Examination from the Patient Perspective of Factors and Influences of Cost of Care-Related Communication between Physicians and African American Women with Asthma.

Asthma is a prevalent chronic condition where associated costs to patients are high and perceptions of financial burden may be evident. Communication between clinician and patient (cost of care-related communication) may mitigate perceptions and improve disease management. Through mixed methods approaches, this dissertation examined 1) economic factors that mediate patient characteristics and perception of financial burden and preferences for cost of care-related communication, 2) associations between cost of care-related communication and asthma self-management behaviors, and 3) clinical factors that mediate communication and asthma-related urgent care use. Baseline data were collected from 343 African American women seeking services for asthma in Southeast Michigan. Additional qualitative data were collected from sub-samples via two focus groups (n=14) and in-depth interviews (n=25). Mediation was assessed with structural equation modeling. In the first and second study, associations between perceptions of financial burden, preferences for cost of care-related communication, and patient characteristics were examined through hypothesized mediators (household income, health insurance, out-of-pocket expenses). In the third study, the relationship between cost of care-related communication and self-management behaviors and urgent care use was assessed with linear regression models, and structural equation models. Coded transcripts from the qualitative data were analyzed for themes to provide supporting information. More than half of women with asthma reported perceptions of financial burden. Three-fourths reported a preference to discuss cost with their clinician; however, less than half reported such discussions actually occurring. Household income, health insurance, and out-of-pocket expenses accounted for the relationships between patients’ characteristics and their perceptions of burden and preferences for communication. No associations between cost of care-related communication, self-management behaviors and asthma-related urgent care use were found. Many people perceive financial burden and would like to discuss cost with their clinician, but these discussions occur infrequently, and are often initiated by patients. Burden may be present despite having economic resources. Given the high percentage of women desiring cost-of-care discussions, more research is needed in order to strengthen capacity of care teams and patients in order to integrate financial concerns with disease management into routine care.PHDHealth Behavior & Health EducationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/97902/1/minalrp_1.pd

Streptococcus viridans osteomyelitis and endocarditis following dental treatment: a case report

Vertebral osteomyelitis is an uncommon complication of infective endocarditis with the organism Streptococcus viridans being a rare cause of the condition. This case highlights an unusual presentation of Streptococcus viridans associated with infective endocarditis and pyogenic osteomyelitis in a patient following a dental procedure

A qualitative study of physician perspectives of cost-related communication and patients’ financial burden with managing chronic disease

Abstract Background Patient financial burden with chronic disease poses significant health risks, yet it remains outside the scope of clinical visits. Little is known about how physicians perceive their patients’ health-related financial burden in the context of primary care. The purpose of this study was to describe physician experiences with patients’ financial burden while managing chronic disease and the communication of these issues. Methods In November 2013, four focus groups were conducted in an academic medical center. A convenience sample of 29 internal and family medicine resident physicians was used in this study. A semi-structured interview protocol was employed by trained facilitators. Coded transcripts were analyzed for themes regarding physicians’ experiences with identifying, managing, and communicating financial burden with their patients in the context of primary care. Results Major themes identified were 1) patient financial burden with chronic care is visible to physicians, 2) patient’s financial burden with chronic care and discussing these issues is important to physicians, 3) ability to identify patients who perceive financial burden is imperfect, 4) communication of financial burden with patients is complex and difficult to navigate, 5) strategies utilized to address concerns are not always generalizable, and 6) physicians have ideas for widespread change to make these conversations easier for them. Conclusion Awareness of physician perspectives in identifying and addressing their patients’ disease-related financial burden may better equip researchers and medical educators to develop interventions that aid care teams in better understanding these patient concerns to promote compliance with treatment recommendations.http://deepblue.lib.umich.edu/bitstream/2027.42/116043/1/12913_2015_Article_1189.pd

Maternal outcome in pregnancy with sickle cell trait haemoglobinopathie

Background: Sickle cell trait, the heterozygous state for sickle cell disorders (SCD), which is associated with various obstetrical and non- obstetrical complication. Our objective was to study the pregnancy outcome in women with sickle cell trait.Methods: A prospective observational study was conducted collecting data from medical records of around 40 consecutive consenting subjects admitted in a tertiary health care center of south Gujarat over a period of May 2020 to April 2021 after Human Research Ethics Committee (HREC) approval.Results: In our study majority of the subjects (52.5%) belonged to age group of 18-25 years, majority (62.5%) of subjects were belonged to tribal population. Majority (92.5%) of subjects in our study diagnosed as sickle cell trait post -conceptional. 67% of subjects had various antenatal maternal morbidity among them anemia (45%); preterm labour (12.5%); hypertensive disorder (7.5%) and respiratory failure (2.5%). 65% of our subjects were delivered vaginaly. 5% of subjects had post- partum complication.Conclusions: Though sickle cell trait is considered as a low risk factor during pregnancy, expansion of SCT screening and educational efforts, the availability of reproductive technologies, and the increasing research on clinical complications of SCT have important implications for reproductive and genetic counselling guidelines

A prospective observational study of foetal outcome in twin pregnancy delivering at a tertiary health care center of South Gujarat

Background: Worldwide increased incidence of twin gestation. The rates of twin gestation have a direct effect on the rates of preterm birth and its co-morbidities. Importantly, this increased risk applies to each fetus and is not simply the result of more foetuses.Methods: This prospective study was carried out in department of obstetrics and gynaecology. 100 consecutive subjects fulfilling inclusion criteria   admitted to labour room and obstetrics intensive care enrolled over a period of around 1 year.Results: In this study twin delivery accounted for 1.3% of all delivery at our institute. On analysing neonatal morbidities Prematurity was commonest 65%, VLBW (23% first twin, 30% second twin), RDS (9% first twin, 13% second twin), birth asphyxia (7% first twin, 12% second twin), neonatal hyperbilirubinemia (7% first twin, 8% second twin). 34% of first twin and 40% of second twin required NICU admission. Early neonatal death observed in 6% of first twin and 8% of second twin. It was observed that proportion of neonatal complications was more in MCDA as compared to DCDA and in un-booked subjects as compared to booked subjects. This difference is statistically significant among both twin (p value<0.05).Conclusions: Twin pregnancy is associated with high perinatal morbidity. Specialized obstetrics and Intensive Neonatal care can decrease neonatal morbidity and mortality in twin gestation. We need to be extra vigilant in monochorionic twins and twin pregnancy with inadequate antenatal care

Study protocol for improving asthma outcomes through cross-cultural communication training for physicians: a randomized trial of physician training

Abstract Background Massive resources are expended every year on cross-cultural communication training for physicians. Such training is a focus of continuing medical education nationwide and is part of the curriculum of virtually every medical school in America. There is a pressing need for evidence regarding the effects on patients of cross-cultural communication training for physicians. There is a need to understand the added benefit of such training compared to more general communication. We know of no rigorous study that has assessed whether cross-cultural communication training for physicians results in better health outcomes for their patients. The current study aims to answer this question by enhancing the Physician Asthma Care Education (PACE) program to cross cultural communication (PACE Plus), and comparing the effect of the enhanced program to PACE on the health outcomes of African American and Latino/Hispanic children with asthma. Methods/Design A three-arm randomized control trial is used to compare PACE Plus, PACE, and usual care. Both PACE and PACE Plus are delivered in two, two-hour sessions over a period of two weeks to 5–10 primary care physicians who treat African American and Latino/Hispanic children with asthma. One hundred twelve physicians and 1060 of their pediatric patients were recruited who self-identify as African American or Latino/Hispanic and experience persistent asthma. Physicians were randomized into receiving either the PACE Plus or PACE intervention or into the control group. The comparative effectiveness of PACE and PACE Plus on clinician’s therapeutic and communication practices with the family/patient, children’s urgent care use for asthma, asthma control, and quality of life, and parent/caretaker satisfaction with physician performance will be assessed. Data are collected via telephone survey and medical record review at baseline, 9 months following the intervention, and 21 months following the intervention. Discussion This study aims to reduce disparities in asthma outcomes among African American and Latino/Hispanic children through cross-cultural communication training of their physicians and assessing the added value of this training compared to general communication. The results of this study will provide important information about the value of cross-cultural training in helping to address persistent racial disparities in outcomes. Trial registration ClinicalTrials.gov: NCT01251523 December 1, 2010http://deepblue.lib.umich.edu/bitstream/2027.42/109533/1/12909_2014_Article_948.pd

Clinical Impact of Ceftriaxone Resistance in Escherichia coli Bloodstream Infections: A Multicenter Prospective Cohort Study

BACKGROUND: Ceftriaxone-resistant (CRO-R) Escherichia coli bloodstream infections (BSIs) are common. METHODS: This is a prospective cohort of patients with E coli BSI at 14 United States hospitals between November 2020 and April 2021. For each patient with a CRO-R E coli BSI enrolled, the next consecutive patient with a ceftriaxone-susceptible (CRO-S) E coli BSI was included. Primary outcome was desirability of outcome ranking (DOOR) at day 30, with 50% probability of worse outcomes in the CRO-R group as the null hypothesis. Inverse probability weighting (IPW) was used to reduce confounding. RESULTS: Notable differences between patients infected with CRO-R and CRO-S E coli BSI included the proportion with Pitt bacteremia score ≥4 (23% vs 15%, P = .079) and the median time to active antibiotic therapy (12 hours [interquartile range {IQR}, 1-35 hours] vs 1 hour [IQR, 0-6 hours]; P \u3c .001). Unadjusted DOOR analyses indicated a 58% probability (95% confidence interval [CI], 52%-63%) for a worse clinical outcome in CRO-R versus CRO-S BSI. In the IPW-adjusted cohort, no difference was observed (54% [95% CI, 47%-61%]). Secondary outcomes included unadjusted and adjusted differences in the proportion of 30-day mortality between CRO-R and CRO-S BSIs (-5.3% [95% CI, -10.3% to -.4%] and -1.8 [95% CI, -6.7% to 3.2%], respectively), postculture median length of stay (8 days [IQR, 5-13 days] vs 6 days [IQR, 4-9 days]; P \u3c .001), and incident admission to a long-term care facility (22% vs 12%, P = .045). CONCLUSIONS: Patients with CRO-R E coli BSI generally have poorer outcomes compared to patients infected with CRO-S E coli BSI, even after adjusting for important confounders

Chronic exposure to outdoor air pollution and diagnosed cardiovascular disease: meta-analysis of three large cross-sectional surveys

BACKGROUND: Higher exposure to outdoor air pollution is associated with increased cardiopulmonary deaths, but there is limited evidence about the association between outdoor air pollution and diagnosed cardiovascular disease. Our study aimed to estimate the size of the association between long term exposure to outdoor air pollution and prevalent cardiovascular disease. METHODS: We carried out a cross-sectional analysis of data on more than 19,000 white adults aged 45 and older who participated in three representative surveys of the English population in 1994, 1998 and 2003, examining the relationship between self-reported doctor-diagnosed cardiovascular disease and exposure to outdoor air pollutants using multilevel regression techniques and meta-analysis. RESULTS: The combined estimates suggested that an increase of 1 microg m-3 in concentration of particulate matter less than 10 microns in diameter was associated with an increase of 2.9% (95% CI -0.6% to 6.5%) in prevalence of cardiovascular disease in men, and an increase of 1.6% (95%CI -2.1% to 5.5%) in women. The year-specific analyses showed strongly positive associations in 2003 between odds of cardiovascular disease in both men and women and exposure to particulate matter but not in 1994 or 1998. We found no consistent associations between exposure to gaseous air pollutants and doctor-diagnosed cardiovascular disease. CONCLUSION: The associations of prevalent cardiovascular disease with concentration of particulate matter less than 10 microns in diameter, while only weakly positive, were consistent with the effects reported in cohort studies. The results provide evidence of the size of the association between particulate air pollution and the prevalence of cardiovascular disease but no evidence for an association with gaseous pollutants. We found strongly positive associations between particulate matter and cardiovascular disease in 2003 only, which highlights the importance of replicating findings in more than one population

Duration of effectiveness of vaccines against SARS-CoV-2 infection and COVID-19 disease: results of a systematic review and meta-regression.

BACKGROUND: Knowing whether COVID-19 vaccine effectiveness wanes is crucial for informing vaccine policy, such as the need for and timing of booster doses. We aimed to systematically review the evidence for the duration of protection of COVID-19 vaccines against various clinical outcomes, and to assess changes in the rates of breakthrough infection caused by the delta variant with increasing time since vaccination. METHODS: This study was designed as a systematic review and meta-regression. We did a systematic review of preprint and peer-reviewed published article databases from June 17, 2021, to Dec 2, 2021. Randomised controlled trials of COVID-19 vaccine efficacy and observational studies of COVID-19 vaccine effectiveness were eligible. Studies with vaccine efficacy or effectiveness estimates at discrete time intervals of people who had received full vaccination and that met predefined screening criteria underwent full-text review. We used random-effects meta-regression to estimate the average change in vaccine efficacy or effectiveness 1-6 months after full vaccination. FINDINGS: Of 13 744 studies screened, 310 underwent full-text review, and 18 studies were included (all studies were carried out before the omicron variant began to circulate widely). Risk of bias, established using the risk of bias 2 tool for randomised controlled trials or the risk of bias in non-randomised studies of interventions tool was low for three studies, moderate for eight studies, and serious for seven studies. We included 78 vaccine-specific vaccine efficacy or effectiveness evaluations (Pfizer-BioNTech-Comirnaty, n=38; Moderna-mRNA-1273, n=23; Janssen-Ad26.COV2.S, n=9; and AstraZeneca-Vaxzevria, n=8). On average, vaccine efficacy or effectiveness against SARS-CoV-2 infection decreased from 1 month to 6 months after full vaccination by 21·0 percentage points (95% CI 13·9-29·8) among people of all ages and 20·7 percentage points (10·2-36·6) among older people (as defined by each study, who were at least 50 years old). For symptomatic COVID-19 disease, vaccine efficacy or effectiveness decreased by 24·9 percentage points (95% CI 13·4-41·6) in people of all ages and 32·0 percentage points (11·0-69·0) in older people. For severe COVID-19 disease, vaccine efficacy or effectiveness decreased by 10·0 percentage points (95% CI 6·1-15·4) in people of all ages and 9·5 percentage points (5·7-14·6) in older people. Most (81%) vaccine efficacy or effectiveness estimates against severe disease remained greater than 70% over time. INTERPRETATION: COVID-19 vaccine efficacy or effectiveness against severe disease remained high, although it did decrease somewhat by 6 months after full vaccination. By contrast, vaccine efficacy or effectiveness against infection and symptomatic disease decreased approximately 20-30 percentage points by 6 months. The decrease in vaccine efficacy or effectiveness is likely caused by, at least in part, waning immunity, although an effect of bias cannot be ruled out. Evaluating vaccine efficacy or effectiveness beyond 6 months will be crucial for updating COVID-19 vaccine policy. FUNDING: Coalition for Epidemic Preparedness Innovations