Understanding care coordination for Veterans with complex care needs: protocol of a multiple-methods study to build evidence for an effectiveness and implementation study

Background For patients with complex health and social needs, care coordination is crucial for improving their access to care, clinical outcomes, care experiences, and controlling their healthcare costs. However, evidence is inconsistent regarding the core elements of care coordination interventions, and lack of standardized processes for assessing patients’ needs has made it challenging for providers to optimize care coordination based on patient needs and preferences. Further, ensuring providers have reliable and timely means of communicating about care plans, patients’ full spectrum of needs, and transitions in care is important for overcoming potential care fragmentation. In the Veterans Health Administration (VA), several initiatives are underway to implement care coordination processes and services. In this paper, we describe our study underway in the VA aimed at building evidence for designing and implementing care coordination practices that enhance care integration and improve health and care outcomes for Veterans with complex care needs. Methods In a prospective observational multiple methods study, for Aim 1 we will use existing data to identify Veterans with complex care needs who have and have not received care coordination services. We will examine the relationship between receipt of care coordination services and their health outcomes. In Aim 2, we will adapt the Patient Perceptions of Integrated Veteran Care questionnaire to survey a sample of Veterans about their experiences regarding coordination, integration, and the extent to which their care needs are being met. For Aim 3, we will interview providers and care teams about their perceptions of the innovation attributes of current care coordination needs assessment tools and processes, including their improvement over other approaches (relative advantage), fit with current practices (compatibility and innovation fit), complexity, and ability to visualize how the steps proceed to impact the right care at the right time (observability). The provider interviews will inform design and deployment of a widescale provider survey. Discussion Taken together, our study will inform development of an enhanced care coordination intervention that seeks to improve care and outcomes for Veterans with complex care needs

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multi-centre observational study

There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%)

Clinical Off-Label Use of Deep Transcranial Magnetic Stimulation in Psychiatric Conditions

Purpose of review:Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation approach to psychiatric treatment that is FDA approved for the management of major depressive disorder (MDD) and obsessive compulsive disorder (OCD). Standard TMS appears to exert biological effects by inducing current in the cortex more shallowly than deep TMS (dTMS); it may be that this modality of treatment differs from standard TMS. Given the potential difference in the manner in which dTMS stimulates the targeted brain regions, it is reasonable to review and summarize the various off-label and experimental applications of this variation of TMS.Recent findings:Deep TMS has demonstrated promise in treating mood disorders including bipolar depression and PTSD, but it is clear that more work is needed to clarify the utility of dTMS compared with rTMS. Future work may help delineate the role dTMS plays in addressing a wide spectrum of psychiatric illnesses. In addition, direct fundamental work is needed to characterize any effectiveness of dTMS in schizophrenia, anxiety, and autism spectrum disorder.Summary:Overall, neuromodulation holds promise for treating a variety of psychiatric conditions but more extensive works aimed at understanding the mechanisms and applicability are sorely needed. Continued efforts in understanding the unique application of dTMS may pave the way for future methodologies that could enhance treatment options for both mood and thought disorder