribution (SED) models, which allow us to infer physical parameters from spectrophotometric data. In recent years, thanks to wide and deep multiwave band galaxy surveys, the volume of high-quality data have significantly increased. Alongside the increased data, algorithms performing SED fitting have improved, including better modeling prescriptions, newer templates, and more extensive sampling in wavelength space. We present a comprehensive analysis of different SED-fitting codes including their methods and output with the aim of measuring the uncertainties caused by the modeling assumptions. We apply 14 of the most commonly used SED-fitting codes on samples from the CANDELS photometric catalogs at z ∼ 1 and z ∼ 3. We find agreement on the stellar mass, while we observe some discrepancies in the star formation rate (SFR) and dust-attenuation results. To explore the differences and biases among the codes, we explore the impact of the various modeling assumptions as they are set in the codes (e.g., star formation histories, nebular, dust and active galactic nucleus models) on the derived stellar masses, SFRs, and A _V values. We then assess the difference among the codes on the SFR–stellar mass relation and we measure the contribution to the uncertainties by the modeling choices (i.e., the modeling uncertainties) in stellar mass (∼0.1 dex), SFR (∼0.3 dex), and dust attenuation (∼0.3 mag). Finally, we present some resources summarizing best practices in SED fitting